Modernising Medical Careers has a lot to answer for. As a profession, we need to radically rethink how doctors with childcare responsibilities are supported to achieve their full potential
Health Secretary Jeremy Hunt has announced that he is “determined” to eliminate the gender pay gap in medicine, with the launch of an independent review to be led by Professor Jane Dacre, president of the Royal College of Physicians. This announcement is timely: the past few months have seen the UK’s gender pay gap laid bare via a steady stream of reports from all sectors, including the NHS.
In February, it was reported that full time women consultants earn on average £14 000 less a year than their male counterparts (a pay gap of 12%), and that just five of the top 100 earning consultants in the UK are women. Last year we learnt that female doctors working full time earned 34% less a year than male doctors. And that not only is the gender pay gap for Britain’s doctors significantly higher than for any other professional group, but that the gap has increased by almost 50% since 2006. Clearly, this is a complex issue, and it would be oversimplistic to blame childbirth and childcare alone for this disparity. However, as we await the outcome of the review, we need to acknowledge a painful truth: since the launch of Modernising Medical Careers (MMC) in 2005, it has become significantly harder for women with children to complete their training.
Our female predecessors fought hard for the rights of women to train as doctors. To retain credibility in a male dominated profession, they either coped with the demands of motherhood without complaint, or sacrificed family life for their careers. The same sacrifices cannot be expected of today’s growing female medical workforce. Yet the logistical difficulties posed by core and specialty training in the UK today cause many women to leave training when they have children, and to move into roles with a more limited scope for career or pay progression. Meanwhile, those women who manage to obtain the certificate of completion of training (CCT) as less than full time trainees find themselves lagging years behind their male colleagues in terms of pay progression—never quite being paid the same amount for performing the same job.
This is not to suggest that women cannot combine motherhood with a successful career in medicine: there have been inspirational women leading the way in every specialty for decades. Sadly, though, there are also many women who have found that juggling motherhood and medicine is incompatible with serious career success. This is borne out in the statistics: despite almost half of all UK doctors being female, there are disproportionately fewer women consultants, fewer women heads of department, and fewer women medical or clinical directors. Given that women have outnumbered men at medical school since the mid 1990s, this really should not be the case. Yet research in this area is lacking. Perhaps because the very people who are impacted by this inequality are working so hard to juggle their work and home lives, there is no opportunity—or energy—left over for the business of bringing about meaningful change.
We know that the restructuring of postgraduate medical training by MMC in 2005 had an immediate detrimental impact on women doctors. This was caused by a combination of factors, including rigidity in the applications process, and uncertainty about the location of future posts. Inflexibility in the allocation of appointments left some married couples working hundreds of miles apart and led to a reduction in applications to flexible training. The system was changed after the 2007 recruitment crisis, but the continued growth of the gender pay gap during the past decade indicates that the negative impact of MMC—with its centralised recruitment system and emphasis on competency based learning—has persisted.
There can also be little doubt that the geographical expansion of most medical training schemes in recent decades—due in part to MMC, but also due to changes in healthcare provision—has seen postgraduate training in the UK become more challenging for those with children. Take psychiatry: in 1971, the training scheme in Oxford comprised of 12 placements, of which 10 were in the city of Oxford and two were just outside the city. The same region today consists of 59 posts provided by five different NHS trusts across three different counties. No matter how supportive and understanding the head of school might be, with posts distributed across such a wide area, the practical difficulties associated with getting one’s child to and from school or nursery, and oneself to and from a regularly changing workplace that could be well over an hour from home, may easily seem insurmountable to the potential trainee.
Night shifts, on-call rotas, and Jeremy Hunt’s redefinition of unsociable hours create yet more challenges; how does one find reliable and affordable childcare outside of “normal working hours?” And, assuming that these basic logistical challenges can be overcome, how do trainees find the time to meet both their childcare responsibilities and the many non-clinical requirements of post MMC higher training schemes? To maintain their portfolio? To study for, and pass, exams? To complete audit, research, teaching, and appraisal? It should come as no surprise that many women choose to pause their training to take a specialty doctor post—one from which it may be surprisingly difficult, at a later date, to resume training. The limited opportunities for career development (following the closure, by MMC, of the associate specialist grade in 2008) and the lack of educational provision given to doctors in these roles is a waste of their talent, and is contributing to a nationwide shortage of consultants in many specialties, which is damaging the NHS.
So how do we tackle this inequality? We could begin by openly acknowledging and discussing the multiple logistical difficulties that many, often female, doctors with young children face. These issues are real and pressing. The GMC may have finally begun this conversation, but as a professional body we must do more. We need to question whether it is really essential for trainees—men and women—to move between posts that may be geographically distant from their homes and families. We need to shift away from traditional ideas about the acquisition of competencies and embrace new technology to enable trainees to learn closer to home. More challenging still is the need to bring about cultural change within our profession (and our society) so as to enable both parents to actively share in the logistics of parenting, rather than creating an environment where one partner as the “carer” works part time, while the other’s value is reduced to the role of “breadwinner.”
Secondly, we need to consider how we support all doctors, not just trainees, to reach their full potential. We need to proactively identify and support those specialty doctors who may wish to become consultants. Equivalency is at present a challenging and underused route to the specialist register. It is ironic that many doctors who are unable to complete higher training because of childcare responsibilities find themselves employed in these vital, labour intensive roles, providing essential frontline patient care and accumulating valuable clinical experience, but often without access to adequate supporting professional activity (SPA) time to enable them to complete their CESR portfolio, or the meaningful support of their local deanery. Specialty doctors should be offered as much support by their deaneries to obtain the CESR as their trainee colleagues are to obtain the CCT.
The gender pay gap in medicine is a complex, multifactorial problem. Resolving the challenges faced by doctors with young families, and providing meaningful development opportunities for specialty and associate specialist doctors, will not erase the pay gap completely, but it will go a long way towards doing so. If we are to protect our future medical workforce it is essential that we rethink medical training, so as to support all doctors with childcare responsibilities to achieve their full potential.
Gill Cresswell is a long term NHS locum consultant psychiatrist, and has just been awarded a CESR in old age psychiatry.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.