Keywords
medical students - speciality preference - influencing factors - clerkship
Introduction
Medical education is an ongoing process that starts with medical school and progresses
to specialization and subspecialization. Henceforth, in the early stages of medical
education, medical students get exposed to a wide range of specialties. This exposure
serves as the building block for students' future specialization direction. Despite
this fact, even medical school applicants often have strong preferences for or against
medical specialty.[1]
These preferences have a significant impact on several important determinants of the
healthcare services,[2] as medical graduates are a valuable part of the healthcare system, and they determine
the medical workforce.[3]
To date, factors that play a role in career preferences are partially understood,
which can affect career choice before, during, and after medical school.[2] Factors that were identified in the previous studies showed that “medical school
characteristics, personal interactions, and lifestyle preferences” are important factors
that influence the students' choices.[4] Moreover, the clinical experience helps students to construct their professional
identity and influence specialty choices in terms of views and approaches.[4] Therefore, understanding the student's views and directions by defining the factors
that influence career choice is important to anticipate whether those views fit the
expected demand for healthcare services and to use it in the process of policy implication
to manage the number of specialties, especially in a current situation related to
severe acute respiratory syndrome coronavirus 2 pandemic related shortage in qualified
healthcare workers.[3]
[4]
[5]
Health Authority of Abu Dhabi, United Arab Emirates (UAE), reported in 2013 an expected
need of 2000 doctors and over 5000 nurses by 2022, which translates into 1500 doctors
and over 2000 nurses to be recruited annually. Yet, these figures are not reflective
of the new reality post-coronavirus disease 2019 pandemic. The main gaps in specialties
like critical care medicine, emergency medicine, neonatology, pediatrics, oncology,
and orthopaedics.[6]
The matching system in the UAE follows a similar pattern to the matching system in
North America, in which students must take a medical licensing exam “Emirates Medical
Residency Entrance Examination (EMREE).”[6] The exam is usually taken by intern house officer physicians during their intern
year.[2] After passing the exam, students can apply to the residency match under one of three
governing bodies Department of Health that oversees the training in the emirate of
Abu Dhabi, Dubai Academic Health Corporation that oversees the training in the emirate
of Dubai, and Emirates Health Services that oversees the training in the norther emirates.[6] With most of the governing bodies awarding Arab Board of Health Specializations
degree upon completion of training and successfully passing the required exams.[6] Overall due to limited training seats getting into medical residency is quite competitive
in the UAE, with surgical specialities being more competitive.[6] The exact number of seats per specialty varies per year, but with an overall all
estimate of around 59 seats in pediatrics, 55 seats in internal medicine, 39 seats
in emergency medicine, and 17 seats in general surgery, with other specialities having
a smaller number of seats.[6]
A recent study in the UAE by Abdulrahman et al showed that students' career choices
included internal medicine, surgery, and emergency medicine. Students reported factors
such as intellectual satisfaction, work–life balance, secure future, and easier to
find a resident position as the main reasons to choose a specialty.[5]
A plethora of evidence pinpointed factors affecting medical students' career choices.
Yet, unfortunately, there are not enough studies that explore the factors that affect
the career preference for medical students in the region in general. Therefore, this
study aimed to identify factors affecting the selection of future specialty among
medical students. Such outcomes would help students and mentors utilize while choosing
or enrolling in residency training programs in areas where such information is scarce.
Also, outcomes would be of value to decision-makers given the expected rise in demand
for medical specialists due to pandemic related stress on the health system and the
increase in population number.
Methods
Study Population and Design
Data were collected using a cross-sectional study design. A self-administered questionnaire
was distributed among medical students enrolled in years 1 to 5 at the College of
Medicine during the academic year 2014 to 2015. The total number of medical students
enrolled at our institution was 517 medical students; a minimum of 226 subjects was
targeted to achieve statistical significance with a confidence interval (CI) of 95%
and a margin of error of 5%. All the subjects were interviewed, questions were explained
to all the students included in the study, anonymity was assured, and their participation
was voluntary.
Study Instrument
Data was collected through a self-administered questionnaire developed after a comprehensive
review of relevant topics in the literature and using different questionnaires from
previous studies.[2]
[7]
[8]
[9] The survey was developed in English by two experts in medical education and internally
validated in a pilot survey of a randomly selected small group of students from the
total student population of the college.
The questionnaire consisted of 43 questions divided into three sections. The first
section determined the sociodemographic characteristics of the participant. In the
second section, the participant had to choose the three most preferred specialties
from 14 specialties which included: general medicine/family medicine, internal medicine
subspecialties, surgery, pediatrics, obstetrics and gynecology, psychiatry, anesthesia,
emergency medicine, dermatology, orthopaedic surgery, ophthalmology, otorhinolaryngology
(ENT), urology, radiology, and basic science. In addition, a separate group of ''other''
specialties was constructed to include subjects like neurosurgery and forensic medicine.
This list was chosen based on the popularity of listed specialties in clerkship and
elective rotations. Certain subspecialties were not included in the study as the subspecialty
choice is made after finishing the residency in major specialties. The third section
provided 30 factors that the participant had to evaluate the degree to which the factors
influenced their specialty choice on a 5-point Likert scale (1= Not at all influential,
2= slightly influential, 3= somewhat influential, 4= very influential, and 5= extremely
influential); these factors covered the characteristics of specialty, the personal
experience, the experience during clerkship, advice from others, and considering future
work condition. The 5-point scale was collapsed to a 3-point scale (Not at all influential,
Somewhat influential, Influential) during the analysis of the data to represent the
percentage of students' responses graphically.
The questionnaire included two additional questions about how satisfied the students
are with the opportunity provided during the medical college to explore potential
career choice and about the need for career counseling in the process of choosing
the specialty before starting the residency after completion of undergraduate studies.
These two questions were added to assess the student's satisfaction with the medical
curriculum to explore the future career choice and how much they are motivated to
attend a session for career counseling for choosing the specialty.
The questionnaire included a consent form on the first page that the participants
read and signed voluntarily without undue influence before answering any of the questions.
The consent included the title of the study, brief information about the research,
the name of the principal investigators, and their contact details. In addition, ethical
approval from the University of Sharjah ethics committee was obtained prior to starting
the study.
Data Analyses
Data were entered into a database and analyzed using the Statistical Package for Social
Sciences (SPSS) version 22. The 5-point Likert scale was collapsed into three categories
(not at all influential, somewhat influential, and influential). After data entry,
frequencies and percentages were computed. The chi-squared test was used to assess
the association between specialty choices and the sociodemographic characteristics,
academic characteristics, gender, and influential factors of the participants. It
was also used to assess the significance of the factors in relation to the first chosen
specialties individually. A two-tailed p-value of 0.05 is the cutoff value for significance. To ensure data confidentiality,
data was saved on a password-protected external USB drive accessible only to the primary
investigators.
Results
The total response rate was 391 out of 517 students, around 75.6% of the total population
agreed to participate. Females represented 61.4% of the respondents, while males represented
38.6% ([Supplementary Table S1], available in the online version). Students at the preclerkship level represented
70.80%, and clinical clerkship turnout was 29.20%. The mean age of the study population
was 20.7 ranging from 18 to 25 years old ([Supplementary Table S2], available in the online version).
The most preferred specialties included surgery 30.3%, internal medicine 22.7%, and
pediatrics 15%. Meanwhile, ENT and urology were the least selected and only chosen
by 0.2% as their preferred specialty. No one has selected anesthesia as a preferred
specialty ([Fig. 1]).
Fig. 1 Speciality preference among medical students, n = 391.
In our study, students who chose surgery were influenced by factors such as memorable
experience at clinical rotation, followed by an interest in the surgical procedures
and technologies, 78.8 and 77%, respectively. Another factor is a comfortable atmosphere
at the specialty department (68.8%).
On the one hand, the preferred specialties have a statistically significant difference
between male and female medical students (p-value < 0.0005); males were mainly interested in specialties like orthopaedics (69.2%)
and ophthalmology (52.6%). While females showed interest in dermatology (92%) and
pediatrics (87.3%) ([Table 1]), the percentage of males who chose surgery is almost two times that of females;
41.6 and 23.3%, respectively. It is worth mentioning that internal medicine was chosen
equally by both genders ([Fig. 2]).
Table 1
Factors influencing specialty preference to have a significant difference between
male and female students
|
Factors affecting the career choice
|
Male
|
Female
|
|
|
Not at all influential
|
Somewhat influential
|
Influential
|
Not at all influential
|
Somewhat influential
|
Influential
|
p-Value
|
|
Interest in the targeted population (e.g., children, the elderly)
|
32.50%
|
36.90%
|
30.60%
|
20%
|
29.40%
|
50.60%
|
>0.0005
|
|
Expected high income
|
25.60%
|
29.50%
|
44.90%
|
37.20%
|
31.20%
|
31.60%
|
0.013
|
|
Highly respected in society/good social life
|
15.60%
|
26.30%
|
58.10%
|
26.50%
|
24.90%
|
48.60%
|
0.031
|
|
Not interested to have a direct interaction with patients (in following up)
|
48.70%
|
25.90%
|
25.30%
|
62.50%
|
20.20%
|
17.40%
|
0.022
|
Fig. 2 Medical student's future career preference by gender, n = 391.
On the other hand, there was no association between preclerkship and clerkship students'
career choices (p-value = 0.226). Association between year allocation, whether basic medical sciences
(years 1-3) or clinical sciences (years 4-5), seems to impact students' preferences
(p-value = 0.014). Students reported that experiencing satisfactory patient treatment
outcomes in the specialty would affect their choice 72.9% of the time. Students who
chose surgery were influenced by factors such as memorable experiences at clinical
rotation, followed by an interest in surgical procedures and technologies, 78.8 and
77%, respectively. Another factor is the comfortable atmosphere in the specialty department
(68.8%). Other factors, such as the perceived skills required for a particular specialty
(67.3%) and the prospect for further field development (61.4%), were also considered
during decision-making. Other factors reported to have some influence included recommendations
from friends and family influenced career choice in 19.9%, loss of interest to have
direct interaction with patients in 20.4%, and the span of working hours in 26.4%
([Fig. 3]).
Fig. 3 Factors influencing specialty preferences among medical students, n = 391.
Generally, both genders leaned towards specialties with higher income rates and viewed
it as an influential factor while choosing their training with a CI of 40.15 to 49.65
for males and 27.16 to 36.04 for females, and the p-value was 0.013. Meanwhile, the targeted population who would receive medical services
also played a major role during the training selection process, particularly for females
with a 95% CI of 45.82 to 55.38, whereas a lesser degree of males 95% CI of 26.2 to
35 viewed the end-user served population would affect their specialty selection, p > 0.0005. On the same note, both genders cited lesser interest regarding direct interactions
or follow-ups with patients post services, with a p-value of 0.022. In addition, perceived views about specialties in terms of respect
and social acceptance, and work/life balance played a lesser role while the specialty
choosing process with approximately 25.6%, p-value of 0.031.
Role models influenced 46% of the students included in our study. Moreover, 91.6%
of the students were interested in attending a specialty counseling workshop before
starting the residency and after completing undergraduate studies, while 8.4% were
not interested in such an activity. Furthermore, students' satisfaction with opportunities
for guidance toward potential career choices during undergraduate medical studies
and training showed that 22.8% were satisfied, and 47.7 and 29.5% were neutral and
dissatisfied, respectively.
Discussion
Factors influencing a medical students' future career choice vary with culture, personal
experience, and progression through the medical school curriculum. Knowledge of such
factors aid decision-makers and other stakeholders in planning for a given country's
future medical workforce. [Fig. 4] shows a thematic map of the identified factors. With limited training spots and
an increasing number of medical graduates, hence increasing competitiveness of the
selection process, factors that affect medical student's career choice play a pivotal
role in the future of any healthcare system. With a recent decree in the UAE that
application to training is only allowed up to 4 years after graduation from medical
school, medical students' specialty choice is time critical. This study showed a similar
trend to other gulf countries regarding medical students' career preference, as the
most preferred specialties were surgery, internal medicine, and paediatrics.[8]
Fig. 4 Thematic map of factors influencing specialty preferences among medical students.
Previous reports showed that the vast majority of students showed interest in internal
medicine, surgery, emergency medicine and critical care, and family medicine as their
specialty of choice.[7]
[8]
[10]
[11]
[12] A similar trend was seen globally in resource-rich and resource-poor countries,
including KSA, Kuwait, Japan, Canada, Greece, Sudan, and Jordan.[7]
[8]
[10]
[11]
[12] Henceforth, medical students in the UAE show similar career preferences to their
peers in other parts of the world. This can be attributed to students' exposure during
clinical and preclinical years in these specialties.
Our results advocate similar findings of previous studies done in Jordan and Sudan.[10]
[11] In the gulf region, surgery was reported as the most preferred future specialty
by medical students, similar to our results, as surgery was also the most preferred
specialty within both genders.[1]
[2]
[8] Furthermore, worldwide surgery was listed in the top three selected specialties.[4]
[7]
[12] This finding can be explained by the opportunity to perform practical procedures
and operations during clerkship in surgical versus nonsurgical specialties.
The above can be further explained via other factors. In our study, students who chose
surgery were influenced by factors such as memorable experiences at clinical rotation,
followed by an interest in surgical procedures and technologies. These factors show
that the opportunity to perform practical procedures and operations is an important
factor that makes students like surgery a future career choice. Another factor is
the comfortable atmosphere in the specialty department. This all adds up to the principle
of exposure, which indicates that exposure to the medical field can have a role in
building interest in the specialty.
Furthermore, role models can affect and impact students' choices, whether to choose
a specialty or to drive away from a particular specialty. The role model can be a
parent or other relative, personal physician, family friend, or even a medical school
faculty member. In most studies, relatives' or seniors' advice played a major role
in the specialty choice.[2]
[11]
[12] However, this was not seen in our study. Students instead were influenced by treatment
outcomes expectations in the specialty itself (e.g., critical care medicine compared
to pediatrics), specialty compatibility, and field development. However, Alawad et
al, in 2015, reported that 46% (n = 887) of their cohort had role models from their families as an impactful reason
for their preferred specialty choice and information.[10] Other than this, memorable experiences during clerkship rotations influenced students'
career preferences, which indicate that exposure to the medical field can have a role
in building an interest in the speciality.[10]
Anesthesia was the least selected specialty, which is consistent with other studies
done in the Kingdom of Saudi Arabia. This can be explained by students' minimal exposure
to anesthesiology, which in turn is attributed to the low weight in students' curriculum
compared to other specialties.[1] Another reason could be a lack of awareness about the clinical responsibilities
the specialty encompasses and possible underrepresentation in social media and TV
shows.[2]
An association between gender and specialty choice was found in our study. Khader
et al, in 2008, found that the most preferred specialty among male students was surgery,
followed by internal medicine and orthopaedics, while the most preferred by female
students was obstetrics and gynecology, followed by pediatrics and surgery.[11] However, in our study surgery was the most preferred specialty by both genders.
The percentage of males is almost two times that of females, while females were five
times more likely to choose pediatrics than males; these findings align with Alawad
et al findings from Sudan.[10]
An interesting observation by Zolaly et al, in 2013, reported marital status for females
as a factor in future specialty preference, while this was not a factor in their male
counterparts, which reported work achievement-derived career choices in males.[13]
The gender ratio seems to have contributed to our final results as the majority of
respondents were females, despite the fact that pediatrics was chosen as one of the
most preferred specialties overall. Similarly, this was seen in the study conducted
in Kuwait, where their gender ratio was (57.1%: 42.9%), and pediatrics was their first
preferred specialty.[8] Bittaye et al, in 2012, findings showed that career preference might vary according
to gender, similar to our study findings. In contrast, factors such as residency program
duration and lack of subspecialists in the field of interest had the same impact.
On one hand in our study, expected income and targeted population under services (children,
elderly, males or females, for example) had a significant impact on students' decision
during the selection process of a preferred specialty, on the other hand Bittaye et
al 2012 findings did not show a similar trend.
Although there was no follow-up for the student during their medical years, the results
showed that the specialty preferences differed across years of study. Yet, based on
Abdulrahman et al,[5] findings can help elucidate a trend in the country. Our result showed a trend to
select surgery in the first, second, and fifth year, while internal medicine in the
third and fourth years. This finding agrees with the fact that exposure to different
fields through undergraduate medical studies changes the students' perception of the
specialties and develops within the students some feeling for or against different
specialties, which was found in previous studies.[11]
[12]
[14] Yet it is worth mentioning that a significant association was found between progress
through medical school (basic sciences phase compared to clinical sciences), p-value = 0.014.
The additional questions responses showed the students' interest in attending a workshop
on career counseling before starting the residency and after completion of their undergraduate
studies. This reflects the need to provide support to the students, which will help
them to determine the best way for them in the residency program and help to distribute
the future students with regard to their abilities and interest in the fields that
have capacity gaps. This is compatible with what was found in the previous studies.
Therefore, we recommend the establishment of a career counseling department in the
college and providing sessions of career counseling during medical education.[2]
[7]
[15]
Limitations and Future Plans
The limitations of the study are as follows: first, the study was conducted in one
institution and would not fully reflect the national trend, yet this was compensated
for as there was a previous study done locally a few years earlier and was used as
a baseline to compare for trends changes in specialty preferences among medical students
and an indirect way to follow up students. In addition, the study tool was only internally
validated via a pilot study at our institution. Furthermore, there were few double-barreled
questions in the survey that might obscure the respondents' true intentions. Our study
did not investigate medical students' summer electives as a factor in specialty selection,
which can be done in future studies. The results might have been skewed by the number
of nonrespondents despite a good response rate; this could have been further investigated
by sensitivity analysis of respondents versus nonrespondents. We also recommend career
counseling not only to senior students but rather across the board to all medical
students in a periodic manner, as well as prospects of research in the fields of interest
as a factor in future specialty decisions. In addition, doing a prospective cohort
study to look at the same group of students' interests and factors that might affect
their specialty choice can give another perspective on confounding factors.
Conclusion
Surgery and internal medicine were preferred specialties by both genders. Significant
gender differences existed in specialty choices among students that were attributed
to factors like future prospects, income, served population, treatment outcomes, and
possessing the right abilities needed for training. Lack of exposure and knowledge
of certain specialties were among the reasons for the lack of interest in some specialties.
Career counseling and elective training in specialties of interest can help medical
students ascertain their perspective desired specialties.
