Background
Methods
Sample
Qualitative and quantitative phases
Data collection and analysis
Results
Quantitative
Participant characteristics and migration intentions
Definitely stay | Probably stay | Undecided | Probably leave | Definitely leave | Total |
P
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n
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Sex | ||||||||||||||
Female | 47 | 20 | 93 | 39 | 45 | 19 | 34 | 14 | 21 | 9 | 240 | 100 | ||
Male | 29 | 17 | 62 | 36 | 44 | 26 | 19 | 11 | 17 | 10 | 171 | 100 | 0.454 | |
Age | ||||||||||||||
Mean (IQR) | 32.4 | (29–35) | 33 | (30–35) | 32.4 | (29–34) | 32.9 | (30–37) | 32.3 | (30–35) | 32.7 | (30–35) | ||
0– | 20 | 20 | 38 | 38 | 24 | 24 | 11 | 11 | 7 | 7 | 100 | 100 | ||
30– | 33 | 17 | 67 | 35 | 43 | 23 | 27 | 14 | 21 | 11 | 191 | 100 | 0.804 | |
35– | 24 | 20 | 51 | 42 | 21 | 17 | 15 | 12 | 10 | 8 | 121 | 100 | ||
Entry routea
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DEM | 48 | 20 | 101 | 41 | 47 | 19 | 28 | 11 | 20 | 8 | 244 | 100 | ||
GEM | 12 | 17 | 26 | 36 | 20 | 28 | 7 | 10 | 7 | 10 | 72 | 100 | 0.531 | |
Non-EU fees | 4 | 12 | 11 | 33 | 8 | 24 | 4 | 12 | 6 | 18 | 33 | 100 | ||
Employment status | ||||||||||||||
Private/otherb
| 20 | 27 | 33 | 44 | 11 | 15 | 8 | 11 | 3 | 4 | 75 | 100 | ||
Public | 58 | 17 | 125 | 36 | 81 | 23 | 45 | 13 | 36 | 10 | 345 | 100 | 0.051 | |
Happy with work-life balance | ||||||||||||||
No | 20 | 11 | 56 | 31 | 54 | 30 | 28 | 16 | 22 | 12 | 180 | 100 | ||
Yes | 58 | 24 | 102 | 42 | 39 | 16 | 25 | 10 | 17 | 7 | 241 | 100 | <0.001 | |
Relationship status | ||||||||||||||
Married | 39 | 20 | 70 | 36 | 39 | 20 | 29 | 15 | 17 | 9 | 194 | 100 | ||
Other | 38 | 17 | 86 | 39 | 50 | 23 | 24 | 11 | 21 | 10 | 219 | 100 | 0.662 | |
Children | ||||||||||||||
No | 47 | 18 | 97 | 36 | 59 | 22 | 36 | 14 | 27 | 10 | 266 | 100 | ||
Yes | 30 | 21 | 58 | 40 | 28 | 19 | 17 | 12 | 11 | 8 | 144 | 100 | 0.729 | |
Current gradec
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SHO | 14 | 21 | 23 | 34 | 16 | 24 | 8 | 12 | 7 | 10 | 68 | 100 | ||
Registrar | 19 | 22 | 28 | 32 | 18 | 21 | 14 | 16 | 8 | 9 | 87 | 100 | ||
GP trainee | 6 | 16 | 15 | 39 | 13 | 34 | 2 | 5 | 2 | 5 | 38 | 100 | ||
SpR | 19 | 13 | 66 | 44 | 32 | 21 | 20 | 13 | 13 | 9 | 150 | 100 | 0.191 | |
GP | 9 | 18 | 21 | 41 | 12 | 24 | 5 | 10 | 4 | 8 | 51 | 100 | ||
Consultant | 10 | 42 | 6 | 25 | 2 | 8 | 2 | 8 | 4 | 17 | 24 | 100 | ||
Other | 1 | 33 | 0 | 0 | 0 | 0 | 1 | 33 | 1 | 33 | 3 | 100 | ||
Bullied in Ireland | ||||||||||||||
No | 34 | 22 | 60 | 39 | 33 | 22 | 15 | 10 | 10 | 7 | 152 | 100 | ||
Yes | 44 | 16 | 99 | 37 | 60 | 22 | 38 | 14 | 29 | 11 | 270 | 100 | 0.253 | |
Return to Ireland | ||||||||||||||
Likely | 86 | 84 | 60 | 68 | 32 | 60 | 20 | 51 | 198 | 70 | ||||
Unlikely | 17 | 17 | 28 | 32 | 21 | 40 | 19 | 49 | 85 | 30 | < 0.001 |
Factors influencing decision to leave
Univariable | Multivariable | |||||
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OR | 95% CI | LRT | OR | 95% CI | LRT | |
Happy with current work-life balance | ||||||
Yes | 1.00 | – | 1.00 | – | ||
No | 2.51 | 1.53–4.10 | < 0.001 | 2.51 | 1.53–4.10 | < 0.001 |
Univariable | Multivariable | |||||
---|---|---|---|---|---|---|
OR | 95% CI | LRT | OR | 95% CI | LRT | |
Quality of training available here is poor | ||||||
Disagree | 1.00 | – | 1.00 | – | ||
Agree | 1.82 | 1.09–3.02 | 0.021 | 1.82 | 1.09–3.05 | 0.022 |
Leave for family/ personal reasons | ||||||
Disagree | 1.00 | – | 1.00 | – | ||
Agree | 1.80 | 1.06–3.06 | 0.031 | 1.85 | 1.08–3.17 | 0.027 |
Supervision of training inadequate | ||||||
Disagree | 1.00 | – | – | – | – | |
Agree | 1.79 | 1.07–2.98 | 0.025 | – | – | – |
Qualitative
Lack of consultant supervisors
Definitely there wasn’t enough supervision. You’d need more consultants just for simple stuff. You’d know that you were able to do something but you just want somebody to say that you're doing it right. (Participant 42).
There aren’t enough consultants to actually watch you doing everything that they should be watching you doing and making sure that you’re doing everything right all the time. So you don’t get supervised as much as you should do really. (Participant 45).
But I think that there’s a lot of trainees then that are a bit more cautious, and they would end up with less in their log book at the end of the year because, you know, they’d be looking for more support to do an operation and because of manpower issues, ….that might mean they miss out on doing the case altogether because the consultant would say ‘okay, you stay here and do this simple thing and I’ll do the complex thing’. (Participant 28)
The stress associated with lack of supervision during training
So I was receiving acute patients in the ED (emergency department)… a week after being an intern. I can tell you without fear of contradiction that I wasn’t ready for that. You can make the argument that nothing makes you ready for that, but I certainly hadn’t had any sort of graduated exposure to the setting or guidelines or supervised performance…. (Participant 37)
Several participants contrasted the supervised environment in other jurisdictions to the lack of supervision and accessible consultants in Ireland.You kind of learn by pure panic… you just work it out and then you’ve done it and you know the next time. But the first time you have to do something and you don’t have that support, it’s quite scary (Participant 14)
Some contrasted the benefits of supervision in the UK with training in Ireland which gave doctors a strong sense of capability, albeit while sometimes practicing on a knife-edge.In the UK, there’s a lot more emphasis on being shown how to do something before being let off to do it. Whereas here a lot of the time, especially in surgery, it’s kind of like either you’re happy to do it by yourself unsupervised or else you don’t get to do it because the consultant will do it just because of the time pressure. (Participant 28)
I know in the UK you're much more supervised and you progress a lot more slowly and in a much more controlled fashion. But I suspect that when you come to the end of your training you might not feel as capable as you do here because you’ve had to manage difficult situations on your own, from quite early on, which is kind of dangerous. (Participant 14)
Certainly trainees here [UK] are supervised almost all of the time and it’s only really when they're on a night shift for eight hours that they actually get the chance to run a department by themselves. I suppose we got to take responsibility a bit sooner than they would. (Participant 42)
Service provision overrides training
Often described as ad hoc and arbitrary, training also depended on the attitude of individual consultant-trainers.When I got onto a training scheme … I expected the college to be more interested in training and I suppose overall I feel the priority most of the time is . . . service provision (Participant 1).
It just seems like that, that there’s no clear structure to it, that it’s hit or miss, that it’s very dependent on the site and on the consultant that you’d be training with. (Participant 18)
Lack of structure in training
One of the consequences of the lack of clearly structured training schemes was the lack of clear and predictable career pathways:There’s more formal and structured training available in the UK than you can get in Ireland… it’s very ad hoc here and if you’re not in the right job, working for the right person, you mightn’t get much out of it. (Participant 34)
It is about structure and career path and creating more clear progression on the way up and creating more streamlined training. (Participant 32)
Family personal reasons
I’d prefer to stay, mainly for family reasons. …… And I suppose here is where home is and where family is. (Participant 15)
However, several participants felt that the structure of higher specialist training had a disruptive effect on their lives outside of work and was a key factor in the decision among some doctors to train and practice abroad. Postgraduate medical training involves rotations through different hospitals across the country and many participants highlighted how trainees were often assigned jobs without consideration for practical issues, such as organising accommodation. Participant 40 described the need to relocate frequently as “constantly uprooting your life”. Participant 11 described the difficulty of rotations when one has a family:It’s all based on my personal life rather than anything else. So family, I suppose as they get older, and friends and, you know, a realisation that the job is just a job. (Participant 16)
The financial strain of rotating around the country was noted by several trainee doctors. Some compared specialist training in Ireland with countries such as the UK and Australia where trainees could remain in one hospital or metropolitan area for the duration of training. The impact of the rotation system was noted by some as a major disincentive for doctors with young families or those who were planning families to remain in Ireland.Like moving around over here, when you’re married and you have a family to look after. So our allocations are designed in a way that you’re allocated in one hospital for six months, so you change from one hospital to another every now and then….You hardly settle in one hospital and then you have to move on. And that, in a way, affects your family life. (Participant 11)
If people knew that their families were protected, I think you’d get a lot people who’d be much more willing to engage in training programmes in Ireland… [Rotations are] disruptive on the family. (Participant 43)