MEDICAL STUDENT CAREER A CONCEPTUALIZATION WAYNE D. University

CHOICE:

MITCHELL*

of New

Mexico

Abstract-A model is proposed which conceives the making of career choice decisions by medical students as a process in which the student seeks an optimum match between the career alternatives open to him and his own preferences and life circumstances. The elements conceptualized in this process are the personal characteristics domain. the cognitive lens, the medical school environment, and the choice domain. These elements are given broad and Fairly open-ended conceptualizations in order to provide a generalized framework within which to unify and guide respectively past and future empirical research. To illustrate the utility of the model in this respect. a general strategy of theory construction is first described and then demonstrated using the model as a cohesive framework. It is suggested that several heretofore distinct areas of investigation can be fruitfully brought together by the model in ways which can both increase our understanding of medical students’ career choices and point the way to future research having theoretical and practical import.

of the factors influencing a medical student’s choice of speciality has been of increasing interest during the past two decades to medical educators and others who are concerned with the problem of health care distribution. Many studies have sought to ascertain which factors are associated with the choice of various specialties. During the past two decades there has also been a fairly large body of literature on what has been termed “professional socialization” [l-6]. Such studies have been primarily concerned with looking at how prospective entrants into various professional fields learn about and adapt themselves to professional roles and standards of conduct. In studies of the medical profession, these two areas have been somewhat distinct in regards to their foci as well as in regard to the investigators who have been doing work in these areas. The two areas do overlap, however; given one as the major interest of an investigator, the other area will become a significant but smaller subset of the phenomena with which he is concerned. In this paper, the emphasis is on specialty selection; thus professional socialization will be a subordinate concern whose relevance and position in the conceptualization will be discussed but not dealt with in detail. Those who wish to pursue this topic in further depth are referred to Bucher [7-lo]. A comprehensive review of studies of medical specialty selection [ll] from 1960-1972 found that background, economic, ability, personality, and experiential factors have all been examined in relation to specialty choice. The findings from studies during this period have been mixed: some are mutually supporting, some are conflicting and inconsistent, and others are not comparable due to the use of different instruments on different populations. Nevertheless, ope dominant impression given by the work of this period is that. with the exception of economic influences, these kinds of factors appear to be important in attempting to account for specialty choice. A second impression one gets from these studies is that while there is an abundance of evidence linking such factors to specialty selection, little work has been done to explicate the processes through which they affect specialty choice. At this point, it would appear that some kind of unifying conceptual framework is needed to carry future Identification

* The work upon which this publication is based was performed pursuant to contract number l-MI-24197 with the Health Resources Administration, Department of Health. Education. and Welfare. However, conclusions and recommendations expressed here do not necessarily represent the views of HRA or the DHEW. Reprint requests to: Professor Wayne Mitchell. School of Medicine. University of New Mexico, Albuquerque. New Mexico 87106. U.S.A.

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research beyond the “identification of relevant factors” stage to a more fruitful and useful explanatory stage. This paper attempts some beginning steps in the latter direction. A few preliminary comments are in order before examining the conceptualization presented here. First of all, specialty choice is seen as only one aspect of the choice situation confronting the medical student. The student must also make choices regarding such things as type of practice (e.g. solo, small group. mixed large group). type of communit> in which he will practice, allocation of professional effort. etc. Together these \,srious choices constitute the career “niche” which the student must select. The conceptualization below is concerned with selection of niches rather than with the choice of a specialty alone. Second, it is assumed that the student has already made a committment to some type of medical career and that the alternatives he is actively considering are limited to that occupational domain. The first section to follow will be concerned with the basic assumptions and concepts of the model: the second will present a discussion of the general strategy of theory construction which underlies the effort presented here: and the third will provide an example of the way in which the concepts and relationships in the model could be specified at a lower level of generality. NICHE

SELECTION:

A MATCHING

PROCESS

As conceptualized here, career choice on the part of medical students involves a matching process in which the student matches his own personal life circumstances and predispositions (or preferences) with a domain of possible medical career choices. The basic assumption of the model is that the student will select that niche which (a) he sees as optimally satisfying his preferences and priorities, and which (b) is compatible with the constraints imposed by his abilities and life circumstances. The various elements involved in the matching process are shown in Figure 1. Additional assumptions of the model will be made explicit as these elements and the relations among them are described. In modeling terminology, these elements are primitive terms, i.e.. they are to be described below rather than defined, and intentionally so. The reason for this is that at this point and level of discourse regarding the model, it is desirable to give these elements quite broad “definitions” in order not to exclude any interesting phenomena nor to cut off potentially fruitful explorations on a more concrete level. Such a modeling strategy is not peculiar to the social sciences and their “fuzzy” concepts, nor is it mere laziness on the part of a theorist who does not want to take the trouble to be more precise. Rather, it is an approach commonly employed in other sciences when an attempt is being made to generate a more productive theoretical approach through the synthesis of developments in several fields or areas of investigation. Wilson’s [17] work in sociobiology is a good example.

Personalcharaciwlstlcs domaln: prawous and present wcumstances

Fig. 1. Schematic

Cogitiva

life

diagram

MedIcal school enwronment

of components

Chace doman possible niches

of the matching

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1. Persoiurl c/~mrcter.istic.s dornuin This domain of characteristics consists of past experience, present life circumstances, personality, and the beliefs, attitudes, values, and predispositions held by an individual at a given time. (a) Pm experience. To the extent that the student is a product of his past socialization experiences, such experiences will have shaped his personality, his ways of looking at the world. his values. his interests. his life style, etc. Thus past experience, one sub-component of this domain. may help account, directly and indirectly, for the student’s present life circumstances, personality, and beliefs, attitudes, and values. In any operationalization of the model’s concepts, family background characteristics such as father’s and mother’s occupations, educations, and social class could be considered as part of past experience. Obviously these factors have very little, if any, direct influence on a student’s choice of a career niche. However, they are indirect indicators of past socialization experiences which have helped mold the student as he is presently. Consequently, an investigator might wish to use these characteristics to specify this abstract concept at a concrete level which would permit testing of some of the model’s relationships. b) Present /ifi circumtmces. At a concrete level. this sub-component may include such things as marital status, number of children, financial status, age, religion, and occupation of spouse, among other things. These circumstances continue to shape an individual. and often provide constraints on what opportunities he may pursue. (c) Persodity. Broad conceived, this refers to those relatively stable psychic attributes which are concerned with how an individual interacts with and adapts to the world around him. This is a crucial element in the matching process since it is important in accounting for a student’s predispositions and preferences for certain types of work activities [13]. his reactions to various experiences, and his perceptions of the alternatives open to him [14]. Being such a broad, open-ended term covering a multitude of aspects, it is quite likely that not all personality attributes will be relevant to niche selection. Otis et 01. [l l] report. for example, that although the MMPI has been used extensively, no “overriding patterns” have been identified which relate the attributes measured by that instrument to specialty choice. The Jungian Type indicator developed by Myers [lS] appears to be more useful in differentiating students choosing different specialties. We . merely note here that personality is broadly conceived in this conceptualization so that further research may determine which attributes are relevant to the matching process. (d) Attitudrs. heli+. dues arm’ pedisposifions. These elements have been grouped together as comprising one sub-component because they all seem to involve potentially active states of mind towards oneself, “objects” in the environment, or towards relations between self and the environment. The term “active state of mind” is used to connote several things: (a) that these elements are either maintained at the conscious level or can be and are brought to the conscious level by the situational context; (b) that these elements are more likely to be immediate precursors of action or behavior than are more dormant memories: and (c) that these elements are perhaps more readily changed than are underlying personality traits or preferences. Consequently, these elements should have a much more direct influence on career choice than does past experience, and we would expect these elements to be more strongly related to career preferences and choices than the latter. Indeed. recent research has confirmed this, at least for students at one medical school [16]. The elements or sub-components of the personal characteristics domain are complex and interesting in themselves and constitute an area of the model rich in unexplored but potentially ver) fruitful recursive and non-recursive relationships. In this paper, however. we can only point out the model’s capacity for subsuming and generating these relationships: their study will have to await another paper. For the moment our concern is with the inter-component relationships which are generated and/or subsumed bx the model.

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2. Cognitive

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MITC.HELL

lens

This term includes the general. underlying. enduring ways in which the individual deals with information coming from his environment. as well as the more fleeting processes of cognition. The cognitive lens is shaped by personality and experience. so much so that it is difficult to talk about it without taking into account the effects of these two factors. Personality in part determines how an individual deals with the vvorld around him, including the ways he deals with incoming information. Knowledge gained through past experience provides a structure or framework within which new information and experiences are processed and integrated. Personality and experience also have an effect on the more momentary processes of cognition. In part. they determine on which aspects of his environment a person will focus his attention, i.e.. \c,/~rrnew information he will seek out. They also determine the wlr_t’sin which an individual will seek out new information. The complexities of the cognitive lens are significant and interesting enough, however. that it seems worthwhile to include this component as a separate entity. Furthermore, the effects of personality and experience primarily account for the structure of an individual’s cognitive processes. For an understanding of the dynamics of these processes in given situations, it is more useful to focus on cognition as a separate entity with its own complexities. There is a whole field of research and theory which could be brought to bear on this point in the model, viz., that dealing with information processing and choice behavior [17-211. This work has been undertaken for its own sake and without thought of being integrated into a more comprehensive model such as the one presented here. Nevertheless much of this work has been quite general in nature and is easily adapted to this model. One recent work in fact. has suggested the potential applicability of one of these information processing theories to medical career choice [X]. For present purposes, we need not go into the details of these theories except to note two points. First of all, there are many different theories of choice behavior and information processing, and it is quite likely that various personality types tend to use different cognitive processes. Furthermore, it also seems likely that similar personality types employ different cognitive processes under different circumstances. Second. cognition has often not received the attention it deserves in social science research, and yet its importance cannot be ignored when one is attempting an explanation of behavior [ 181 or even disease [23]. 3. Educationul

environment

The medical school milieu determines what information and experiences the student will be exposed to. There are two basic aspects to this environment which are important to the matching process. (a) Mirror. In any social environment. the individual sees reflected back to him from that environment some image of himself. This notion has a long history in the behavioral sciences [24,25] and is particularly true of an environment concerned with making judgments about an individual’s abilities. The student receives images of himself and his abilities and weaknesses through the judgments made of him by faculty. If he does poorly in a course, his estimate of his ability in that area of medicine may be reduced. If a faculty member encourages him to pursue study in pediatrics. his estimate of his ability in that area may rise. He also gets some idea of himself as a future physician through comparison of himself with other students and faculty. The social environment of the medical school, then, acts as a kind of mirror in which the student sees reflected images of himself and his abilities. These images may not necessarily be consonant. either with each other or with the student’s own continuously evolving image of himself. Any resolution of the disparities in these images will occur through the cognitive lens. i.e. the student’s ways of processing and evaluating information from his environment. It may be, for example that the student will attribute one faculty member’s low opinion of his performance to personality differences rather than to his own inadequacies. In

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such a case, his interest in that particular area of medicine may be maintained until or unless he receives information from other sources which forces him to alter his estimate of his own abilities. Here again, the importance of cognitive processing is apparent: we cannot know how the student will respond to his environment’s evaluation of him without taking account of the kinds of information processing mechanisms he is likely to use under given conditions. (b) Prism. The values of the faculty and their views of certain aspects of medicine will be part of the information flow to which the student is exposed, as will the views, attitudes. and values of other students. The specialties, types of practice, and other alternatives about which the student must make choices are not perceived or experienced directly, but rather are refracted through and colored by the beliefs, attitudes, and values of other students and faculty in the medical school environment. In this respect, the educational environment acts as a prism through which are refracted images of the various career choices the student must make. These images may or may not be accurate. 4. Choice donzair7

This is the domain of career niches, and among other things it includes specialties, work settings. type of community, and type of practice. These constitute the reality with which the student will be faced upon leaving medical school. Without actually going into practice, he can know of these only through the images he gets of them through the medical school environment. As he gains more information about them, hopefully he will be able to make a choice which matches himself with reality. But this will not always be the case. Either he may change or the reality may change. Thus it is possible that an individual may change his specialty or niche after entering practice. To a certain extent, this is indeed what happens [26,27]. Equally important in the choice domain, although less tangible, are the ethos associated with various niches. As conceived here, the ethos is the over-all orientation towards work, self, patients, other physicians, and any other salient aspects of the physical and social milieu in which a given activity is carried out. It constitutes the collective definitions that arise among those working in a given niche. The various aspects of a niche may interact to produce a distinctive ethos: the ethos surrounding the practice of surgery in a military work setting may be quite different from that surrounding its practice in a research hospital. and the latter may be quite different from the ethos in a city hospital. The image the student gets of the ethos of a given niche is, of course. filtered through the educational environment prism. With respect to the matching process, a student considering a given alternative must match himself with the ethos of that alternative. as well as with the skills, knowledge, and abilities which it demands. Implicit in our discussion of the model to this point has been the assumption that the matching process is a dynamic one, i.e.. it rarely, if ever, involves an individual’s attempt to match static aspects of himself with static aspects of the choice domain confronting him. Perhaps nowhere in the model is this more evident than in the student’s attempting to match himself with one or more of the various ethos in the choice domain. This particular aspect of the matching process, while not necessarily the most theoretically (for us) or practically (for the student) significant feature of the model, does illustrate the dynamic character of all of the relationships involved in matching phenomena, and for this reason we examine it briefly as one example of matching dynamics. Once he enters medical school, the individual undergoes new socialization experiences, and consequently both he and the components of his personal characteristics domain are continually changing. He is acquiring new abilities. attitudes. values and orientations as well as new knowledge. Certain attitudes and values are as much requisites for becoming a physician as are certain skills, and students do not leave medical school with the same attitudes or values they had when they entered [28-311. All socialization leav,es its mark upon an individual. and this. in fact. is what should happen if the socialization experience called medical training is to be successful.

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It is evident that again there is a whole body of research which could be drawn upon to elaborate this particular aspect of the model. viz.. the literature on professional socialization, including reference group theory [3l]. As with our discussion regarding cognition, however, the aim here is not to pursue this elaboration. Rather. we mereI> note that once again the model is capable of drawing on an area which has been researched independently of the other areas subsumed by the model and is capable of integrating it with these other areas at a higher level of generality. Our main concern in this phase of the model is with the implications which some of the processes and outcomes of professional socialization have for other relationships within the model. It is obvious at this point that the matching process involves dynamic relationships among continually changing components. First. the student’s images of various specialties, for example, may change as he learns more about the activities. practices. and ethos surrounding each niche. These new images may alter what he had thought originally was a “match” between himself and a particular career alternative. Second, as the student internalizes the attitudes and values associated with. say. surgery. he himself will change. With such changes in himself may come a realization that there exist better “matches” than he had originally thought (e.g., he may realize that surgery fits his own evolving image of himself better than does psychiatry). and consequently he may change his career preference(s). One major implication of all this is that some associations between personal characteristics of first year medical students and career preferences may be weaker or no longer exist by the senior year, while other associations may be stronger by the senior year. Another less obvious implication is that during the undergraduate years of medical training, we may find that students’ career preferences exhibit seemingly eratic fluctuations over time. The model would suggest that such surges and declines in student interest in certain areas of medicine may be accounted for by students’ exposure to new experiences (as in clerkships) or to a particularly strong faculty role model who may give students an unforgetable but incomplete image of a given area of medical practice. In the latter case. subsequent adjustments in student interest levels may occur when students obtain additional information from other sources. As discussed thus far, the model is at a fairly general level of abstraction. and any propositions we might wish to derive from it in its present form must necessarily be at a similar level of abstraction. There is no question that the relationships derived at this level are not very helpful in providing us with testable hypotheses. They can best be described as telling us “where” to look and “what to look at” and thus function more as guides to research than as hypotheses to be tested. A GENERAL

STRATEGY

OF

THEORY

CONSTRUCTION

To develop testable propositions using the model as a motivating framework requires that we delimit or specify the components and relationships in the model at a lower level of abstraction. In Merton’s [33] terminology, what we need to do is to develop some theories and/or propositions of the “middle range.” The actual process of accomplishing this task depends to a large extent on the theorist’s creativity and imagination. Before looking at some examples of how this might be done, we first examine in more detail the nature of this particular theory-building stiategy. Figure 2 displays three levels with which we shall be concerned in our discussion. These levels have been chosen for heuristic purposes: in reality the process may involve a variety of levels of abstraction which fall in between these three. Level I. This level is the highest level of abstraction at which we deal with concepts and relationships in the model. All of our discussion of the model to this point has been concerned with components at this level. Here we are concerned with broad, openended concepts refering to general areas to be investigated. Concepts at this level embody no specific theories, and relations between concepts are constrained (i.e.. specified) mainly by the basic assumptions of the overall model.

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Medical student career choice

Level 1: highest of abstraction

* specific personality theory chosen by mvestxgator

1

A specifw cognitive theory chosen by investigator

level

Level II: “middlr range” theDriesand orcmositians at a lower l&=1 bf abstractron

t Observation and lneasurer..ent of empirical phenomena corresponding to

case, personahty preierences

same as at left: in this case cognitions of ,nd,v,duai students.

same as at left: in this case measures of sociallzatlon preSS*reS andf or experiences.

same as at left: in this case measures of the relationships among choice doma>n components.

Fig. 2. Three levels involved in the theory construction

Level III: operational level at whmh constructs from level Ii are “translatrd” into empirical assessment procedures or measurements

process.

Level II. This level comprises “middle range” theories which have been specified at a lower level of abstraction than exists in level I. Theories at this level embody specific constructs, assumptions, and propositions. The term constructs as used here refers to concepts which are chosen or devised (i.e., constructed) by the investigator for the purposes of (a) delimiting the scope of the phenomena in ways which have not been done before but which are necessary for the thrust of his investigation; (b) delimiting the phenomena in ways which will permit empirical investigation; and (c) specifying lower level assumptions and testable propositions about the phenomena. This is the level at which the actual “working out” and verification of theories takes place. Developments here are shaped and acted upon by both of the other two levels. (i) The model as developed at level I guides and constrains in very broad and general ways the nature of the theories, constructs, and assumptions which the investigator may select for testing and research. The model presented here gives considerable latitude to the investigator in this regard. Generally speaking, in any theory construction effort such latitude may be either a blessing or a curse. If very little empirical work has been done on the phenomena with which the model is concerned, the investigator will have few guidelines for developing middle range, testable propositions. On the other hand, if there has been a considerable body of disconnected, independently conducted, but relevant research in the area, then the framework at level I can aid the investigator significantly in his attempt to unify this knowledge in a (hopefully) fruitful way. (ii) The empirical research at level III, to be discussed below, provides a check on the “fit” of level II propositions with reality by yielding infirming or confirming data. The empirical feedback from level III may act in several ways on the middle range theories and propositions at level II. First, research from level III may provide confirmation of the propositions developed at the middle range level, in which case the investigator can proceed to elaborate his theory and propositions or to’test other crucial parts of his theory. Second, empirical research may refute some or all of the propositions at level II. In this case. these propositions can be revised or the theory respecified in a manner consistent with the framework of the more abstract model at level I. The revised propositions are then tested and the process repeated if necessary until confirming evidence is obtained which indicates that the middle range propositions are empirically justifiable. Third, the empirical evidence at level III may disconfirm the original proposition(s), but at the same time may suggest promising alternative middle range propositions which the investigator may wish to explore.

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Whichever of these three possible outcomes occurs. in one sense the result is the same. That is, the empirical data at level III provides the investigator with information which he can use to improve or elaborate his theoretical developments at level II. the middle range. It is at this middle range that the actual construction of a viable. testable theory takes place. It should be noted here that empirical results do not bear on the model as it has been developed at level I. The model is not a theory, is not testable in the sense that theories are, and is not “proved” or “disproved” by empirical results at level III. Rather, the model is seen as a very general. abstract conceptual framework which is more or less useful in (a) guiding the development of middle range. testable hypotheses. and (b) suggesting areas of potentially fruitful research. This view of the relationships between model, theory, and empirical test is similar to that of Willer [34], although his conception of the nature and role of models is much more complex than that used here. At any rate, the developments to follow will be consistent with the relationships described in Fig. 2, and are primarily for the purpose of illustrating the kind of theoretical fruitfulness and unification which are possible within the model’s framework. Level 1ZZ.This is the level at which the constructs of middle range theories or propositions at level II are operationalized. That is, instead of working with concepts or constructs, we are here working with measures of these. Such measures may take the form of existing instruments, such as those for measuring personality characteristics or preferences; or, they may take the form of new instruments developed by the investigator. as is likely to be the case when a researcher desires to operationalize a construct which he may have devised in the course of developing new middle range propositions. Operationalizing procedures per se are beyond the scope of this paper. but they are nonetheless critical to the practical application of any theory. Before proceeding with the development of middle range propositions. several important points should be mentioned. First of all, given the very general nature of the model’s framework, we may choose from a variety of possible middle range theories or propositions all of which might be consistent with the basic framework of the model. There are several theories of personality from which we might choose, for example. and numerous theories of choice behavior and socialization processes which could be incorporated into the framework. This does not mean that the model is so broad or general that it is unable to tell us which middle range theories to use; this is not its function at all. The model’s function is to indicate which content areas (e.g., personality, choice theories, and socialization theories) of middle range theories or propositions can be fruitfully combined in certain ways (including causal or even interactive orderings) to increase our understanding of the niche selection process. Which specific middle range theories should be used is initially up to the investigator but ultimately is determined by the criteria of empirical test and fruitfulness in generating propositions once these theories have been combined in ways suggested by the model. Second, since the model comprises a broad range of phenomena, it is quite likely that we may not wish to investigate all of these phenomena simultaneously. We may wish, for example, to limit our inquiry at first to the relationships between personality and the cognitive lens. Once substantial progress has been made in this area we may subsequently investigate other relationships in the model. Thus, the examples to be discussed below are only that. They are not the only middle range theories which might be used, and they do not involve the entire scope of phenomena covered by the model. DEVELOPING

MIDDLE

RANGE

PROPOSlTlONS

Any middle range theories we might use must be consistent with the model’s assumptions. To recapitulate, the basic assumptions of the model’s framework within which we must work are the following: (1) The student will seek to select that niche which he sees as optimally satisfying his preferences and priorities. and which is compatible with the limitations imposed by his abilities and life circumstances.

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(2) From his medical training experiences the student acquires information about (a) himself and (b) career niches which he will use in attempting to make an optimal match between the two. (3) The components involved in this matching process and the relations among them are those specified in Figure 1. Within this framework we can now select middle range theories to investigate. First. we will examine a personality theory and look at the hypotheses suggested by it alone, following which we will propose some additional hypotheses resulting from placing it in the context of the model. Next we will look at some theories of choice behavior, first examining hypotheses suggested by them alone and then examining hypotheses generated by combining these theories with the personality theory.

Incorporation of a personality theor!. We begin with Jung’s theory of psychological types as it has been elaborated by Myers [15]. The Myers-Briggs Type Indicator (MBTI) assesses four basic personality preferences, each of which involves two aspects. These are (1) two preferred areas in which one may function, extraversion (E)/introversion (I); (2) .two ways of perceiving, sensing (S)jintuition (N): (3) two preferences for making judgments or evaluations, thinking (T)/feeling (F); and (4) two underlying attitudes toward the outside world, judging (J)/perceiving (P). Those who prefer extraversion (E) tend to focus on the outer world of people, things and action, while those preferring introversion (I) prefer the inner world of ideas and like to reflect at length before acting. Sensing types (S) tend to be realistic, practical, and good at working with facts and sensory data, whereas intuitives (N) value imagination, inspirations, and creative problem-solving. Thinking types (T) tend to deal with the world by means of realities and logic rather than human emotions. Feeling types (F) tend to be sympathetic and to value human likes, dislikes, and values more than logic. Judging (J) types prefer order and planning in their lives and aim to control their life situations, Perceiving types (P) prefer flexibility and spontaneity and approach life in an attempt to understand and adapt to it. These four preferences are combined in all possible ways (e.g., ESTJ, INFP, ISFJ, etc.) to produce a total of sixteen different personality types, each of which exhibits a particular pattern of preferences regarding their most favored types of activities and ways of dealing with the world. The theory speaks of preferences rather than traits since all individuals are seen as possessing varying degrees of all of these qualities. The personality theory embodied in the MBTI is capable of generating numerous hypotheses regarding which personality types will tend to prefer, for example, various medical specialties. Extraverted, sensing. thinking, judging types (ESTJ’s) are good managers. like to work with concrete realities, and prefer decisive action; consequently we would expect them to exhibit preferences for surgery, technique and instrument specialties such as otorhinolaryngology, or general practice. Opposite types, the introverted, intuitive. feeling, perceiving types (INFP’s) who enjoy complex problem solving and theory. would tend to prefer psychiatry. Many other hypotheses are suggested by this particular personality theory and have been supported by a considerable body of research. The interested reader is referred to the literature in this area [13,35-37-J. We now turn to additional propositions generated by incorporating this personality theory into the model’s framework. From assumption 2 of the model. we would expect. as mentioned earlier, that students’ preferences will change as they acquire more information about themselves and the career niches open to them. The less information they have, as is the case for freshmen, the less “certain” will be their preferences. As they gain more information. their preferences will become somewhat more definite. and hence we would expect the preferences of seniors to be more highly correlated with both personal characteristics and ultimate career decisions than are the preferences of freshmen.

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By incorporating Jung’s theory of psychological types into the model. however. we can say much- more than we can using either our model or the personality theory alone. First of all, we would expect judging types. and particularly extraverted. sensing. judging types (ES-J’s) to reach more definite preferences earlier in their training than perceiving types, especially introverted. intuitive. perceiving types (IN-P’s). This statement actually embodies two propositions: (1) that ES-J’s will tend to be actively considering a smaller set of specialties at any one time. for example. than will IN-P: and (2) that ES-J’s will make an earlier decision about specialty choice. say. than will IN-P’s It is also probable that these personality types will exhibit the same differences with respect to decisions about the other niche components. such as community size, geographic area, and allocation of professional time to various activities such as direct patient care, research, and teaching. Second, assumption 2 in the model also suggests that in the absence of complete information about career niches, certain types of information may be more important than others. Thus, impressions created by strong faculty role models may have more impact on students’ thinking than will the impressions created by less influential sources. In addition, type theory suggests that certain types of students are more likely to respond to strong role models than are others. While the model alone suggests that ffuctuations in student interest in various career alternatives may occur during the four years of undergraduate training, the incorporation of type theory into the model enables us to be more specific and to hypothesize that (1) extraverted types will exhibit greater fluctuations of interest under the influence of strong faculty role models than will introverted types; and (2) these surges of interest are apt to be longer lasting for IS-J types than for EN-P types. There are other propositions which might be developed from the incorporation of this particular personality theory into the model. but those discussed above should suffice to illustrate what can be done with the model once we have specified the nature of even one component (in this case. personality) at the middle range level. We now turn to the middle range specification of another component of the model. the cognitive lens.

Incorporution of choice theories As mentioned earlier, there is a fairly large body of work in the areas of choice. judgment, and decision making on which we can draw in specifying the nature of the cognitive lens at a lower level of abstraction. It would be kept in mind that the theories which are envisioned as being relevant here are not “normative” theories which specify what behavior “should” be like. Rather, they are the “paramorphic” theories [38] which have been developed to predict the outcomes of decision making processes. Many such paramorphic theories do not presuppose rational or logical thought processes at all. but are capable of subsuming non-rational types of behavior. We will discuss here only two general classes of these theories, qualitative and quantitative. In general, qualitative theories of choice behavior [18,22] are concerned with the presence or absence of various properties which might be present in the alternative with which the individual is confronted; that is, choice is seen to be the result of evaluating alternatives on the basis of which properties the individual thinks are present or absent. Quantitative theories. on the other hand, view choice as resulting from evaluations based on the degree to which various properties are believed to be present in the alternatives [20]. It has been suggested that these two classes of choice theory may describe choices that are made under different circumstances [32]. Qualitative theories may be appropriated when the alternatives are quite dissimilar or when the individual has only limited information about or experience with the alternatives. Quantitative theories may best predict choice behavior when the individual has narrowed the range of alternatives he is seriously considering and/or has considerable information about each. In the context of the model. we might thus hypothesize that early in their training.

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medical students’ preferences for various niche characteristics are best predicted by qualitative theories of choice. The preferences of juniors and seniors are hypothesized to be described best by quantitative theories. While there exists a wide range of choice theories of sufficient development to suggest considerably more hypotheses than those above, further discussion of these would be quite lengthy. Hopefully the examples described are adequate to illustrate the richness of possibilities that exists in this aspect of the model. These possibilities become even more numerous and practically significant when we examine the potential results of combining personality and choice theories. Combining personalit!. and choice theories under the model In addition to differentiation by the qualitative-quantitative criterion, theories of judgment may also be classified on the basis of their complexity. Some theories of decision making processes are relatively simple in that they take account of only limited aspects of the phenomena being judged or else they specify fairly simple ways in which these aspects are combined when an individual arrives at a decision or choice. Other theories are more complex in that they describe the decision maker as using relatively complicated combinations of aspects to make a decision. Some of these theories even involve several levels or stages in the evaluative process that precedes a decision. Given type theory’s descriptions of the EI and JP preferences, it seems likely that the decisions of E--J types might tend to be more accurately described by the simpler decision theories, whereas the decisions of I--P types might be more accurately described by complex theories. The assumption behind this tentative proposition is that individuals using more complex decision-making processes require a longer time period in which to reach a decision. Since I--P’s usually prefer to reflect at length more than do E--J’s, this suggests that they may be using more complex decision-making mechanisms that are best approximated by complex theories. Another tentative proposition in this area is that thinking types will tend to use rational, logical decision processes, whereas the decision-making behavior of feeling types might best be described by theories depicting non-rational, more value-based types of “logic.” Further, we might also hypothesize that sensing types will tend to seek out or respond more readily to concrete and specific types of information, whereas intuitives will tend more to seek Gestalt or “holistic” impressions in attempting to arrive at decisions. It is true, of course. that type theory and choice theories could be integrated independently of the model developed in this paper. However, it is also true that the model’s framework itself suggests such an integration. and hence in this respect it acts as a kind of guide to an area of potentially fruitful development which has not yet been undertaken. But the utility of the model’s capacity for incorporating the integration of type theory and decision theories goes beyond this. Assuming for the moment that empirical results will confirm the integrability of type and decision theories, we would then be in a position to make some inferences regarding what kinds of information about specialties, for example, could be given to various types of students at certain points in their undergraduate medical training. Such information could be used to help students acquire more realistic images of various specialties and thus aid them in making more realistic decisions. The “information” to be provided, of course, might have to be tailored to various personality types: and some such “information” might not be “facts” at all. but rather first-hand experiences. To be more concrete in this example, we note that type theory identifies -NFP’s as being highly idealistic. while -STJ’s are much more realistic, practical and hardnosed. To put it another way. -NFP’s may “fantasize” about certain aspects of medicine much more than -STJ’s. Thus if we knew what types of decision models -NFP’s tend to use, it would be possible to expose them to the appropriate types of information and/or experiences which would provide them with a reality check to help them make more realistic decisions regarding choices of electives and internships. For -STJ’s, on the

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other hand, we would suspect that the nature and duration of experiences needed to help them make realistic choices would be quite different. The model as developed in this paper suggests that such information and experiences should be provided to -STJ’s fairly early in their training, whereas for -NFP’s the exposure to experiences could occur later, but might have to be of longer duration. It is only the nature of the information to be presented or experiences appropriate to each personality type that are unknown: and the research suggested earlier should elucidate these points. Should the notions presented here be borne out by the data, such information would be of significant use to those medical schools and students who are experimenting with shorter training periods for physicians. SUMMARY

The model developed here has been presented at a very general level specifically for the purpose of leaving it flexible and open-ended. It is thought that at this stage of investigation into career choice processes of medical students some kind of cohesive framework is needed within which a variety of empirical results can be unified. The advantages of using such an open-ended model are twofold. First of all. it remains flexible enough that it does not close to one’s thinking potentially fruitful areas of inquiry, yet it provides a definite structure which serves to guide and integrate past and future research. Second, it permits the researcher to experiment with various middle range theories and propositions in order to determine which are the most fruitful within the context of the model’s framework. The ultimate success of the constraints and specihcations a researcher chooses to use will, of course, depend on the nature and number of hypotheses which are generated as a result. In this latter respect, it was suggested as an example that the use of a specific personality theory could be particularly fruitful in that it (1) could offer its own hypotheses about niche preferences, and (2) in conjunction with the model could yield quite specific predictions above and beyond what would be generated either by it or the model alone. In addition, the model implies that personality and cognitive processes are interrelated: thus the model suggests that the personality theory chosen for an example might well be investigated in relation to various models of cognitive processes which have been developed independently. This latter was used as an example of the model’s capacity for generating lines of inquiry which appear worthwhile but which have had little or no research effort. Finally, it was pointed out that some of the hypotheses developed by the means described here could be of use to policy-makers in medical education should they be confirmed by empirical data. REFERENCES I. D. J. Levinson. Medical education and the theory of adult socialization. J. H/t/t Sot. Behct~. 8. 153. 1967. 2. A. G. Olmstead and M. A. Paget. Some theoretical issues in professional socialization. J. .\lrr/. Ehc. 44. 663. 1969. 3. W. E. Moore. The Professmrrs: R&s and Rules. Russell Sage Foundation. New York. 1970. 4. R. Pavalko, Sociology of Occuputions und Professions. F. E. Peacock. Itasca. 1971. 5. R. Merton. G. G. Reader and P. L. Kendall, Thr S~udenr Physiciun. Harvard Universtty Press. Cambridge. 1957. 6. H. S. Becker and J. W. Carper. The development of identitication with an occupation. .4rn. J. SK. 61. ‘89. 1954. 7. R. Bucher. Implications of prior socialization for residency programs in psychtatry. 4rch. Gm. Pv!~hi~rt. 20. 395. 1969. 8. R. Bucher. Professions in process. Am. .I. Sot. 72. 467; 1961. 9. R. Bucher, A situational model of professional socialization. unpublished manuscript. work supported by USPH Career Development Award No. 5-K-3-MH-25. 203, and by USPH Grant No MH 10391. 1969. IO. R. Bucher. J. Stelling and P. Dommeruth, Differential prior socialization: a comparison of four professional training programs. Sot. Forcrs. 28, 213, 1969. ,Mrt/icrt/ Sprc~itrltI Srkctiotl : .-I I I. G. Otis. N. Quenk. J. Weiss. M. Albert. J. Offir and C. Richardson. Rrrinll. DHEW Publication No. (HRA) 75-8. U.S. Dept. of Health. Educ.. and Welfare. Pub. Health Serv.. Health Resources Admin.. 1975.

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12. E. 0. Wilson, Sociohioloyi.. Harvard Univ. Press, Cambridge, 1975. 13. 1. B. Myers and J. A. Davis, Relation of medical students’ psychological type to their specialties twelve years later. Educations Testing Service Research Memorandum RM64-15, Princeton, 1964. 14. G. Otis and J. Weiss. Eunlorurions in Medical Career Choice. Univ. New Mexico, NIH Contract No. 71-4066. 1972. 15. 1. G. Myers, The Myers-Briggs Type Indicator Manual. Educational Testing Service, Princeton, 1962. 16. G. Otis and W. Mitchell A model of physician career dispositions. Univ. New Mexico Study Report 1. Bureau of Health Resources Development. Health Resources Admin., Contract No. I-MI-24197. 1975. 17. R. D. Lute. Individual Choice Behacior. Wiley, New York, 1959. 18. F. Restle P.s~~cholo~gy of Judgment and Choice. Wiley, New York, 1961. 19. R. N. Shepard. On subjectively optimum selection among multiattribute alternatives. In Humun Judgmrnrs tmd Optimrrlir!. (Edited by Shellv M. W. and Bryan G. L.). Wiley. New York, 1964. 20. H. J. Einhorn. The use of no&ear. noncompensatory models in decision making. Psych. Bull. 73. 221. 1970. 21. P. Slavic and S. Lichtenstein, Comparison of Bayesian and regression approaches to the study of information processing in judgment. Oryan. Behac. Human Per. 6, 649, 1971. 22. W. D. Mitchell. Restle’s choice model: a reconceptualization for a special case. J. Voc. Behar. 6, 315, 1975. 23. S. M. Stahl. C. E. Grim. C. Donald and H. J. Neikirk. A model for the social sciences and medicine: the case for hypertension. Sot. Sci. Med. 9, 31. 1975. 24. C. H. Cooley. Humun Nature and rhe Social Order. Scribner, New York, 1902. 25. G. H. Mead, Mind. Se!/: and Society. University of Chicago Press, Chicago, 1934. 26. J. Knight, Medical Srudenrs: Doctor in the Making. Appleton-Century Crofts, New York, 1973. 27. N. Quenk and M. Albert. A taxonomy of physician work settings. Univ. of New Mexico Study Report 2. Bureau of Health Resources Development, Health Resources Admin. Contract No. l-MI-24197, 1975. 28. H. S. Becker and B. Greer. The fate of idealism in medical school. Am. Sot. Rev. 23. 50. 1958. 29. L. V. Gordon and I. N. Mensh. Values of medical students at different levels of training. J. Educ. Psrch. 53, 48. 1962. 30. A. M. Reinhardt and R. M. Gray. A social psychological study of attitude change in physicians. J. Med. Educ. 47, 112, 1972. 31. A. G. Rezler. Attitude changes during medical school: a review of the literature. J. Med. Educ. 49, 1023. 1974. 32. H. H. Hyman and E. Singer. (editors) Readings in Reference Group Theory und Reseurch. The Free Press, New York. 1968. 33. R. Merton. Sociul Theor!, and Social Structure. (rev. ed.), The Free Press, Glencoe. 1957. 34. D. Wilier. Scientific Socioloav. Prentice-Hall. Enelewood Cliffs. 1969. 35. M. McCaulley, The Myers%-iggs Type lndic&r in Medicni Education. Amer. Assoc. Med. Colleges, Washington D.C.. in press. 1975. 36. N. Quenk and W. Heffron. Types of family practice teachers and residents: a comparative study. J. Fum. Pmt. 2, 195. 1975. 37. N. Quenk. Characteristics of physician work settings in relation to Myers-Briggs type preferences. Paper to be presented at 1st National Conference on the Uses of the MBTI, Oct. 1417, Gainesville. 1975. 38. P. Hoffman. The paramorphic representation of clinical judgment. Psych. Bul. 57, 116. 1960.