1. “Where Are They Now?” A Survey of Histopathology Trainees 2001-2008 P.A. Bennett 1, S. Cossins 1, A.H. McGregor 1 1 National Histopathology Training Schools Board INTRODUCTION Histopathology training schools were introduced in 2001 following an investment from the NHS Cancer Plan. 1 The aim of these schools was to standardise and improve training of first year histopathology registrars and address a shortage of consultant histopathologists, a significant barrier to the improvement of cancer services. Following the success of the first three schools (Leeds, Leicester and Southampton) the scheme had expanded to twelve schools by 2008 as part of a plan to continue to modernise pathology services. 2 A total number of 313 trainees had been enrolled by the 2007-08 intake, representing most areas of England and Wales (Figure 1). It was decided to survey all appointed trainees, past and present, since the commencement of the training school scheme. We examined the backgrounds and current aspirations of each trainee, as well as contacting those who had left the scheme prematurely to explore their reasons for doing so. The survey aimed to identify common features amongst histopathology trainees with a view to aiding recruitment and lowering future attrition rates. METHODS AND TECHNOLOGY A questionnaire was devised and divided into three sections. Section A dealt with life before histopathology and asked questions on demographics, medical training and prior specialities. Section B was focused on current histopathology training, including expected dates for completion of training and future aspirations within the specialty. Section C was targeted at those who had left training prior to completion, and enquired into new career paths and reasons for leaving the histopathology training scheme. The survey was largely tick-box based, with an opportunity for free text comments. Of the 313 trainees recruited since 2001, contact details were available for 290. The questionnaire was emailed out in a Microsoft Word based format, with instructions to be returned by email or post. A period of one month was allowed for return. RESULTS Of the 290 questionnaires sent out, 158 were returned, a 55% return rate. All data were anonymised. This return rate was lower than expected, possibly due to the questionnaire coinciding with the annual PMETB “National Survey of Trainee Doctors” 3 and the Royal College examinations. The results have been split into 3 sections: Respondent profile, Career Aspirations and Attrition Rates. A. Respondent Profile There has been a demographic variation of trainees since the introduction of the training schools. The most notable change has been the increased prevalence of younger doctors entering directly from the Foundation Programme, together with an increasing number of female trainees. (See Figures 2-5). B. Career Aspirations Where stated, aspirations of trainees varied between general histopathology (49%), sub- specialisation (31%) and research (7%), with 13% undecided. The most commonly stated sub-specialist areas were forensic pathology (19%), gastrointestinal pathology (19%) and dermatopathology (12%). The least popular area was cytology (2%). (See Figure 6). C. Attrition Rates Of the total number of 313 trainees, 22 have left prior to completion of training. The attrition rate has been relatively constant (between 11-14%) with lower rates of 0%, 5% and 1.5% recorded in 2003, 2005 and 2007 respectively. (See Figure 7) The background of the leavers varied, although the highest proportion (33%) had entered histopathology directly from Foundation / House Officer training. Other previous careers included medicine, surgery, and a range of other specialities. After leaving only two doctors returned to their original specialities. 27% moved to General Practice, 13% to general medicine, 7% to research and 7% to overseas training. 26% of trainees moved to the pharmaceutical industry and 7% moved to the Civil Service. One ex- trainee is currently unemployed, and the current location of another ex-trainee is unknown. Reasons for leaving included dissatisfaction with the speciality and an opportunity for career change. Other common issues were personal/health reasons, the un-banded salary and desire to return to a role involving full-time patient contact. Some reported serious grievances, such as ethnic discrimination and bullying. One trainee commented on a lack of responsibility in histopathology training, whilst another reported a problem with flexible training. DISCUSSION Results from survey represent the backgrounds and career aspirations of 143 trainees, plus the current whereabouts of 15 ex-trainees and their reasons for leaving the training programme. In common with other specialities and medical school intakes 4, the number of female trainees is rising. This may have future implications for service provision & training. 5 Post-foundation applications may be due to recent trend for early specialisation and a decline in doctors working standalone “SHO rotations” in medicine/surgery. The attraction of run-through training may also be key factor in attracting foundation doctors. Career and subspecialty aspirations varied. Only one trainee aiming for career in cytology may indicate a potential future shortage - this warrants further study. Of those that left histopathology training prematurely, post-foundation year doctors were most numerous. These trainees in particular reported general dissatisfaction with training as a reason for leaving. A possible reason is a lack of histopathology experience prior to application together with the pressure of early specialisation. The fact that most trainees left for entirely different specialities, all with direct patient contact, indicates that most were not suited to the working style of the discipline. REFERENCES 1.The NHS Cancer plan: a plan for investment, a plan for reform. 27 th Sept 2000. http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/Cancer/fs/en 2.Modernising Pathology Services. 17 th Feb 2004 http://www.dh.gov.uk/assetRoot/04/07/31/12/04073112.pdf 3. 2008/09 National Survey of Trainee Doctors, Post Graduate Medical Education and Training Board. 8 th December 2008 http://www.pmetb.org.uk/index.php?id=traineesurvey 4.Dacre, J. BMJ (2008) 336:749 5.“BMA calls for flexible working as new research shows increasing numbers of women doctors” BMA Press Release (23 rd Jun 2007) https://registration.bma.org.uk/pressrel.nsf/wlu/SGOY74ECWB?OpenDocument&vw=wfmms 6.Person Specification, ST1 Histopathology, MMC Website http://www.mmc.nhs.uk/pdf/PS%202009%20ST1%20histopath.pdf 7.Longo, WE el al. Am J Surg (2009) 197(6)774-8 Figure 2a shows that the majority of trainees fall into the 25-35 age bracket. Figure 2b shows that since 2006 older trainee numbers have fallen, whilst the 25-30 group has increased. Figure 3a shows a similar number of male and female trainees. Female trainees have increased in number nearly every year, contrasting with falling male trainees since 2005 (Fig 3b) Figure 4a shows that most trainees are UK graduates. The proportion of trainees from the EEA and elsewhere has remained steady, with the exception of a peak in 2005 (Fig 4b) Figure 5a shows that foundation training, medicine and surgery are the main source of histopathology trainees, with the majority of recent trainees enrolling from foundation training. Figure 6a shows that most trainees are aiming for a career in general histopathology. Of those wishing to sub-specialise, a wide range of interests were stated, with forensic and dermatopathology being the most popular, and cytology the least popular (Fig 6b) “ The survey aimed to identify common features amongst histopathology trainees, with a view to aiding recruitment and lowering future attrition rates. ” Fig 1 Fig 2 “An increased prevalence of doctors entering histopathology from Foundation Training corresponds with the increasing number of younger trainees in the speciality, and reflects the importance of Foundation competencies during selection. ” 6 Suggested action from study: The attrition rate in histopathology training is low, and comparable to other specialities. 7 However, we believe a number of actions could be useful in reducing rate further. We feel that focusing on junior doctors prior to application would be useful, as trends indicate that numbers of post-Foundation trainees are likely to remain high. We suggest that more histopathology foundation rotation posts be created, and we feel that “taster days/weeks” would be beneficial. We suggest more focus on educating potential applicants at careers fairs and through development of the histopathology website. The provision of flexible training has now been improved. Fig 3 Fig 6 Fig 5 Fig 4 Section A: Section B: Section C: YearNo. SchoolsLocationsAppointments 20013Leeds, Leicester, Southampton18 20023Leeds, Leicester, Southampton18 20033Leeds, Leicester, Southampton24 20046Eastern, Leeds, Leicester, Newcastle, Southampton, West Midlands 43 200511Eastern, Leeds, Leicester, Newcastle, Southampton, West Midlands, Liverpool, Manchester, Oxford, South West, Thames 96 200612Eastern, Leeds, Leicester, Liverpool, Manchester, Newcastle, Oxford, Southampton, South West, Thames, West Midlands 51 200712Eastern, Leeds, Leicester, Newcastle, Southampton, West Midlands, Liverpool, Manchester, Oxford, South West, Thames, Wales 67 Fig 7 Figure 6b: Sub-Specialist Interests Figure 6a: Career Aspirations Trainees Sub-Speciality