Effect of sex on specialty training application outcomes: a longitudinal administrative data study of UK medical graduates

Background 

The proportion of men and women in different medical specialties varies greatly, with relatively more women in general practice (GP), paediatrics and obstetrics and gynaecology (O&G), and more men in surgery and radiology. This so-called sex segregation is the result of preferences and constraints, themselves influenced by experiences and gendered societal norms and expectations.1–8

Less is known about whether selection processes influence sex ratios in different specialties, either directly (if the methods used to select applicants show sex differences) or indirectly (if selection methods rely on other measures such as previous academic attainment that themselves show sex differences). For example, it is known that women generally do better on Situational Judgement Tests (SJTs)9 which are used in some specialty selection programmes in the UK, and they also have slightly higher medical school performance as judged by the Educational Performance Measure (EPM) used to select newly qualified doctors to UK Foundation Training.10 Understanding whether selection processes contribute to differences in the proportions of men and women in different specialties is important for effective workforce planning and the provision of future healthcare, and could influence efforts to reduce sex segregation in some specialties.

Relatively little published research addresses the potential influence of selection processes on outcomes. Studies and data tend to show either no sex differences, or women doing slightly better than men. In the UK, a 2013 evaluation of selection in five English regions into five specialties (core medical training, core surgical training, psychiatry, O&G and paediatrics), found women in the sample achieved higher scores in selection into core surgical training and psychiatry after adjusting for other demographic factors, with no significant sex differences in the other specialties.11 A 2016 evaluation of GP selection found women were more likely to be successful.12 A 2017 study of selection into general and vascular surgery found no effect of sex on selection scores.13 Publicly available Canadian Resident Matching Service data from 2017 showed female Canadian medical graduates were slightly more likely to be successfully matched to a surgical specialty, with no differences in other specialties.14 Similar data for the USA are not publicly available, but an historical analysis of data from 1987 found women were more likely to get their first choice of specialty and less likely not to be matched.15 More recent studies of radiology and anaesthesia residency selection found female applicants outperformed men.16 17

Research in this area may also help us understand other areas of stark sex differences in medicine, such as disciplinary action, where male doctors have nearly 2.5 times the odds of facing medicolegal action.18 Recent research has shown male UK medical graduates have increased odds of a fitness to practise (FtP) issue at medical school,19 and professionalism problems at medical school are known to predict later sanctions.20–22 It is also known that doctors from certain specialties are at higher risk of receiving sanctions.23 It is unknown however whether graduates with an FtP declaration may favour certain specialties.

The aims of this study are:

1. To measure sex differences in specialty applications, offers and acceptances.

2. To examine whether sex differences are present in specialty applications, offers and acceptances after controlling for previous academic attainment, and other potential confounders.

3. To examine whether medical school FtP declarations predict specialty choice, taking into account sex and prior academic attainment.

Methods

Results

Nearly three quarters of doctors (7634/10 559; 72.2%) had applied for specialty training. Of 22 specialties recorded, nine had 250+ applicants and 90+ acceptances: acute care common stem emergency medicine (ACCS EM), clinical radiology, core anaesthetics training, core medical training, core psychiatry training, core surgical training, GP, O&G and paediatrics. One hundred and seventy-three doctors had only applied to smaller specialties and were excluded from the analyses on the larger specialties.

Discussion

There were significant sex differences in the specialty applications of this sample of 10 559 UK medical graduates. Women were more likely to apply to GP, O&G and paediatrics, and men were more likely to apply to core surgical training, ACCS EM and clinical radiology. Women were more likely to receive an offer versus none, and to receive an offer in GP and paediatrics specifically. Women were more likely to accept an offer if they received one, and to accept an offer in GP specifically. Sex differences largely remained after controlling for prior academic attainment and having a FtP declaration, as well as medical school attended and other demographics. In the fully adjusted models, GP was the only specialty with significant sex differences at all three stages: applications, offers and acceptances; women being more likely to apply and to accept an offer, and also being more likely to be offered a place. Having an FtP declaration was a small predictor of not applying to specialty training, and of rejecting an offer across all specialties, although the large number of tests performed increases the possibility that this was due to type I error.

The raw sex differences in applications are consistent with previous research from the UK and other countries.2 3 15 26 30 Our finding that women were more likely than men to get an offer in GP selection, but not in selection for core surgical training reflects Davison and colleagues’ analysis of national data12 but differs from Thomas and colleagues’ analysis of a smaller subsample.11 To our knowledge this is the first study to assess sex differences in the likelihood of receiving and accepting an offer to specialty training after controlling for prior attainment, as well as controlling for medical school, other demographics and a measure of medical school professionalism. It is also the first that we know of to assess whether FtP issues at medical school predict specialty preferences and selection outcomes.

A considerable strength of the study is the large sample size (three quarters of all entrants to medical school from 2007 to 2008) and the longitudinal nature of the data, obtained from the UKMED. This made it possible to examine recruitment to nine different specialties in the UK. It also meant we could conduct multivariate analyses to understand whether sex segregation in some specialties is due to sex differences on the potential confounder of academic attainment, both prior to and during medical school. Because UKMED data are collected by the GMC as part of their statutory duty to regulate medical education in the UK, we did not have to rely on voluntary completion of surveys for data, unlike previous analyses.11

The study has some methodological weaknesses. We did not consider multiple applications or acceptances from multiple offers. Seventy per cent of doctors in our sample applied to one specialty only, and this did not differ by sex (p=0.77); however, it is likely that the number of multiple applications varies by specialty. For example, a previous study using the same dataset but looking only at GP applicants found that only 59% (vs 70%) made a single specialty training application; however, women were more likely to apply to GP after controlling for prior attainment and other demographics regardless of whether they had applied to multiple specialties or not.26 We also did not formally compare sex differences between specialties taking into account competition ratios, and we only analysed data from first applications. Since women were more likely to receive and accept and offer first time around, it is possible that men are more likely to apply a second time around, which may then influence the final proportions of men and women in different specialties. We combined applications across years, which meant we could not account for the possibility that different selection processes occurred during different application cycles. We did not look at potential interactions, for example between age and sex, or medical school and sex, which have been shown in other studies to influence specialty choice.25 31 Using administrative data rather than data collected for research purposes limited our ability to infer reasons for the sex differences observed. There were also considerable amounts of missing data on some variables, in particular because some of the cohorts within the sample had not taken a test, with multiple imputation used to avoid excluding large amounts of data. Our dataset was truncated because we could only include graduates who were eligible to apply to specialty training by 2015. The study findings are not generalisable outside of the UK.

This study suggests that sex differences in specialty applications and outcomes are driven largely by factors unmeasured in this study, and not by academic, other demographic or medical school differences. In terms of differential applications, previous research has shown that these factors are likely to include how ‘plannable’, technical and people-oriented a specialty is,2 the career prospects a specialty offers, a trainee’s domestic circumstances and their perceptions of their own ability and interests.32 There is also evidence that, while some specialties such as surgery and paediatrics show sex differences very early in medical school training,33 experiences during medical school and postgraduate training can influence specialty choices.12 34 This suggests that efforts to reduce sex segregation should focus on understanding and addressing medical career choice early on, as well as on understanding whether men and women have different experiences during training, and on removing any perceived or real barriers to career progression and enjoyment within sex-segregated specialties.

It is unclear why women were more likely to receive an offer, and to accept an offer compared with men. The sex differences in GP were the most striking of any of the nine largest specialties, and this itself requires more research to understand. It is important to note that sex differences in applications and acceptances are the result of doctors’ choices, which themselves are underpinned by sociological and educational factors; whereas sex differences in offers reflect the specialty selection processes. GP selection comprises written and face-to-face assessments, and potential sex differences on those assessments were not taken into account in our analysis of offers. Performance in GP selection has been found to predict subsequent performance in the Membership of the Royal College of General Practitioners exit examinations,35 in which women outperform men.36 37 As such, the relationship between sex differences in offers and sex differences within GP training also merits further exploration.

Conclusions

Sex differences in specialty applications, offers and acceptances result from factors other than prior academic attainment, medical school FtP declarations, medical school and other demographics. GP was the only specialty with significant sex differences in applications, offers and acceptances: women were more likely to apply; of those who applied, women were more likely to be offered a place; and of those offered a place, women were more likely to accept. Further research exploring the reasons underlying sex differences in applications and acceptances, as well as the differences in offers within GP and paediatrics, is important for future work place planning and equity.