In the United Kingdom, medical students typically undergo 5 years of undergraduate medical education, which may be extended if obtaining an additional degree during medical school, commonly known as an intercalated degree. Additionally, for those with previous degrees and pursuing a graduate-entry medical course, it generally spans 4 years. Following medical school, graduates enter the National Health Service’s (NHS) 2-year foundation program, exposing them to a variety of medical specialties. As specialty training commences immediately after the completion of the foundation program, those not intending to take a career break must apply to specialty training (also known as residency training) in the United Kingdom at the beginning of their second year of their career (Foundation Year 2). This underscores the early career decision-making required of medical graduates [1].

Postgraduate medical training in the United Kingdom follows 2 main pathways: “run-through” and “uncoupled” program. “Run-through” programs allow trainees to secure training posts from the outset and, subject to satisfactory progress, continue for the full duration of the program unencumbered by further application processes. Examples of run-through specialties include general practice, pediatrics, and ophthalmology. By contrast, “uncoupled” programs require trainees first to secure a training post at “core” level, in the broad specialty such as anesthetics, surgery, or internal medicine, and then again to enter “higher specialty training,” such as in cardiology or vascular surgery [2]. Notably, in the UK health care system, salary progression for doctors, whether in training or at the consultant level, is uniform across specialties. The primary factors that could influence the professional experience within the NHS are not solely the chosen specialty but include wildly variable aspects such as the duration of working hours, the intensity of the clinical environment, and the specific nature of clinical settings.

Since 2007, recruitment for much of specialty training in the United Kingdom has been centralized, using competitive national processes in which applicants are ranked according to various criteria [3]. Competition for specialty training in the United Kingdom is at an all-time high, having surged in recent years. In 2016, there were 20,044 applications for 10,671 posts aggregated across all specialties, conferring a ratio of 1.88 applications per post. By 2023, this ratio had risen to 3.37, with applications increasing by 249% while training places only grew by 183%. Some specialties, already renowned for being competitive have seen marked increases in their competition ratios. In neurosurgery, for example, the ratio climbed from 6.50 in 2016 to 12.75 in 2023. Meanwhile, even in specialties where the demand for services is exceedingly high—and rising—competition has intensified, with the ratio rising from 1.28 to 2.67 over the same period in general practice for instance [4]. Competition for residency training in the United Kingdom is set to worsen yet further, as the government announces plans to double medical school places by 2031/32 [5-8].

Medical students’ decisions may be influenced by their demographic backgrounds [9-13], experiences at medical school [14-16], and perceptions of the chosen specialty’s lifestyle, including work-life balance [17-19], financial incentives, and prestige [20]. External guidance from mentors [21] or family [22] and internal drivers, such as personal health experiences or the desire to serve particular patient demographics, also contribute to this complex decision-making process [22]. Although there have been international studies exploring which specialties resident doctors or medical students intend on pursuing and factors affecting these decisions [14,23-27], UK studies focused on why individuals are attracted to pursuing one specialty, and studies exploring which factors attract them to one specific specialty [28-44], there is currently a lack of broad, high-powered studies investigating the choice of specialty among UK medical students of all year groups and the factors influencing this preference.

Recently, we conducted the largest UK medical student study—the (Ascertaining the Career Intentions of UK Medical Students (AIMS) study—which investigated medical students career intentions and demonstrated that a noteworthy 35% of medical students intend to leave the NHS within 2 years of graduation [45,46]. Among our findings, we identified that a majority of medical students were dissatisfied with several aspects of residency training in the United Kingdom, including the cost of training, the rotational aspect of training, the ease of entry into a specialty training program, and the length and standard of training. This highlights the need to better understand medical students’ views, concerns, and expectations of specialty training in the United Kingdom.

We previously explored the role of medical schools in mitigating the current trends of medical students intending to leave the NHS. This work emphasized the importance of understanding and developing strategies within medical education to retain future doctors in the UK health care system. It also raised critical questions about the influence of medical school experiences, mentorship, and curricular design on career decisions [7,47].

The Factors Affecting Specialty Training Preference Among UK Medical Students (FAST) study seeks to understand the factors influencing specialty training choices among UK medical students. By examining these determinants across all student year groups, the study seeks to inform policy and educational strategies to better align training opportunities with the expectations and needs of the future medical workforce.

Following study completion, it is intended that results will be presented at local, regional, national, and international conferences. In addition, the results will be disseminated via publication in a peer-reviewed medical journal. All collaborators will be given PubMed-citable collaborative coauthorship under the institutional name: the FAST Collaborative. We will have a hybrid authorship list of named authors and the institutional collaborative.

Following study completion, medical school collaborators will be able to request their institution-specific data and the analysis performed on said data from the FAST steering committee. These data will be anonymized. The fully anonymized data set will be made publicly available.

Data collection is currently underway, with the study being launched nationally on December 4, 2023. Data collection will close on March 1, 2024, and data analysis will commence. The results are expected to be available later in the year.

The FAST study anticipates significant variability in specialty preferences among medical students, influenced by the wide array of factors being explored in this investigation. Personal interests, prior experiences, and perceptions of the lifestyle conferred by pursuing different specialties are anticipated to be highly influential. We hypothesize that demographic factors, including gender, ethnicity, socioeconomic background, and geographical location, will also play a significant role in shaping specialty preferences. In addition, medical school experiences, such as teaching quality and clinical exposure, are expected to strongly influence students’ decisions regarding specialty training. The role of mentorship is predicted to impact specialty choice in a similar fashion. Other factors, including personal health experiences may also influence some students, while awareness of specialty training opportunities and current health care trends could shape students’ perceptions of certain specialties. Furthermore, we predict that knowledge of specialty pathways, application processes, and portfolio quality will increase as students progress through medical school, thus, leading to more informed decisions relating to specialization.

Although this study is centered on the UK health care system, the insights derived will have broader implications. The challenges and decision-making processes—and their associated challenges—faced by UK medical students are not unique to the NHS and often reflect wider global trends in medical education. For instance, factors influencing specialty choice, such as work-life balance and financial considerations, have been highlighted as also significant among medics in other health care systems [49-65]. This study’s findings can, therefore, offer valuable perspectives to international audiences, serving as a reference point for similar research conducted in other countries. Moreover, the detailed exploration of the UK system may help other nations identify and address similar challenges within their own medical education frameworks.

The FAST study is poised to provide a comprehensive examination of the factors influencing UK medical students’ preferred medical specialties. The strategic focus on a broad spectrum of elements, from work-life balance to mentorship, will yield critical insights valuable for educational institutions and policy makers in understanding the determinants of specialty selection. Furthermore, by incorporating a wide-ranging demographic profile, this study aims to discern patterns and potential inequities in the specialty choice process, affording a detailed perspective on how students’ different backgrounds might steer career trajectories within the medical field. Additionally, the study’s inclusive approach, encompassing students from all year groups and UK medical schools, will help to create a robust and diverse data set: one which offers a more accurate cross-section of the current student body and enhances the generalizability of the findings.

It is important to note the potential limitations of the FAST study. As with many cross-sectional studies, the FAST study’s main limitation is its snapshot view, which precludes tracking changes in students’ preferences and influencing factors over time. There is also the potential for selection bias, where students with certainty regarding their specialty training choices or strong opinions about factors influencing their decision-making may be more inclined to participate. Therefore, this could unintentionally exclude some students who are in the process of making these decisions. To address this, the study’s distribution strategy is extensive, involving a variety of channels and touchpoints to encourage a balanced response rate across the student population. The survey was also explicitly designed to be inclusive of those whose future specialty is uncertain. Recruitment and engagement challenges could also pose a risk to achieving a truly representative sample. Acknowledging this, extensive efforts are being made to secure a comprehensive and representative collaborator network to support student outreach. Finally, the survey design could restrict the depth of insights obtainable from predefined responses. However, the iterative process used during the extensive preparatory phase involving peer review and expert consultation, along with the provision for free-text responses, will ensure a rich and nuanced collection of data pertinent to specialty training choices.

The FAST study endeavors not only to inform but also stimulate strategic improvements in the way medical education is structured and how future doctors are supported with making decisions about their career. Insights gained could drive initiatives aimed at increasing the appeal of less popular specialties, improving mentorship programs, and refining the career guidance offered to medical students. These actions could potentially mitigate the specialty imbalances and contribute to a more even distribution of medical professionals across the health care system and increase retention rates of medical graduates in the NHS by providing a stronger sense of identity through specialty interest [7].

By capturing the preferences and perceptions of the future workforce, the FAST study will support the broader objective of establishing a regular, comprehensive survey of UK medical students, akin to a workforce census. This initiative could aid the government and educational authorities in their workforce planning strategies, ultimately fostering a more satisfied, fulfilled, and well-distributed medical workforce.