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The training of good physicians: Critical factors in career choice
Sot. Sci. & Merl. 1970, Vol. 3, pp. 699-718. Pergamon
Press. Printed
in Great Britain .
REVIEWS THE TRAINING OF GOOD PHYSICIANS: CRITICAL FACTORS IN CAREER CHOICE by FREMONT J. LYDEN, H. JACK GEIGER and OSLER L. PETERSON. Harvard University Press (a Commonwealth Fund Book), Cambridge, Mass. 1968. $6.95. study of medical education is an area in which the social sciences can fairly claim to have made a useful and practical contribution to medicine. Studies such as The Ecology qf the Medical Student Cl], The Student Physician [2] and BOJLSill White [3], have provided medical educators with an objective framework for taking stock of themselves and their activities and have influenced the re-appraisals of curricula that many schools have undertaken. This book is in the same tradition as these earlier works and concerns itself with the post-graduate training of the physician and the factors that influence career choice. The book reports a retrospective study of doctors graduating from 12 selected medical schools in the United States in 1950 and 1954. 1887 graduates were sent a questionnaire by mail in 1960 and 177 1 (94 “/,) replied. The schools were selected on the basis of a number of variables-public or private ownership, size, geographic location and “traditional output” (that is, their tendency to produce specialists, teachers or general practitioners). The data are not based on a population sample of medical graduates, therefore, but the authors argue that the schools they selected are a cross section of American schools and point out that the doctors who returned questionnaires constituted about 15 yi of all medical graduates in the two years they studied. The questionnaire (which is not reproduced in the book) was preceded and covereda wide variety of topics. The questions were primarily concerned with the present practice circumstances of the doctors, with the nature of their post-graduate training and with the factors which influenced decisions in these areas. The responses are presented in chapters with headings of this kind and tend to appear rather as a catalogue of results. thus making it difficult for the reader to assess the effect of various factors on the continuity of the training the influence of family background on career process. It would be easier to appreciate choice, for example, if the effect of their influence had not been fragmented between chapters. One finds reference to father’s occupation and education on page 54 (in relation to choice of field of practice), on page 73 (educational debt) and page 126 (internship and residency training) but one has to wait until the final chapter (page 214) for these to be brought together in the general statement that family and financial background had an important effect on the nature and length of the doctors’ training and. therefore, on the career choice open to him. My difficulty in this regard was increased by the authors’ retention of their retrospective approach in the arrangement of chapters-‘Present Practice Circumstances’ comes first with ‘Hospital Training Decisions’ two chapters later. It would have been simpler the ,other way round. The study confirms aspects of medical education demonstrated in other studies-for example, that doctors are recruited largely from the upper strata of society [l, 41 and that THE
699
700
Boon
REVIEWS
social and family characteristics are an important element in career choice. Similarities between the United States and the United Kingdom in this regard are continued in the authors’ observation that “the student who is likely to become a general practitioner is more likely to rank in the lowest third of the class”: Last and Martin [5] have published similar results from their studies of young British doctors. There are striking differences between public and private medical schools which seem to go further than simple differences in recruitment or finance-these differences are heavily influenced by the greater proportion of intending ‘family doctors’ from public medical schools but the implication that public and private medical schools have a different ‘ecology’ is not entirely explained in this way. Becker and his colleagues [3] have provided a detailed account of the ecology of one such school, and the criticisms of medical education expressed by the doctors in this study fit well alongside their picture. In this context the authors make two points: firstly, that the “polar-paired model” which associates welleducated specialists and teachers with private schools and poorly trained general practitioners with public schools is an unsatisfactory state of affairs (although one wonders how much it has changed since 1954) and, secondly, the related point, that medical schools have been slow to appreciate that medical education cannot be divorced from the needs of the medical care system. During the past decade there has been an increasing appreciation of the organisational complexities of modern medicine and a concomitant development in the planning of facilities to meet the needs of society. Such phrases as ‘medical manpower’ and ‘the medical care system’ are much in vogue. The values of studies such as this is that they provide an important background to the discussion of these issues-whatever ‘the system’ it can only employ the doctors that are available and these will only be as good as the training provided for them. In its turn, the doctor’s training is influenced byavariety of factors of which intellectual ability will not necessarily be the most important. It is a pity that the study has been so long in appearing; it would be more than simply interesting to know whether the changes the authors urge are, in fact, taking place. F. A. BODDY. M.B. Department of’ Epidemiology ond Preventive Medicine. University qf Glaqgow, Scotland. REFERENCES
I. GEE, HELEN H. and GLAZER, R. J. (eds.), T/W Ecology of the MedicnlSrh~rr. Association Medical Colleges, Evanston, Illinois, 1958. 2. MERTON, R. et al. The Studenr Harvard University Cambridge, Mass. 3. BECKER, S. et Boys in Chicago University 1961. 4. J. H. et ul. Report of Medical Smdenr Association of Education, London, (Mimeographed). 5. LAST, J. PI al. Academic record and subsequent career. Proc. R. Sue. Med. 60, 813-816.
of American
for 1967.
Study
Press. Printed
in Great Britain .
REVIEWS THE TRAINING OF GOOD PHYSICIANS: CRITICAL FACTORS IN CAREER CHOICE by FREMONT J. LYDEN, H. JACK GEIGER and OSLER L. PETERSON. Harvard University Press (a Commonwealth Fund Book), Cambridge, Mass. 1968. $6.95. study of medical education is an area in which the social sciences can fairly claim to have made a useful and practical contribution to medicine. Studies such as The Ecology qf the Medical Student Cl], The Student Physician [2] and BOJLSill White [3], have provided medical educators with an objective framework for taking stock of themselves and their activities and have influenced the re-appraisals of curricula that many schools have undertaken. This book is in the same tradition as these earlier works and concerns itself with the post-graduate training of the physician and the factors that influence career choice. The book reports a retrospective study of doctors graduating from 12 selected medical schools in the United States in 1950 and 1954. 1887 graduates were sent a questionnaire by mail in 1960 and 177 1 (94 “/,) replied. The schools were selected on the basis of a number of variables-public or private ownership, size, geographic location and “traditional output” (that is, their tendency to produce specialists, teachers or general practitioners). The data are not based on a population sample of medical graduates, therefore, but the authors argue that the schools they selected are a cross section of American schools and point out that the doctors who returned questionnaires constituted about 15 yi of all medical graduates in the two years they studied. The questionnaire (which is not reproduced in the book) was preceded and covereda wide variety of topics. The questions were primarily concerned with the present practice circumstances of the doctors, with the nature of their post-graduate training and with the factors which influenced decisions in these areas. The responses are presented in chapters with headings of this kind and tend to appear rather as a catalogue of results. thus making it difficult for the reader to assess the effect of various factors on the continuity of the training the influence of family background on career process. It would be easier to appreciate choice, for example, if the effect of their influence had not been fragmented between chapters. One finds reference to father’s occupation and education on page 54 (in relation to choice of field of practice), on page 73 (educational debt) and page 126 (internship and residency training) but one has to wait until the final chapter (page 214) for these to be brought together in the general statement that family and financial background had an important effect on the nature and length of the doctors’ training and. therefore, on the career choice open to him. My difficulty in this regard was increased by the authors’ retention of their retrospective approach in the arrangement of chapters-‘Present Practice Circumstances’ comes first with ‘Hospital Training Decisions’ two chapters later. It would have been simpler the ,other way round. The study confirms aspects of medical education demonstrated in other studies-for example, that doctors are recruited largely from the upper strata of society [l, 41 and that THE
699
700
Boon
REVIEWS
social and family characteristics are an important element in career choice. Similarities between the United States and the United Kingdom in this regard are continued in the authors’ observation that “the student who is likely to become a general practitioner is more likely to rank in the lowest third of the class”: Last and Martin [5] have published similar results from their studies of young British doctors. There are striking differences between public and private medical schools which seem to go further than simple differences in recruitment or finance-these differences are heavily influenced by the greater proportion of intending ‘family doctors’ from public medical schools but the implication that public and private medical schools have a different ‘ecology’ is not entirely explained in this way. Becker and his colleagues [3] have provided a detailed account of the ecology of one such school, and the criticisms of medical education expressed by the doctors in this study fit well alongside their picture. In this context the authors make two points: firstly, that the “polar-paired model” which associates welleducated specialists and teachers with private schools and poorly trained general practitioners with public schools is an unsatisfactory state of affairs (although one wonders how much it has changed since 1954) and, secondly, the related point, that medical schools have been slow to appreciate that medical education cannot be divorced from the needs of the medical care system. During the past decade there has been an increasing appreciation of the organisational complexities of modern medicine and a concomitant development in the planning of facilities to meet the needs of society. Such phrases as ‘medical manpower’ and ‘the medical care system’ are much in vogue. The values of studies such as this is that they provide an important background to the discussion of these issues-whatever ‘the system’ it can only employ the doctors that are available and these will only be as good as the training provided for them. In its turn, the doctor’s training is influenced byavariety of factors of which intellectual ability will not necessarily be the most important. It is a pity that the study has been so long in appearing; it would be more than simply interesting to know whether the changes the authors urge are, in fact, taking place. F. A. BODDY. M.B. Department of’ Epidemiology ond Preventive Medicine. University qf Glaqgow, Scotland. REFERENCES
I. GEE, HELEN H. and GLAZER, R. J. (eds.), T/W Ecology of the MedicnlSrh~rr. Association Medical Colleges, Evanston, Illinois, 1958. 2. MERTON, R. et al. The Studenr Harvard University Cambridge, Mass. 3. BECKER, S. et Boys in Chicago University 1961. 4. J. H. et ul. Report of Medical Smdenr Association of Education, London, (Mimeographed). 5. LAST, J. PI al. Academic record and subsequent career. Proc. R. Sue. Med. 60, 813-816.
of American
for 1967.
Study