2014, 36: 1064–1072
What factors influence British medical students’ career intentions? MICHAEL IBRAHIM, ANGELA FANSHAWE, VANASH PATEL, KARAN GOSWAMI, GEOFFREY CHILVERS, MICHELLE TING, YIANNIS PILAVAKIS, CHRISTOPHER RAO & THANOS ATHANASIOU Imperial College London, UK
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Abstract Aim: The aim of this study was to identify factors that influence career choice in UK medical students. Methods: Students at seven institutions were invited to rate how important various factors were on influencing their career choices and how interested they were in pursuing different specialties. The influence of interpersonal relationship networks on career choice was also evaluated. Results: 641 responses were collected. 44% (283) were male, 16% (105) were graduates and 41% (263) were final-year students. For Dermatology (p ¼ 0.009), Paediatrics (p ¼ 0.000), Radiology (p ¼ 0.000), Emergency Medicine (p ¼ 0.018) and Cardiothoracic Surgery (p ¼ 0.000), there was a clear correlation between completing a clinical attachment and an interest in pursuing the specialty. Perceived characteristics of the speciality, individually and in clusters were considered important by specific subgroups of students, such as those interested in surgery. These students considered prestige (p ¼ 0.0003), role models (p ¼ 0.014), financial rewards after training (p ¼ 0.0196) and technical challenge (p ¼ 0.0011) as important factors. Demographics such as sex and age played a significant role in career choice. Interpersonal relationship networks do not have a significant influence on career intentions. Conclusions: This study shows that the career intentions of British medical students are influenced by their undergraduate experience and by the weight they place on different specialty-related factors.
Introduction The experiences of students at medical school are important in determining their career choice (Schwartz et al. 1989; Erzurum et al. 2000; Chen et al. 2001; O’Herrin et al. 2003; O’Herrin et al. 2004). Such experiences include exposure to a particular specialty, positive role models and specialty-related research activity. In addition, multiple modifiable and non-modifiable factors affect career intentions (Table 1). Some of these factors including financial reward, prestige and workload have been shown previously to be important in determining career choice (Schwartz et al. 1989; Burack et al. 1997; Greene et al. 2000; Azizzadeh et al. 2003; O’Herrin et al. 2003; O’Herrin et al. 2004; James et al. 2009; Takeda et al. 2013). These findings have mostly been demonstrated in studies of medical students in the United States (US) (O’Herrin et al. 2003, 2004). Compared to medical students studying in England, US medical students are generally older at the time of entry into medical school, hold a prior undergraduate degree, and pay higher tuition fees. It is therefore of interest to evaluate these potentially career-modifying factors in an English cohort, at a time of change in many specialties due to technological advances and socio-economic change. Evolving medical technology impacts the clinical practice and future of specialties. The future outlook of some surgical
Practice points
Medical students select careers based on modifiable and non-modifiable factors Groups of factors considered important by students tend to cluster together, driving career intentions Interpersonal relationship networks appear to have no significant influence in determining career choice
specialties, such as cardiac surgery, has arguably become less certain as non-surgical, non-invasive techniques and primary prevention have become more widely adopted (Fowler & Christakis 2008). Practical skills are increasingly important in several medical specialities such as gastroenterology and cardiology. Socio-economic and organisational factors also significantly change the dynamics of medical specialities. An ageing population will increasingly lead to the growth of primary care and geriatrics specialties in developed countries (Christakis & Fowler 2008). The role of primary care physicians (general practitioners, GPs) is likely to continue to grow and become more integrated with specialist care (Christakis & Fowler 2007).
Correspondence: Thanos Athanasiou, Professor and Consultant Cardiothoracic Surgeon, Department of Surgery and Cancer, Imperial College London, 10th Floor, QEQM Wing, St Mary’s Campus, London W2 1NY, UK. Tel: +44 (0) 208 886 7630; E-mail: [email protected]; [email protected]
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ISSN 0142-159X print/ISSN 1466-187X online/14/121064–9 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.923560
Medical student careers, factors and networks
Table 1. Modifiable and non-modifiable factors that students were asked to rate on a 5-point scale in terms of importance in influencing their career choice.
‘Factors’
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Modifiable Intellectual challenge Private practice opportunities Length of training to consultancy Lack of competition Long-term relationship with patients Lifestyle Compatibility with family life Specialty is well-respected Absence of emergencies Prestige Role model Financial rewards after training Gender distribution of doctors in the specialty Technical challenge Diversity of patients Personal experience of disease Peer group choices
Non-modifiable Age Year of Study Gender Marital Status BSc Option Doctor in the Family Merits in Examinations
With greater recruitment of graduate-entry medical students and an increasing proportion of women, there is a greater need than ever to understand the factors that determine the career choices of medical students. It is only then that medical school recruitment curricula and culture can be evaluated to ensure doctors are motivated to aspire to careers in the specialities where they are most needed. The aim of this study was to assess whether intrinsic personal characteristics of English medical students and their undergraduate clinical experience influenced their desire to pursue specific clinical specialties.
Methods Subjects We used an online survey sent by e-mail to all medical students in the final clinical years of the medical course at seven medical schools in England who agreed to circulate the survey (Barts & the London Medical School, Bristol University, Imperial College London, King’s College London, Oxford University, St. George’s University of London, and University College London). This approximates to a maximum of 5400 possible respondents.
Survey We performed a literature search (MEDLINE) to identify which factors had previously been shown to be important in determining career choices amongst medical students. We searched the term ‘career’ AND ‘medical school’ OR ‘medical student’ and screened the results for relevant publications. We included factors identified in previous studies in our survey, as well as other factors we postulated might be relevant by examining personal references and group discussion. Our survey was then piloted by several of the study authors and changes were made based on their recommendations.
The survey was designed so that it could be completed within a maximum of 10 minutes. Specialties included were General Practice (Family Medicine), Surgical and Medical Specialties, Emergency Medicine, Psychiatry and Obstetrics and Gynaecology. For the purpose of this study, ‘medic’ refers to a student interested in a medically-orientated specialty and ‘surgeon’ to a student interested in a surgically-orientated specialty. Our survey was split into three sections: (1) Demographic Details: Students were asked for their email address (in case later clarification of responses was needed), year of study, graduate status, gender, age, marital status, which subject they chose to study if they did an intercalated degree (BSc option), whether either their parents or siblings were doctors and whether they had ever received a merit in their medical school exams. They were also asked to comment, on a 5-point Likert scale, whether they had a clear idea of which specialty they wanted to pursue and whether they wanted to pursue surgery (1 ¼ ‘strongly disagree with the statement’, 2 ¼ ‘disagree’, 3 ¼ ‘neither agree nor disagree’, 4 ¼ ‘agree’, 5 ¼ ‘strongly agree with the statement’). Finally, students were asked to choose which (of a set list) of clubs/ societies they participated in at medical school and to name their three closest friends at medical school (in order to analyse the influence of interpersonal relationship networks). (2) Factors Important in Career Choice: Students were asked to what extent they agreed (on the same 5-point Likert scale) that each of the 15 statements listed in Table 1 were important in their career choice. (3) Influence of Clinical Experience on Career Choice: Students were asked to complete two sections (one for surgical specialties, one for medical specialties), detailing their intention to pursue a given specialty before clinical experience and their intention to pursue the same specialty after clinical experience (on the same 5-point Likert scale). They were also asked their degree of clinical experience (as measured by number of operations observed for surgery, or number of cases clerked for medicine), whether they had had a positive interaction with doctors in a given specialty (both on a 5-point Likert scale) and whether they were involved in specialtyspecific research (a yes/no answer).
Interpersonal relationship network model Interpersonal relationship networks – defined as interactions between people – have previously been shown to influence decision-making, both through direct interaction (interactions within a circle of friends, for example) and indirect interaction (shared social features) (Christakis & Fowler 2007, 2008; Fowler & Christakis 2008). We postulated that interpersonal relationship interaction may influence career choice amongst medical students. We created an adjacency matrix of all medical students from Imperial College London that responded to the survey. We linked the medical students using friendship (specified on the questionnaire) and membership to clubs and societies (specified on the questionnaire).
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An interpersonal relationship network was created by inputting the adjacency matrix into Visual Social Networks (Visone) 2.6.3 (http://visone.info/). Each medical student represented a node within the network, and a node was linked to another node if they were friends or belonged to the same club or society. We extracted centrality measures such as degree (number of interpersonal relationship interactions a node has), betweenness (the importance of a node based on the proportion of paths between other nodes in the network), and eigenvector (a measure of the influence of a node based on the connections to nodes with higher degree) to determine whether interpersonal relationship interaction influenced a career choice in medical or surgical specialties.
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Statistical analysis We anonymised and codified the data for SPSS Software (IBM, Armonk, NY). We tested for correlations between demographic factors, factors that students indicated were important in career choice and interest in pursuing a specialty by using Spearman’s rank correlation coefficient. We used the Wilcoxon signed-rank test to look for changes in interest in pursuing a given specialty, e.g. before and after exposure to that specialty. Multivariate regression analysis was used to determine the relationship between Interpersonal relationship network centrality measures, gender, ethnicity and career choice. Significance was defined as p50.05.
Results A total number of 641 responses were received out of an estimated maximum of 5400 students, which equates to a response rate of approximately 12%. 283 respondents were male (44%), 105 were graduates (16%), 263 were final-year students (41%) and 379 (59%) were pre-final year students. The response rates from each of the different medical schools are illustrated in Supplementary Table 1.
Internal validation Internal controls were used to validate the data obtained, by asking the same question twice in different formats to ensure subjects were not entering random answers. They were asked to rate the importance of both ‘specialty is well-respected’ and ‘prestige’ as important career determinants. They were also asked to comment separately on ‘compatibility with family life’ and ‘lifestyle’, as well as ‘financial rewards after training’ and ‘private practice opportunities’. Students entered non-random answers, as demonstrated in Supplementary Table 2.
Influence of gender on career decision making Male participants regarded the perceived prestige of a specialty as an important factor in selecting a career (r ¼ 0.154). Male gender was negatively correlated with regarding a long-term relationship with patients as an important factor in selecting a career (r ¼ 0.168). Although male students were no more likely to want to pursue a career in surgery (as defined by giving a Likert score of 4 or 5 to the 1066
statement ‘I want to pursue surgery’) than female students, there was a correlation between being male and a desire to pursue specific surgical specialties, namely cardiothoracic surgery (r ¼ 0.201), orthopaedics (r ¼ 0.160), urology (r ¼ 0.192), neurosurgery (r ¼ 0.240) and plastic surgery (r ¼ 0.310). Male gender was negatively correlated with an interest in obstetrics and gynaecology as a career (r ¼ 0.356) and this was not changed following exposure to this specialty. Female gender was not significantly correlated with any specialty, nor factor considered important in determining career choice.
Influence of graduate-entry on career decision making There was no correlation between being a graduate student and any factors in determining career choice. Being a graduate student was positively correlated with an intention to pursue anaesthesia (r ¼ 0.184) or neurosurgery (r ¼ 0.809) as a career.
Influence of age and year of study on career decision making Increased age was positively correlated with wanting to pursue a career in orthopaedic surgery (r ¼ 0.261), dermatology (r ¼ 0.256), rheumatology (r ¼ 0.164) and radiology (r ¼ 0.157). Year of study was not correlated with wanting to pursue a career in orthopaedic surgery or radiology, but, like age, was positively correlated with wanting a career in dermatology (r ¼ 0.297) and rheumatology (r ¼ 0.260) – as well as paediatrics (r ¼ 0.264). Year of study was negatively correlated with a desire to pursue surgery in general (r ¼ 0.172).
Influence of academic achievement in determining career decision making Academic achievement was defined as having achieved a merit, or equivalent, in an examination at any point during medical school. This was not correlated with factors students considered to be important in career choice.
Influence of having a doctor in family on career decision making Having a doctor in the family was defined as having either parents and/or siblings as doctors. Students who came from a family of doctors reported not wanting to pursue obstetrics & gynaecology (r ¼ 0.298), ophthalmology (r ¼ 0.303) or Emergency Medicine (r ¼ 0.238). There was also a negative correlation between students who came from a family of doctors and regarding a diversity of patients as an important factor in career choice (r ¼ 0.236).
Influence of clear career intentions and career decision making Students who have already chosen a career are more likely to consider technical challenge (r ¼ 0.249) and a diversity of patients (r ¼ 0.193) as important factors in influencing their careers. They are less likely to want to pursue specialties that they perceive to have an absence of emergencies (r ¼ 0.181),
Medical student careers, factors and networks
Table 2. The relationships between factors that students consider to be important in career choice.
Factors ‘Training’ factors
Length of training to consultancy
Lack of competition
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Role model
Gender distribution of doctors in the specialty
Peer group choices
‘Patient’ factors
Long-term relationship with patients
Absence of emergencies
Diversity of patients
‘Financial/Lifestyle’ Factors
Private practice opportunities
Lifestyle Compatibility with family life Financial rewards after training
Other ‘perceived characteristics’ of a specialty
Intellectual challenge Technical challenge Specialty is well-respected Prestige Personal experience of disease
Positive correlates
Negative correlates
Lack of competition (r ¼ 0.347) Long-term relationship with patients (r ¼ 0.204) Lifestyle (r ¼ 0.429) Compatibility with family-life (r ¼ 0.314) Absence of emergencies (r ¼ 0.265) Financial rewards (r ¼ 0.399) Gender distribution of doctors (r ¼ 0.287) Peer group choices (r ¼ 0.225) Long-term relationship with patients (r ¼ 0.211) Lifestyle (r ¼ 0.353) Compatibility with family-life (r ¼ 0.314) Absence of emergencies (r ¼ 0.369) Gender distribution of doctors (r ¼ 0.189) Peer group choices (r ¼ 0.292) Intellectual challenge (r ¼ 0.254) Specialty is well-respected (r ¼ 0.216) Prestige (r ¼ 0.368) Financial rewards after training (r ¼ 0.274) Technical challenge (r ¼ 0.277) Length of training (r ¼ 0.287) Absence of emergencies (r ¼ 0.182) Personal experience of disease (r ¼ 0.312) Peer group choices (r ¼ 0.390) Absence of emergencies (r ¼ 0.206) Prestige (r ¼ 0.174) Financial rewards (r ¼ 0.172) Personal experience of disease (0.442)
Diversity of patients (r ¼ 0.180)
Lifestyle (r ¼ 0.297) Compatibility with family-life (r ¼ 0.343) Diversity of patients (r ¼ 0.254) Personal experience of disease (r ¼ 0.205) Private Practice Opportunities (r ¼ 0.227) Lifestyle (r ¼ 0.259) Compatibility with family-life (r ¼ 0.295) Financial rewards (r ¼ 0.179) Technical challenge (r ¼ 0.359) Personal experience of disease (r ¼ 0.196)
Intellectual challenge (r ¼ 0.181)
Diversity of Patients (r ¼ 0.199)
Private Practice Opportunities (r ¼ 0.177)
Lifestyle (r ¼ 0.192) Specialty is well-respected (r ¼ 0.154) Prestige (r ¼ 0.415) Financial rewards (r ¼ 0.524) Technical challenge (r ¼ 0.197) Compatibility with family-life (r ¼ 0.679) Financial rewards (r ¼ 0.253) Prestige (r ¼ 0.295) Specialty is well-respected (r ¼ 0.210) Prestige (r ¼ 0.444) Technical challenge (r ¼ 0.178) Specialty is well-respected (r ¼ 0.154) Technical challenge (r ¼ 0.396) Specialty is well-respected (r ¼ 0.162) Prestige (r ¼ 0.253) Prestige (r ¼ 0.490) As above As above
Personal experience of disease (r ¼ 0.159)
Correlations are listed once as they first appear.
a lack of competition (r ¼ 0.209) and that are typically compatible with family life (r ¼ 0.196). They are more likely to want to pursue a surgical specialty (r ¼ 0.216).
Relationships between factors students consider important in choosing a career Relationships between factors that students considered important in choosing a career are described in Table 2, which was
constructed by Spearman rank analysis. This identifies factors which the same student ranks highly, and therefore allows groups of factors which influence career choice to be identified.
Influence of clinical attachment on career choices The influence of clinical attachment on career choice is described in Table 3.
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Table 3. The effect of clinical attachment on intention to pursue any given specialty (as measured by comparing Likert scores pre- and post-clinical attachment in a specific specialty by Wilcoxon Signed Ranks Test, p50.05).
Clinical attachment significantly increased desire to pursue specialty as a career
Clinical attachment did not significantly increase desire to pursue specialty as a career
Medical Specialties
Dermatology (p ¼ 0.009) Paediatrics (p ¼ 0.000) Radiology (p ¼ 0.000) A&E (p ¼ 0.018)
Anaesthetics (p ¼ 0.409) Cardiology (p ¼ 0.177) Gastroenterology (p ¼ 0.362) GP (p ¼ 0.729) Respiratory (0.374) Rheumatology (p ¼ 0.116)
Surgical Specialties
Cardiothoracic surgery (p ¼ 0.00)
ENT (p ¼ 0.211) General surgery (p ¼ 0.604) Neurosurgery (p ¼ 0.332) O&G (p ¼ 0.075) Ophthalmology (p ¼ 0.362) Orthopaedics (p ¼ 0.528) Plastic surgery (p ¼ 0.503) Urology (0.099)
Involvement in research Research activity (audits, publications) in any particular specialty did not correlate with a desire to pursue that specialty.
Are there characteristics that define students with a strong desire to pursue particular specialties? Self-reported ‘surgeons’ Students were asked to comment on both whether they had a clear idea about which specialty they wanted to pursue and whether they wanted to pursue surgery. Students who had already decided that they wished to pursue surgery were motivated by the perceived promise of prestige (r ¼ 0.265), technical challenge (r ¼ 0.434), private practice opportunities (r ¼ 0.218) and financial rewards (r ¼ 0.227). A desire to pursue surgery was negatively correlated with regarding compatibility with family life (r ¼ 0.273), lifestyle (r ¼ 0.173), a long-term relationship with patients (r ¼ 0.191) and an absence of emergencies (r ¼ 0.163) as important factors in selecting a career. For all students, the degree to which they wanted to pursue a given surgical specialty after their clinical attachment correlated with having a positive interaction with the doctors on their attachment and the number of operations observed (Table 4).
Subgroup analysis: ‘Medics’ vs ‘Surgeons’ Responses were further analysed to ascertain which students had a strong desire to pursue medical specialties and which had a strong desire to pursue surgical specialties. Students who rated their desire to pursue any medical specialty as a Likert score of 4 or 5 following clinical attachment (but not rated any surgical specialty as a 4 or 5 following clinical attachment) were labelled as ‘medics’. Students who rated their desire to pursue any surgical specialty as a Likert score of 4 or 5 following clinical attachment (but not rated any medical specialty as a 4 or 5 following clinical attachment) were 1068
Table 4. The correlations between wanting to pursue a specific surgical specialty (after clinical attachment) and having a positive interaction with doctors within that specialty (during the attachment) and the number of operations observed during clinical attachment [Pearson correlations, *p50.05].
Specialty intended to pursue
Number of operations observed
Positive interaction with doctors
Cardiothoracic surgery ENT General surgery Neurosurgery O&G Ophthalmology Orthopaedics Plastics Urology
0.348* 0.315* 0.065 0.388* 0.101 0.034 0.483* 0.383* 0.002
0.452* 0.350* 0.464* 0.446* 0.501* 0.555* 0.531* 0.525* 0.467*
labelled as ‘surgeons’. Out of the 641 students who participated, 245 were ‘medics’ and 34 were ‘surgeons’. Table 5 demonstrates factors considered important by medics and surgeons.
Particular specialty associations Medical.
For three medical specialties, notable findings were seen. Students who wished to be cardiologists were more likely to be motivated by a sense of respect for their specialty (r ¼ 0.240). Those students who wished to pursue dermatology rated a perceived lack of competition (r ¼ 0.394), an absence of emergencies (r ¼ 0.281) and the gender distribution of doctors within a specialty (r ¼ 0.210) as important career determinants. Students who reported wanting to be GPs held factors such as compatibility with family (r ¼ 0.283) and lifestyle in higher regard (r ¼ 0.285), as well as a perceived lack of competition in the specialty (r ¼ 0.297).
Surgical.
For three surgical specialties, notable findings were seen. Students who wished to pursue cardiothoracic surgery were more likely to be motivated by role models within the specialty (r ¼ 0.315), perceived specialty prestige
Medical student careers, factors and networks
Table 5. Factors that ‘medics’ rather ‘surgeons’ (students who expressed a preferential interest in one over the other) considered preferentially important.
Factors considered important to ‘medics’ in career choice
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Length of training to consultancy (p ¼ 0.0044) Lack of competition (p ¼ 0.0152) Long-term relationship with patients (p ¼ 0.0006) Compatibility with family-life (p ¼ 0.0175)
Factors not considered more important to either ‘medics’ or ‘surgeons’ Intellectual challenge (p ¼ 0.7879) Absence of emergencies (p ¼ 0.6912) Gender distribution of doctors in the specialty (p ¼ 0.6353) Personal experience of disease (p ¼ 0.2781) Peer group choices (p ¼ 0.5229)
Factors considered important to ‘surgeons’ in career choice Prestige (p ¼ 0.0003) Role model (p ¼ 0.0140) Financial rewards after training (p ¼ 0.0196) Technical challenge (p ¼ 0.0011)
Figure 1. Interpersonal Relationship Network Analysis of Career Intentions Green circles are those people undecided on career choice, the red squares represent students wanting to be ‘medics’ and the blue triangles those wanting to be ‘surgeons’.
(r ¼ 0.331) as well as private practice opportunities (r ¼ 0.317), technical challenge (r ¼ 0.222), respect for the specialty (r ¼ 0.189) and financial rewards (r ¼ 0.335). There was a negative correlation between wanting to pursue cardiothoracic surgery as a career and regarding a long-term relationship with patients as an important career determinant (r ¼ 0.200). Those who wanted to pursue O&G were motivated by the promise of long-term relationships with patients (r ¼ 0.214) and a diverse patient base (r ¼ 0.200). They were also likely to be female (number), to not have doctor in their family (number) and to report low enthusiasm for a specialty with intellectual challenge (r ¼ 0.227). There was also a negative correlation between wanting to pursue O&G and regarding length of training to consultancy as an important career determinant (r ¼ 0.261). Those students who wished to pursue neurosurgery were more likely to be motivated by
perceived intellectual (r ¼ 0.305) and technical challenges (r ¼ 0.351) of this specialty.
Interpersonal relationship networks Figure 1 shows a diagram of the interpersonal relationship network, which shows that the majority of students wanted to have careers in medical specialties or were undecided. When non-modifiable factors such as gender and ethnicity were considered, there were no statistically significant findings between measures of interpersonal relationship interaction and career choice.
Discussion This study shows that the career choices of medical students are influenced by a variety of factors, some of which are fixed
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(age, gender), some of which are slow to change (perceived characteristics of a specialty) and some of which are modifiable, for example, the degree of clinical exposure and the presence of role models. We have shown that within specific subgroups of students (men, graduates, potential surgeons), factors identified by our literature search have a role in determining students’ career intentions. Other factors, not explored within the remit of this study, may also play a role.
Non-modifiable influences on career choice
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Gender When students were asked to rate whether they would like to pursue surgery overall, there were no more men than women amongst those who said that they did want to pursue surgery. This is in contrast to previous studies, which have shown a preponderance of men to be interested in surgery (Azizzadeh et al. 2003). However, there were a number of surgical specialties that male medical students showed a particular interest in (over female students). Further, when students were analysed into ‘medic’ and ‘surgeon’ subgroups, the surgical subgroup was male-dominated.
Graduates Particularly of interest to the British medical community is that graduate-entry students did not want to pursue traditionally less competitive specialties. We found that graduate students appeared to show a propensity towards a career in neurosurgery, a specialty with a high competition ratio. Previous studies have either shown graduates have no particular specialty preference, or modestly favour general practice as a career choice (Lambert & Goldacre 1998; Lambert et al. 2001; Goldacre et al. 2007, 2009). This study implies that increasing numbers of graduates entering medical school may not be headed to a primary care career but may add to competition in hospital-based specialties.
Factors This study shows that some students tend to consistently rate groups of related factors as important in determining their career choices. We found two clear examples of this, with ‘reward-seeking’ factors clustered together (financial reward correlated with prestige, length of training and private practice) and ‘family/lifestyle-related’ factors correlating together (family life correlated with low competition, relationship with patients and lifestyle). This shows that discrete clusters of factors motivate some students.
Modifiable influences on career choice General This study shows that clinical exposure to a specialty can increase the desire amongst students to pursue a given specialty – as has been demonstrated in other studies (Greene et al. 2000; O’Herrin et al. 2003; Ravindra & Fitzgerald 2011). This is of importance in enhancing recruitment into specialties where there is a need for doctors. However, this relationship was not seen for all specialties. We 1070
did not test the reasons for this within this study, but this provides material for future study – and of interest to planning the workforce.
Medic versus surgeon students We compared a large number of characteristics of students who consistently expressed an interest in a surgical versus medical specialty. These students rated different factors as being important in determining career choice. Of note, students who wanted to be surgeons rated technical challenge as much more important. Moreover, those who were classifiable as medics or surgeons, tended neither to be influenced by peer group choices, nor by a lack of competition. In general, students interested in surgery tended to be motivated by ‘reward’-related factors, such as the presence of a role model, prestige and financial rewards. Those who wanted to pursue medical specialties were motivated more by ‘lifestyle’ related factors, including the length of training and compatibility with family life (Table 5).
Specialties Two specialties of particular interest for workforce planners are cardiothoracic surgery (predicted short-fall in consultants) and obstetrics and gynaecology (move to 24-hour on-call consultants, change in gender profile of trainees). There is a predicted shortfall of cardiothoracic surgeons to meet the needs of the aging population over the next 20 years (Fowler & Christakis 2008). Cardiothoracic surgery was the only surgical specialty in which clinical exposure resulted in a significant increase in desire to pursue the specialty. Improving exposure to this specialty is likely to enhance medical student intention to pursue this career. One way this could be influenced is through role models, which we and others (Stagg et al. 2012) identified as a major influence on careers. Obstetrics and gynaecology (O&G) is a specialty that has struggled to maintain recruitment over the last 20 years, with fewer numbers of men entering the specialty (Hammoud et al. 2006; Gerber & Lo Sasso 2006; Turner et al. 2006). We too report a low level of interest among male students. We also found that students coming from a medical family reported little interest in pursuing O&G and those students who do wish to pursue O&G rate pursuing a specialty with an intellectual challenge as low on their list of priorities. It may be that the experiences of family members in medicine have dissuaded students from considering O&G for a number of reasons, including lifestyle considerations. We did not record which specialty the family member practiced, and so it was not possible to determine whether students were being dissuaded from pursuing O&G by obstetricians or members of other specialties.
Strengths and limitations The strengths of this study lie in its broad scope and applicability to the medical community in England. The authors believe this study to be the first of its kind to broadly evaluate the career intentions of the current cohort of medical students studying in England and their underlying motivating
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Medical student careers, factors and networks
factors. The study is representative of the gender distribution of the English medical student population, with 56% of the responders being women (mirroring the higher proportion of female medical students across the country – 65% in 2002–3) (Dacre 2012). It is also representative of the proportion of graduate students entering English medical schools – 16% in this study, as compared to the 10% of graduate students entering UK medical schools in 2009–10 (Garrud 2011). One of the limitations of this study is the response rate (12%, 641/5400). Obtaining responses from 641 students was a good absolute number but, ideally, should have been higher. 5400 students was the maximum hypothetical number of students. This may be due to the questionnaire we set being lengthy (Jepson et al. 2005). A second limitation is that students were asked to look retrospectively over past experiences (e.g. desire to pursue a specialty before and after clinical experiences). Another limitation is that the students interviewed were all enrolled in large, academic, research-based institutions. It is possible that medical students at other institutions with different course structures and strengths may have other priorities determining their career choices. We had a much larger percentage of final-year medical students answering the questionnaire (41%) than is reflective of the breakdown of students per year (equal numbers of students in each year-group). There was also a potential self-selection bias, with students completing the questionnaire tending to be of particular character types and therefore tending towards certain career choices. Furthermore, the questionnaire presented an incomplete list of specialties to students, meaning that some students would not have been able to select a specialty that they wanted to pursue. The analysis of the interpersonal relationship network analysis was limited because a complete network could not be created due to the low response rate. We assumed that medical students would interact with each other if they belonged to the same club or society. Future studies could focus on following-up such students over time, to see whether their desire to pursue a given specialty was maintained through the first few years after qualifying as a doctor. Furthermore, although we could not detect a role for interpersonal relationship networking in determining career choice amongst the group of medical students studied, the concept of interpersonal relationship networks in determining decision-making remains relevant and important for future study. It could also be important to examine how career intentions change as students progress through pre-clinical to clinical education.
Conclusion This study reveals new links between undergraduate clinical exposure and student characteristics and career intentions. We have shown how both non-modifiable (age, gender, perceived specialty characteristics) and modifiable factors (nature of clinical attachment) can influence specialty career choices. These data provide a substrate for interventions aimed at promoting undersubscribed specialty training
programmes and in line with the future workforce profile in medicine.
Glossary Social Network Analysis: This method analysis the influence of social interaction (e.g. club membership, friendships) on a behaviour by testing whether the social interaction can predict the behaviour. Wasserman S, Faust K. 1994. Social Network Analysis. Cambridge: Cambridge University Press.
Notes on contributors MICHAEL IBRAHIM, MA, MBBS, PhD, Academic Foundation Doctor in Surgery, London. ANGELA FANSHAWE, MA, MBBS, MRCS, Core Surgical Trainee, London. VANASH PATEL, MBBS, MRCS, PhD, Surgical Fellow, London. KARAN GOSWAMI, MA, MBBS, MRCS, Core Surgical Trainee, Coventry. GEOFFREY CHILVERS, BSc, MBBS, MRCS, Core Surgical Trainee, Severn. MICHELLE TING, MA, MBBS, MRCS, Opthalmology Trainee, Moorfields Hospital. YIANNIS PILAVAKIS, MA, MBBS, FY2, Southampton General Hospital. CHRISTOPHER RAO, BSc, MBBS, MRCS, PhD, Academic Clinical Fellow in Surgery, London. THANOS ATHANASIOU, MD, PhD, FRCS, FETC, Professor of Cardiac Surgery, Imperial College London.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. Ethics Review: All participants consented to the anonymous use of their data.
References Azizzadeh A, McCollum CH, Miller 3rd CC, Holliday KM, Shilstone HC, Lucci Jr A. 2003. Factors influencing career choice among medical students interested in surgery. Curr Surg 60:210–213. Burack JH, Irby DM, Carline JD, Ambrozy DM, Ellsbury KE, Stritter FT. 1997. A study of medical students’ specialty-choice pathways: Trying on possible selves. Acad Med 72:534–541. Chen H, Hardacre JM, Martin C, Lillemoe KD. 2001. Do medical school surgical rotations influence subspecialty choice? J Surg Res 97: 172–178. Christakis NA, Fowler JH. 2007. The spread of obesity in a large social network over 32 years. N Engl J Med 357:370–379. Christakis NA, Fowler JH. 2008. The collective dynamics of smoking in a large social network. N Engl J Med 358:2249–2258. Dacre J. 2012. We need female doctors at all levels and in all specialties. BMJ 344:e2325. Erzurum VZ, Obermeyer RJ, Fecher A, Thyagarajan P, Tan P, Koler AK, Hirko MK, Rubin JR. 2000. What influences medical students’ choice of surgical careers. Surgery 128:253–256. Fowler JH, Christakis NA. 2008. Dynamic spread of happiness in a large social network: Longitudinal analysis over 20 years in the Framingham Heart Study. BMJ 337:a2338.
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Garrud P. 2011. Who applies and who gets admitted to UK graduate entry medicine? – An analysis of UK admission statistics. BMC Med Educ 11:71. Gerber SE, Lo Sasso AT. 2006. The evolving gender gap in general obstetrics and gynecology. Am J Obstet Gynecol 195:1427–1430. Goldacre MJ, Davidson JM, Lambert TW. 2007. Career preferences of graduate and non-graduate entrants to medical schools in the UK. Med Educ 41:349–361. Goldacre MJ, Davidson JM, Lambert TW. 2009. Retention in the British National Health Service of medical graduates trained in Britain: Cohort studies. BMJ 338:b1977. Greene AL, Lalli MJ, Ji Y, Babu GJ, Grupp I, Sussman M, Periasamy M. 2000. Overexpression of SERCA2b in the heart leads to an increase in sarcoplasmic reticulum calcium transport function and increased cardiac contractility. J Biol Chem 275:24722–24727. Hammoud MM, Stansfield RB, Katz NT, Dugoff L, McCarthy J, White CB. 2006. The effect of the obstetrics and gynecology clerkship on students’ interest in a career in obstetrics and gynecology. Am J Obstet Gynecol 195:1422–1426. James D, Ferguson E, Powis D, Bore M, Munro D, Symonds I, Yates J. 2009. Graduate entry to medicine: Widening psychological diversity. BMC Med Educ 9:67. Jepson C, Asch DA, Hershey JC, Ubel PA. 2005. In a mailed physician survey, questionnaire length had a threshold effect on response rate. J Clin Epidemiol 58:103–105.
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Lambert TW, Goldacre MJ. 1998. Career destinations seven years on among doctors who qualified in the United Kingdom in 1988: Postal questionnaire survey. BMJ 317:1429–1431. Lambert TW, Goldacre MJ, Davidson JM, Parkhouse J. 2001. Graduate status and age at entry to medical school as predictors of doctors’ choice of long-term career. Med Educ 35:450–454. O’Herrin JK, Lewis BJ, Rikkers LF, Chen H. 2003. Medical student operative experience correlates with a match to a categorical surgical program. Am J Surg 186:125–128. O’Herrin JK, Lewis BJ, Rikkers LF, Chen H. 2004. Why do students choose careers in surgery? J Surg Res 119:124–129. Ravindra P, Fitzgerald JE. 2011. Defining surgical role models and their influence on career choice. World J Surg 35:704–709. Schwartz RW, Jarecky RK, Strodel WE, Haley JV, Young B, Griffen Jr WO. 1989. Controllable lifestyle: A new factor in career choice by medical students. Acad Med 64:606–609. Stagg P, Prideaux D, Greenhill J, Sweet L. 2012. Are medical students influenced by preceptors in making career choices, and if so how? A systematic review. Rural Remote Health 12:1832. Takeda Y, Morio K, Snell L, Otaki J, Takahashi M, Kai I. 2013. Characteristic profiles among students and junior doctors with specific career preferences. BMC Med Educ 13:125. Turner G, Lambert TW, Goldacre MJ, Barlow D. 2006. Career choices for obstetrics and gynaecology: National surveys of graduates of 1974–2002 from UK medical schools. BJOG 113: 350–356.
What factors influence British medical students’ career intentions? MICHAEL IBRAHIM, ANGELA FANSHAWE, VANASH PATEL, KARAN GOSWAMI, GEOFFREY CHILVERS, MICHELLE TING, YIANNIS PILAVAKIS, CHRISTOPHER RAO & THANOS ATHANASIOU Imperial College London, UK
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Abstract Aim: The aim of this study was to identify factors that influence career choice in UK medical students. Methods: Students at seven institutions were invited to rate how important various factors were on influencing their career choices and how interested they were in pursuing different specialties. The influence of interpersonal relationship networks on career choice was also evaluated. Results: 641 responses were collected. 44% (283) were male, 16% (105) were graduates and 41% (263) were final-year students. For Dermatology (p ¼ 0.009), Paediatrics (p ¼ 0.000), Radiology (p ¼ 0.000), Emergency Medicine (p ¼ 0.018) and Cardiothoracic Surgery (p ¼ 0.000), there was a clear correlation between completing a clinical attachment and an interest in pursuing the specialty. Perceived characteristics of the speciality, individually and in clusters were considered important by specific subgroups of students, such as those interested in surgery. These students considered prestige (p ¼ 0.0003), role models (p ¼ 0.014), financial rewards after training (p ¼ 0.0196) and technical challenge (p ¼ 0.0011) as important factors. Demographics such as sex and age played a significant role in career choice. Interpersonal relationship networks do not have a significant influence on career intentions. Conclusions: This study shows that the career intentions of British medical students are influenced by their undergraduate experience and by the weight they place on different specialty-related factors.
Introduction The experiences of students at medical school are important in determining their career choice (Schwartz et al. 1989; Erzurum et al. 2000; Chen et al. 2001; O’Herrin et al. 2003; O’Herrin et al. 2004). Such experiences include exposure to a particular specialty, positive role models and specialty-related research activity. In addition, multiple modifiable and non-modifiable factors affect career intentions (Table 1). Some of these factors including financial reward, prestige and workload have been shown previously to be important in determining career choice (Schwartz et al. 1989; Burack et al. 1997; Greene et al. 2000; Azizzadeh et al. 2003; O’Herrin et al. 2003; O’Herrin et al. 2004; James et al. 2009; Takeda et al. 2013). These findings have mostly been demonstrated in studies of medical students in the United States (US) (O’Herrin et al. 2003, 2004). Compared to medical students studying in England, US medical students are generally older at the time of entry into medical school, hold a prior undergraduate degree, and pay higher tuition fees. It is therefore of interest to evaluate these potentially career-modifying factors in an English cohort, at a time of change in many specialties due to technological advances and socio-economic change. Evolving medical technology impacts the clinical practice and future of specialties. The future outlook of some surgical
Practice points
Medical students select careers based on modifiable and non-modifiable factors Groups of factors considered important by students tend to cluster together, driving career intentions Interpersonal relationship networks appear to have no significant influence in determining career choice
specialties, such as cardiac surgery, has arguably become less certain as non-surgical, non-invasive techniques and primary prevention have become more widely adopted (Fowler & Christakis 2008). Practical skills are increasingly important in several medical specialities such as gastroenterology and cardiology. Socio-economic and organisational factors also significantly change the dynamics of medical specialities. An ageing population will increasingly lead to the growth of primary care and geriatrics specialties in developed countries (Christakis & Fowler 2008). The role of primary care physicians (general practitioners, GPs) is likely to continue to grow and become more integrated with specialist care (Christakis & Fowler 2007).
Correspondence: Thanos Athanasiou, Professor and Consultant Cardiothoracic Surgeon, Department of Surgery and Cancer, Imperial College London, 10th Floor, QEQM Wing, St Mary’s Campus, London W2 1NY, UK. Tel: +44 (0) 208 886 7630; E-mail: [email protected]; [email protected]
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Medical student careers, factors and networks
Table 1. Modifiable and non-modifiable factors that students were asked to rate on a 5-point scale in terms of importance in influencing their career choice.
‘Factors’
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Modifiable Intellectual challenge Private practice opportunities Length of training to consultancy Lack of competition Long-term relationship with patients Lifestyle Compatibility with family life Specialty is well-respected Absence of emergencies Prestige Role model Financial rewards after training Gender distribution of doctors in the specialty Technical challenge Diversity of patients Personal experience of disease Peer group choices
Non-modifiable Age Year of Study Gender Marital Status BSc Option Doctor in the Family Merits in Examinations
With greater recruitment of graduate-entry medical students and an increasing proportion of women, there is a greater need than ever to understand the factors that determine the career choices of medical students. It is only then that medical school recruitment curricula and culture can be evaluated to ensure doctors are motivated to aspire to careers in the specialities where they are most needed. The aim of this study was to assess whether intrinsic personal characteristics of English medical students and their undergraduate clinical experience influenced their desire to pursue specific clinical specialties.
Methods Subjects We used an online survey sent by e-mail to all medical students in the final clinical years of the medical course at seven medical schools in England who agreed to circulate the survey (Barts & the London Medical School, Bristol University, Imperial College London, King’s College London, Oxford University, St. George’s University of London, and University College London). This approximates to a maximum of 5400 possible respondents.
Survey We performed a literature search (MEDLINE) to identify which factors had previously been shown to be important in determining career choices amongst medical students. We searched the term ‘career’ AND ‘medical school’ OR ‘medical student’ and screened the results for relevant publications. We included factors identified in previous studies in our survey, as well as other factors we postulated might be relevant by examining personal references and group discussion. Our survey was then piloted by several of the study authors and changes were made based on their recommendations.
The survey was designed so that it could be completed within a maximum of 10 minutes. Specialties included were General Practice (Family Medicine), Surgical and Medical Specialties, Emergency Medicine, Psychiatry and Obstetrics and Gynaecology. For the purpose of this study, ‘medic’ refers to a student interested in a medically-orientated specialty and ‘surgeon’ to a student interested in a surgically-orientated specialty. Our survey was split into three sections: (1) Demographic Details: Students were asked for their email address (in case later clarification of responses was needed), year of study, graduate status, gender, age, marital status, which subject they chose to study if they did an intercalated degree (BSc option), whether either their parents or siblings were doctors and whether they had ever received a merit in their medical school exams. They were also asked to comment, on a 5-point Likert scale, whether they had a clear idea of which specialty they wanted to pursue and whether they wanted to pursue surgery (1 ¼ ‘strongly disagree with the statement’, 2 ¼ ‘disagree’, 3 ¼ ‘neither agree nor disagree’, 4 ¼ ‘agree’, 5 ¼ ‘strongly agree with the statement’). Finally, students were asked to choose which (of a set list) of clubs/ societies they participated in at medical school and to name their three closest friends at medical school (in order to analyse the influence of interpersonal relationship networks). (2) Factors Important in Career Choice: Students were asked to what extent they agreed (on the same 5-point Likert scale) that each of the 15 statements listed in Table 1 were important in their career choice. (3) Influence of Clinical Experience on Career Choice: Students were asked to complete two sections (one for surgical specialties, one for medical specialties), detailing their intention to pursue a given specialty before clinical experience and their intention to pursue the same specialty after clinical experience (on the same 5-point Likert scale). They were also asked their degree of clinical experience (as measured by number of operations observed for surgery, or number of cases clerked for medicine), whether they had had a positive interaction with doctors in a given specialty (both on a 5-point Likert scale) and whether they were involved in specialtyspecific research (a yes/no answer).
Interpersonal relationship network model Interpersonal relationship networks – defined as interactions between people – have previously been shown to influence decision-making, both through direct interaction (interactions within a circle of friends, for example) and indirect interaction (shared social features) (Christakis & Fowler 2007, 2008; Fowler & Christakis 2008). We postulated that interpersonal relationship interaction may influence career choice amongst medical students. We created an adjacency matrix of all medical students from Imperial College London that responded to the survey. We linked the medical students using friendship (specified on the questionnaire) and membership to clubs and societies (specified on the questionnaire).
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An interpersonal relationship network was created by inputting the adjacency matrix into Visual Social Networks (Visone) 2.6.3 (http://visone.info/). Each medical student represented a node within the network, and a node was linked to another node if they were friends or belonged to the same club or society. We extracted centrality measures such as degree (number of interpersonal relationship interactions a node has), betweenness (the importance of a node based on the proportion of paths between other nodes in the network), and eigenvector (a measure of the influence of a node based on the connections to nodes with higher degree) to determine whether interpersonal relationship interaction influenced a career choice in medical or surgical specialties.
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Statistical analysis We anonymised and codified the data for SPSS Software (IBM, Armonk, NY). We tested for correlations between demographic factors, factors that students indicated were important in career choice and interest in pursuing a specialty by using Spearman’s rank correlation coefficient. We used the Wilcoxon signed-rank test to look for changes in interest in pursuing a given specialty, e.g. before and after exposure to that specialty. Multivariate regression analysis was used to determine the relationship between Interpersonal relationship network centrality measures, gender, ethnicity and career choice. Significance was defined as p50.05.
Results A total number of 641 responses were received out of an estimated maximum of 5400 students, which equates to a response rate of approximately 12%. 283 respondents were male (44%), 105 were graduates (16%), 263 were final-year students (41%) and 379 (59%) were pre-final year students. The response rates from each of the different medical schools are illustrated in Supplementary Table 1.
Internal validation Internal controls were used to validate the data obtained, by asking the same question twice in different formats to ensure subjects were not entering random answers. They were asked to rate the importance of both ‘specialty is well-respected’ and ‘prestige’ as important career determinants. They were also asked to comment separately on ‘compatibility with family life’ and ‘lifestyle’, as well as ‘financial rewards after training’ and ‘private practice opportunities’. Students entered non-random answers, as demonstrated in Supplementary Table 2.
Influence of gender on career decision making Male participants regarded the perceived prestige of a specialty as an important factor in selecting a career (r ¼ 0.154). Male gender was negatively correlated with regarding a long-term relationship with patients as an important factor in selecting a career (r ¼ 0.168). Although male students were no more likely to want to pursue a career in surgery (as defined by giving a Likert score of 4 or 5 to the 1066
statement ‘I want to pursue surgery’) than female students, there was a correlation between being male and a desire to pursue specific surgical specialties, namely cardiothoracic surgery (r ¼ 0.201), orthopaedics (r ¼ 0.160), urology (r ¼ 0.192), neurosurgery (r ¼ 0.240) and plastic surgery (r ¼ 0.310). Male gender was negatively correlated with an interest in obstetrics and gynaecology as a career (r ¼ 0.356) and this was not changed following exposure to this specialty. Female gender was not significantly correlated with any specialty, nor factor considered important in determining career choice.
Influence of graduate-entry on career decision making There was no correlation between being a graduate student and any factors in determining career choice. Being a graduate student was positively correlated with an intention to pursue anaesthesia (r ¼ 0.184) or neurosurgery (r ¼ 0.809) as a career.
Influence of age and year of study on career decision making Increased age was positively correlated with wanting to pursue a career in orthopaedic surgery (r ¼ 0.261), dermatology (r ¼ 0.256), rheumatology (r ¼ 0.164) and radiology (r ¼ 0.157). Year of study was not correlated with wanting to pursue a career in orthopaedic surgery or radiology, but, like age, was positively correlated with wanting a career in dermatology (r ¼ 0.297) and rheumatology (r ¼ 0.260) – as well as paediatrics (r ¼ 0.264). Year of study was negatively correlated with a desire to pursue surgery in general (r ¼ 0.172).
Influence of academic achievement in determining career decision making Academic achievement was defined as having achieved a merit, or equivalent, in an examination at any point during medical school. This was not correlated with factors students considered to be important in career choice.
Influence of having a doctor in family on career decision making Having a doctor in the family was defined as having either parents and/or siblings as doctors. Students who came from a family of doctors reported not wanting to pursue obstetrics & gynaecology (r ¼ 0.298), ophthalmology (r ¼ 0.303) or Emergency Medicine (r ¼ 0.238). There was also a negative correlation between students who came from a family of doctors and regarding a diversity of patients as an important factor in career choice (r ¼ 0.236).
Influence of clear career intentions and career decision making Students who have already chosen a career are more likely to consider technical challenge (r ¼ 0.249) and a diversity of patients (r ¼ 0.193) as important factors in influencing their careers. They are less likely to want to pursue specialties that they perceive to have an absence of emergencies (r ¼ 0.181),
Medical student careers, factors and networks
Table 2. The relationships between factors that students consider to be important in career choice.
Factors ‘Training’ factors
Length of training to consultancy
Lack of competition
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Role model
Gender distribution of doctors in the specialty
Peer group choices
‘Patient’ factors
Long-term relationship with patients
Absence of emergencies
Diversity of patients
‘Financial/Lifestyle’ Factors
Private practice opportunities
Lifestyle Compatibility with family life Financial rewards after training
Other ‘perceived characteristics’ of a specialty
Intellectual challenge Technical challenge Specialty is well-respected Prestige Personal experience of disease
Positive correlates
Negative correlates
Lack of competition (r ¼ 0.347) Long-term relationship with patients (r ¼ 0.204) Lifestyle (r ¼ 0.429) Compatibility with family-life (r ¼ 0.314) Absence of emergencies (r ¼ 0.265) Financial rewards (r ¼ 0.399) Gender distribution of doctors (r ¼ 0.287) Peer group choices (r ¼ 0.225) Long-term relationship with patients (r ¼ 0.211) Lifestyle (r ¼ 0.353) Compatibility with family-life (r ¼ 0.314) Absence of emergencies (r ¼ 0.369) Gender distribution of doctors (r ¼ 0.189) Peer group choices (r ¼ 0.292) Intellectual challenge (r ¼ 0.254) Specialty is well-respected (r ¼ 0.216) Prestige (r ¼ 0.368) Financial rewards after training (r ¼ 0.274) Technical challenge (r ¼ 0.277) Length of training (r ¼ 0.287) Absence of emergencies (r ¼ 0.182) Personal experience of disease (r ¼ 0.312) Peer group choices (r ¼ 0.390) Absence of emergencies (r ¼ 0.206) Prestige (r ¼ 0.174) Financial rewards (r ¼ 0.172) Personal experience of disease (0.442)
Diversity of patients (r ¼ 0.180)
Lifestyle (r ¼ 0.297) Compatibility with family-life (r ¼ 0.343) Diversity of patients (r ¼ 0.254) Personal experience of disease (r ¼ 0.205) Private Practice Opportunities (r ¼ 0.227) Lifestyle (r ¼ 0.259) Compatibility with family-life (r ¼ 0.295) Financial rewards (r ¼ 0.179) Technical challenge (r ¼ 0.359) Personal experience of disease (r ¼ 0.196)
Intellectual challenge (r ¼ 0.181)
Diversity of Patients (r ¼ 0.199)
Private Practice Opportunities (r ¼ 0.177)
Lifestyle (r ¼ 0.192) Specialty is well-respected (r ¼ 0.154) Prestige (r ¼ 0.415) Financial rewards (r ¼ 0.524) Technical challenge (r ¼ 0.197) Compatibility with family-life (r ¼ 0.679) Financial rewards (r ¼ 0.253) Prestige (r ¼ 0.295) Specialty is well-respected (r ¼ 0.210) Prestige (r ¼ 0.444) Technical challenge (r ¼ 0.178) Specialty is well-respected (r ¼ 0.154) Technical challenge (r ¼ 0.396) Specialty is well-respected (r ¼ 0.162) Prestige (r ¼ 0.253) Prestige (r ¼ 0.490) As above As above
Personal experience of disease (r ¼ 0.159)
Correlations are listed once as they first appear.
a lack of competition (r ¼ 0.209) and that are typically compatible with family life (r ¼ 0.196). They are more likely to want to pursue a surgical specialty (r ¼ 0.216).
Relationships between factors students consider important in choosing a career Relationships between factors that students considered important in choosing a career are described in Table 2, which was
constructed by Spearman rank analysis. This identifies factors which the same student ranks highly, and therefore allows groups of factors which influence career choice to be identified.
Influence of clinical attachment on career choices The influence of clinical attachment on career choice is described in Table 3.
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Table 3. The effect of clinical attachment on intention to pursue any given specialty (as measured by comparing Likert scores pre- and post-clinical attachment in a specific specialty by Wilcoxon Signed Ranks Test, p50.05).
Clinical attachment significantly increased desire to pursue specialty as a career
Clinical attachment did not significantly increase desire to pursue specialty as a career
Medical Specialties
Dermatology (p ¼ 0.009) Paediatrics (p ¼ 0.000) Radiology (p ¼ 0.000) A&E (p ¼ 0.018)
Anaesthetics (p ¼ 0.409) Cardiology (p ¼ 0.177) Gastroenterology (p ¼ 0.362) GP (p ¼ 0.729) Respiratory (0.374) Rheumatology (p ¼ 0.116)
Surgical Specialties
Cardiothoracic surgery (p ¼ 0.00)
ENT (p ¼ 0.211) General surgery (p ¼ 0.604) Neurosurgery (p ¼ 0.332) O&G (p ¼ 0.075) Ophthalmology (p ¼ 0.362) Orthopaedics (p ¼ 0.528) Plastic surgery (p ¼ 0.503) Urology (0.099)
Involvement in research Research activity (audits, publications) in any particular specialty did not correlate with a desire to pursue that specialty.
Are there characteristics that define students with a strong desire to pursue particular specialties? Self-reported ‘surgeons’ Students were asked to comment on both whether they had a clear idea about which specialty they wanted to pursue and whether they wanted to pursue surgery. Students who had already decided that they wished to pursue surgery were motivated by the perceived promise of prestige (r ¼ 0.265), technical challenge (r ¼ 0.434), private practice opportunities (r ¼ 0.218) and financial rewards (r ¼ 0.227). A desire to pursue surgery was negatively correlated with regarding compatibility with family life (r ¼ 0.273), lifestyle (r ¼ 0.173), a long-term relationship with patients (r ¼ 0.191) and an absence of emergencies (r ¼ 0.163) as important factors in selecting a career. For all students, the degree to which they wanted to pursue a given surgical specialty after their clinical attachment correlated with having a positive interaction with the doctors on their attachment and the number of operations observed (Table 4).
Subgroup analysis: ‘Medics’ vs ‘Surgeons’ Responses were further analysed to ascertain which students had a strong desire to pursue medical specialties and which had a strong desire to pursue surgical specialties. Students who rated their desire to pursue any medical specialty as a Likert score of 4 or 5 following clinical attachment (but not rated any surgical specialty as a 4 or 5 following clinical attachment) were labelled as ‘medics’. Students who rated their desire to pursue any surgical specialty as a Likert score of 4 or 5 following clinical attachment (but not rated any medical specialty as a 4 or 5 following clinical attachment) were 1068
Table 4. The correlations between wanting to pursue a specific surgical specialty (after clinical attachment) and having a positive interaction with doctors within that specialty (during the attachment) and the number of operations observed during clinical attachment [Pearson correlations, *p50.05].
Specialty intended to pursue
Number of operations observed
Positive interaction with doctors
Cardiothoracic surgery ENT General surgery Neurosurgery O&G Ophthalmology Orthopaedics Plastics Urology
0.348* 0.315* 0.065 0.388* 0.101 0.034 0.483* 0.383* 0.002
0.452* 0.350* 0.464* 0.446* 0.501* 0.555* 0.531* 0.525* 0.467*
labelled as ‘surgeons’. Out of the 641 students who participated, 245 were ‘medics’ and 34 were ‘surgeons’. Table 5 demonstrates factors considered important by medics and surgeons.
Particular specialty associations Medical.
For three medical specialties, notable findings were seen. Students who wished to be cardiologists were more likely to be motivated by a sense of respect for their specialty (r ¼ 0.240). Those students who wished to pursue dermatology rated a perceived lack of competition (r ¼ 0.394), an absence of emergencies (r ¼ 0.281) and the gender distribution of doctors within a specialty (r ¼ 0.210) as important career determinants. Students who reported wanting to be GPs held factors such as compatibility with family (r ¼ 0.283) and lifestyle in higher regard (r ¼ 0.285), as well as a perceived lack of competition in the specialty (r ¼ 0.297).
Surgical.
For three surgical specialties, notable findings were seen. Students who wished to pursue cardiothoracic surgery were more likely to be motivated by role models within the specialty (r ¼ 0.315), perceived specialty prestige
Medical student careers, factors and networks
Table 5. Factors that ‘medics’ rather ‘surgeons’ (students who expressed a preferential interest in one over the other) considered preferentially important.
Factors considered important to ‘medics’ in career choice
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Length of training to consultancy (p ¼ 0.0044) Lack of competition (p ¼ 0.0152) Long-term relationship with patients (p ¼ 0.0006) Compatibility with family-life (p ¼ 0.0175)
Factors not considered more important to either ‘medics’ or ‘surgeons’ Intellectual challenge (p ¼ 0.7879) Absence of emergencies (p ¼ 0.6912) Gender distribution of doctors in the specialty (p ¼ 0.6353) Personal experience of disease (p ¼ 0.2781) Peer group choices (p ¼ 0.5229)
Factors considered important to ‘surgeons’ in career choice Prestige (p ¼ 0.0003) Role model (p ¼ 0.0140) Financial rewards after training (p ¼ 0.0196) Technical challenge (p ¼ 0.0011)
Figure 1. Interpersonal Relationship Network Analysis of Career Intentions Green circles are those people undecided on career choice, the red squares represent students wanting to be ‘medics’ and the blue triangles those wanting to be ‘surgeons’.
(r ¼ 0.331) as well as private practice opportunities (r ¼ 0.317), technical challenge (r ¼ 0.222), respect for the specialty (r ¼ 0.189) and financial rewards (r ¼ 0.335). There was a negative correlation between wanting to pursue cardiothoracic surgery as a career and regarding a long-term relationship with patients as an important career determinant (r ¼ 0.200). Those who wanted to pursue O&G were motivated by the promise of long-term relationships with patients (r ¼ 0.214) and a diverse patient base (r ¼ 0.200). They were also likely to be female (number), to not have doctor in their family (number) and to report low enthusiasm for a specialty with intellectual challenge (r ¼ 0.227). There was also a negative correlation between wanting to pursue O&G and regarding length of training to consultancy as an important career determinant (r ¼ 0.261). Those students who wished to pursue neurosurgery were more likely to be motivated by
perceived intellectual (r ¼ 0.305) and technical challenges (r ¼ 0.351) of this specialty.
Interpersonal relationship networks Figure 1 shows a diagram of the interpersonal relationship network, which shows that the majority of students wanted to have careers in medical specialties or were undecided. When non-modifiable factors such as gender and ethnicity were considered, there were no statistically significant findings between measures of interpersonal relationship interaction and career choice.
Discussion This study shows that the career choices of medical students are influenced by a variety of factors, some of which are fixed
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(age, gender), some of which are slow to change (perceived characteristics of a specialty) and some of which are modifiable, for example, the degree of clinical exposure and the presence of role models. We have shown that within specific subgroups of students (men, graduates, potential surgeons), factors identified by our literature search have a role in determining students’ career intentions. Other factors, not explored within the remit of this study, may also play a role.
Non-modifiable influences on career choice
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Gender When students were asked to rate whether they would like to pursue surgery overall, there were no more men than women amongst those who said that they did want to pursue surgery. This is in contrast to previous studies, which have shown a preponderance of men to be interested in surgery (Azizzadeh et al. 2003). However, there were a number of surgical specialties that male medical students showed a particular interest in (over female students). Further, when students were analysed into ‘medic’ and ‘surgeon’ subgroups, the surgical subgroup was male-dominated.
Graduates Particularly of interest to the British medical community is that graduate-entry students did not want to pursue traditionally less competitive specialties. We found that graduate students appeared to show a propensity towards a career in neurosurgery, a specialty with a high competition ratio. Previous studies have either shown graduates have no particular specialty preference, or modestly favour general practice as a career choice (Lambert & Goldacre 1998; Lambert et al. 2001; Goldacre et al. 2007, 2009). This study implies that increasing numbers of graduates entering medical school may not be headed to a primary care career but may add to competition in hospital-based specialties.
Factors This study shows that some students tend to consistently rate groups of related factors as important in determining their career choices. We found two clear examples of this, with ‘reward-seeking’ factors clustered together (financial reward correlated with prestige, length of training and private practice) and ‘family/lifestyle-related’ factors correlating together (family life correlated with low competition, relationship with patients and lifestyle). This shows that discrete clusters of factors motivate some students.
Modifiable influences on career choice General This study shows that clinical exposure to a specialty can increase the desire amongst students to pursue a given specialty – as has been demonstrated in other studies (Greene et al. 2000; O’Herrin et al. 2003; Ravindra & Fitzgerald 2011). This is of importance in enhancing recruitment into specialties where there is a need for doctors. However, this relationship was not seen for all specialties. We 1070
did not test the reasons for this within this study, but this provides material for future study – and of interest to planning the workforce.
Medic versus surgeon students We compared a large number of characteristics of students who consistently expressed an interest in a surgical versus medical specialty. These students rated different factors as being important in determining career choice. Of note, students who wanted to be surgeons rated technical challenge as much more important. Moreover, those who were classifiable as medics or surgeons, tended neither to be influenced by peer group choices, nor by a lack of competition. In general, students interested in surgery tended to be motivated by ‘reward’-related factors, such as the presence of a role model, prestige and financial rewards. Those who wanted to pursue medical specialties were motivated more by ‘lifestyle’ related factors, including the length of training and compatibility with family life (Table 5).
Specialties Two specialties of particular interest for workforce planners are cardiothoracic surgery (predicted short-fall in consultants) and obstetrics and gynaecology (move to 24-hour on-call consultants, change in gender profile of trainees). There is a predicted shortfall of cardiothoracic surgeons to meet the needs of the aging population over the next 20 years (Fowler & Christakis 2008). Cardiothoracic surgery was the only surgical specialty in which clinical exposure resulted in a significant increase in desire to pursue the specialty. Improving exposure to this specialty is likely to enhance medical student intention to pursue this career. One way this could be influenced is through role models, which we and others (Stagg et al. 2012) identified as a major influence on careers. Obstetrics and gynaecology (O&G) is a specialty that has struggled to maintain recruitment over the last 20 years, with fewer numbers of men entering the specialty (Hammoud et al. 2006; Gerber & Lo Sasso 2006; Turner et al. 2006). We too report a low level of interest among male students. We also found that students coming from a medical family reported little interest in pursuing O&G and those students who do wish to pursue O&G rate pursuing a specialty with an intellectual challenge as low on their list of priorities. It may be that the experiences of family members in medicine have dissuaded students from considering O&G for a number of reasons, including lifestyle considerations. We did not record which specialty the family member practiced, and so it was not possible to determine whether students were being dissuaded from pursuing O&G by obstetricians or members of other specialties.
Strengths and limitations The strengths of this study lie in its broad scope and applicability to the medical community in England. The authors believe this study to be the first of its kind to broadly evaluate the career intentions of the current cohort of medical students studying in England and their underlying motivating
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Medical student careers, factors and networks
factors. The study is representative of the gender distribution of the English medical student population, with 56% of the responders being women (mirroring the higher proportion of female medical students across the country – 65% in 2002–3) (Dacre 2012). It is also representative of the proportion of graduate students entering English medical schools – 16% in this study, as compared to the 10% of graduate students entering UK medical schools in 2009–10 (Garrud 2011). One of the limitations of this study is the response rate (12%, 641/5400). Obtaining responses from 641 students was a good absolute number but, ideally, should have been higher. 5400 students was the maximum hypothetical number of students. This may be due to the questionnaire we set being lengthy (Jepson et al. 2005). A second limitation is that students were asked to look retrospectively over past experiences (e.g. desire to pursue a specialty before and after clinical experiences). Another limitation is that the students interviewed were all enrolled in large, academic, research-based institutions. It is possible that medical students at other institutions with different course structures and strengths may have other priorities determining their career choices. We had a much larger percentage of final-year medical students answering the questionnaire (41%) than is reflective of the breakdown of students per year (equal numbers of students in each year-group). There was also a potential self-selection bias, with students completing the questionnaire tending to be of particular character types and therefore tending towards certain career choices. Furthermore, the questionnaire presented an incomplete list of specialties to students, meaning that some students would not have been able to select a specialty that they wanted to pursue. The analysis of the interpersonal relationship network analysis was limited because a complete network could not be created due to the low response rate. We assumed that medical students would interact with each other if they belonged to the same club or society. Future studies could focus on following-up such students over time, to see whether their desire to pursue a given specialty was maintained through the first few years after qualifying as a doctor. Furthermore, although we could not detect a role for interpersonal relationship networking in determining career choice amongst the group of medical students studied, the concept of interpersonal relationship networks in determining decision-making remains relevant and important for future study. It could also be important to examine how career intentions change as students progress through pre-clinical to clinical education.
Conclusion This study reveals new links between undergraduate clinical exposure and student characteristics and career intentions. We have shown how both non-modifiable (age, gender, perceived specialty characteristics) and modifiable factors (nature of clinical attachment) can influence specialty career choices. These data provide a substrate for interventions aimed at promoting undersubscribed specialty training
programmes and in line with the future workforce profile in medicine.
Glossary Social Network Analysis: This method analysis the influence of social interaction (e.g. club membership, friendships) on a behaviour by testing whether the social interaction can predict the behaviour. Wasserman S, Faust K. 1994. Social Network Analysis. Cambridge: Cambridge University Press.
Notes on contributors MICHAEL IBRAHIM, MA, MBBS, PhD, Academic Foundation Doctor in Surgery, London. ANGELA FANSHAWE, MA, MBBS, MRCS, Core Surgical Trainee, London. VANASH PATEL, MBBS, MRCS, PhD, Surgical Fellow, London. KARAN GOSWAMI, MA, MBBS, MRCS, Core Surgical Trainee, Coventry. GEOFFREY CHILVERS, BSc, MBBS, MRCS, Core Surgical Trainee, Severn. MICHELLE TING, MA, MBBS, MRCS, Opthalmology Trainee, Moorfields Hospital. YIANNIS PILAVAKIS, MA, MBBS, FY2, Southampton General Hospital. CHRISTOPHER RAO, BSc, MBBS, MRCS, PhD, Academic Clinical Fellow in Surgery, London. THANOS ATHANASIOU, MD, PhD, FRCS, FETC, Professor of Cardiac Surgery, Imperial College London.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. Ethics Review: All participants consented to the anonymous use of their data.
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