We summarise findings from surveys of graduates from UK medical schools over 31 years. Serial surveys have been undertaken in 1974, 1977, 1980, 1983, 1993, 1996, 1999, 2000 and 2002. Questionnaires were sent to 33,151 doctors; 24,621 (74.3%) replied. Three years after qualification, 70.8% replied to a second survey; 5-years after qualification, seven cohorts were re-surveyed.

Trauma and orthopaedic surgery was the first choice career for 5.0% (men) and 1.0% (women) 1 year after qualification, and 5.2% (men) and 0.8% (women) at 5 years. Of those with T&O as first choice, 35% who chose it in year one, 56% in year three, and 84% in year five were working in it eventually. Experience as a student or junior, self-appraisal of skills, a particular teacher and enthusiasm for the specialty were the most important influences.

There has been an increase in the percentage of women choosing surgical careers. However, the much higher percentage of men who choose T&O surgery remains striking. The specialty needs to consider whether this matters. Women currently comprise about 60% of the medical school intake in the UK.

This study shows that doctors who ultimately pursued a surgical career made that choice by year 3 (equivalent to ST1) and between 84-92% had settled on the specialty by year 5 (ST3). Career progression for this historical cohort did not require an early commitment and a greater decisiveness may be anticipated in the more expectant system of Modernising Medical Careers.

It is unknown whether recent working time directives will influence career choice. This study defines T&O doctors to be highly motivated by work and not influenced by long working hours or competing domestic demands. This low priority places the specialty at the bottom of comparative tables. A change in work-life balance may directly impact future specialty recruitment.

Our knowledge of the incidence of scoliosis and scoliosis surgery is based on a few small scale studies. The National Health Service (NHS) in the United Kingdom has long collected data on hospital based activity. We have used a five year English database (1998–2002) of hospital admission statistics to study age-adjusted admission rates for scoliosis (code M41 in the International Classification of Diseases, 10th revision) and for two scoliosis surgery codes (V41 ‘instrumental correction of deformity of spine’ and V42 ‘other correction of deformity of spine’ (the latter includes ‘anterolateral release of spine for correction of deformity’).

Results: Three thousand, seven hundred and eighty three patients (2533 females and 1240 males) aged 5–29 years had diagnosis M41 recorded over the five year sample period. Most of the patients were teenagers. 971 (males and females) of these had operation V41 and 1212 had V42, it is likely that the vast majority of these cases had idiopathic scoliosis. We made regional maps based on age-adjusted admission rates/100000 population. Admission rates varied from 5.75/100000 (95% confidence intervals x to y) in London to 2.8/100000 (x to y) in the Yorkshire-Humberside region.

Interpretation: There was wide geographical variation in admission rates. We considered 5 hypotheses:

Social deprivation – we were able to study this, and admission rates appeared independent of social deprivation.

Conclusion: There is wide variation in recorded rates of diagnosis and surgical treatment without obvious explanation. It might be possible to study clinical case notes, identified from the statistical database, to check whether variation is simply attributable to unreliability of coding. To determine whether there may be a genetic explanation for the geographical variation found by us, the possibility could be explored of comparing the scoliosis maps with other maps of genetic profiles of the English population.