Factors influencing career choices made by medical students, residents, and practising physicians

Background

The past few years have seen shortages of family physicians in urban and remote areas throughout Canada. Problems caused by the projected shortfall in the number of family physicians practising over the next few years will be exacerbated by an aging population that requires more health care services. Although there is an increasing demand for primary care physicians, fewer graduating medical students are choosing family medicine. Canadian Resident Matching Service (CaRMS) data indicate that 40% of Canadian medical school graduates made family medicine their first choice in 1982. By 1996, the proportion had declined to 32% and by 2005 to only 28%.[1] Similar trends were observed in the United States, where there was decreasing interest in primary care and increasing interest in subspecialties.[2-4]

As medical science and technology have become more sophisticated, the university spotlight has been focused on subspecialties. Consequently, many medical students appear to find primary care less appealing than other specialties. What further complicates the problem is the reimbursement gap between the generalists and the specialists.

Given the declining interests in primary care, an understanding of the factors that influence career choices made by medical students, residents, and physicians is essential. Although many variables (e.g., level of educational debt, mentorship experiences, income prospects, lifestyle) have been investigated in previous studies,[5-7] little research has been done to compare the relative importance of different factors affecting career choice, and the factors that have the greatest influence thus remain unclear. The purpose of the study described here was to identify the different factors and the relative importance of each in career selection in order to gain some insight into what might enhance interest in primary care as a career choice.

Methods
A one-page questionnaire was designed to identify the factors influencing career choice (see Appendix A and Appendix B). Respondents were asked to provide demographic data and to rank the factors that influenced their residency choice. The factors presented were chosen based on a literature review [5],[6],[8] and discussions with medical students, residents, and physicians.

Study population 
The study population included medical students, internal medicine and general surgery residents, and physicians currently practising in British Columbia. A total of 327 individuals received the survey package: 140 third-year University of British Columbia medical students, 36 internal medicine residents, 11 general surgery residents, and 140 physicians randomly selected from the College of Physicians and Surgeons of British Columbia physician directory.

Survey procedures
Between April and July 2005, survey materials were mailed to the medical students and physicians in practice, and distributed to the residents (who might not have a permanent address) at their academic half days.

The survey packages were completed anonymously and participation in the study was entirely voluntary. A cover letter sent with the survey package explained that completion and return of the material implied consent to participate. Completed forms and questionnaires were returned by fax or mail, and were destroyed after data analysis. The study was reviewed and approved by the Behavioural Research Ethics Board of the University of British Columbia.

Analysis
Chi-square analysis was used to determine the frequency count variables. The mean and median of the ranking variables were computed and reported. Because the subgroup sizes were small, the nonparametric Mann-Whitney U test was applied to the ranking variables.

Results 
The response rate was 36.1%, with 327 survey packages distributed and 118 completed and returned. Of the 118 respondents, 29.7% (35/118) were medical students, 37.3% (44/118) were internal medicine or general surgery residents, and 33% (39/118) were physicians. The response rate was 25.0% (35/140) for the medical students, 93.6% (44/47) for the residents, and 27.9% (39/140) for the physicians. Of the respondents 54.2% were male. The demographic characteristics of all respondents is shown in Table 1.

Factors influencing career choices
Respondents were asked to rank seven factors that influenced their career choices. “Personal interests” was ranked first among all the respondents, followed by “previous positive experience,” “personal reasons,” and “job opportunities.” Selection factors that were considered less important were “influence from a mentor,” “lifestyle and financial rewards,” and “geographical location.” The career choices and selection factors for the medical students, residents, and physicians were further analyzed separately. A summary of these findings is shown in  Table 2.

Medical students. Family medicine was selected as the top choice for a future career by 28.6% of students, while 22.9% expressed interest in internal medicine, and 8.6% were interested in surgical specialties. The remaining 37.1% of students were interested in other specialties, such as anesthesia, emergency medicine, pathology, pediatrics, public health, psychiatry, radiology, and radiation oncology (one student did not answer, so percentages do not total 100%).

Students ranked “personal interests” as the most important factor influencing their residency selection. This was followed by “previous positive clerkship experience,” “personal reasons,” and “lifestyle and financial rewards.” Factors that were considered relatively less influential were “future job opportunities,” “geographical locations,” and “influence from a mentor.”

When we grouped the students according to those who were and were not interested in family medicine and compared their career choice factors, there were significant differences for certain variables. Students who were interested in family medicine ranked “personal reasons” (P = .0329) and job opportunities (P = .0051) higher than other students. Those students not interested in family medicine ranked “previous positive clerkship experience” (P = .0003) and “influence from a mentor” (P = .0142) as more important factors.

Residents. As a group, the residents identified “personal interests” as the most important reason for selecting their specialty. This was followed by “previous positive clerkship experience,” “influence from a mentor,” and “future job opportunities.” Factors that were perceived as less important were “personal reasons,” “lifestyle and financial rewards,” and “geographical location.”

When responses from residents were analyzed according to specialty, “personal interests” ranked first among the internal medicine residents, followed by “previous positive clerkship experience,” “influence from a mentor,” “job opportunities,” “lifestyle and financial rewards,” and “geographical location.” Similarly, “personal interests” was considered as the most influential factor among the surgery residents, followed by “previous positive clerkship experience,” “influence from a mentor,” “job opportunities,” “lifestyle and financial rewards,” and “personal reasons.” “Geographical location” was ranked as the least influential selection factor. The differences between the two specialties were not significant.

Physicians. Along with the students and the residents, the physicians identified “personal interests” as the most important reason for selecting a specialty, followed by “previous positive clerkship experience,” “influence from a mentor,” and “personal reasons.” Factors that were less influential were “lifestyle and financial rewards” and “job opportunities.” Again, “geographical location” was considered the least important selection factor.

Mentorship
Respondents were asked to consider the influence of mentors on their selection of a career. Of those respondents with mentors who answered this question (57/118), more than 60% (38/57) said their mentors had “some influence” or a “strong influence” on their choice of residency. Approximately 40% of respondents in both the student and resident subgroups found their mentors “somewhat helpful” or “pretty helpful.” Respondents with and without mentors ranked “general guidance” and “career counseling” as the kinds of support from mentors that they valued most.

Not surprisingly, when we compared those respondents who had mentors with those who had never had mentors, those who had worked with at least one mentor during their medical training ranked “influence from a mentor” significantly higher than those without mentors, and the difference was statistically significant (P = .008).When we compared mentor influence for students and physicians, there was significant difference between the two groups (P = 0.02478). When we compressed the degree of influence into two subgroups—“no” or “minor” influence and “some” or “strong” influence—the difference was even more significant (P = .00554).

Table 3 summarizes the degree of influence mentors had on respondents, and  Table 4 summarizes the respondents’ ranking of the different kinds of support provided by mentors.

Medical students. Of the 35 student respondents, 23 currently had a mentor. Among these students, 30% found their mentors “very helpful” and 21.7% found their mentor “not at all helpful.” The rest of the students, 43.5%, found their mentors “somewhat helpful” or “pretty helpful” (one student did not answer, so percentages do not total 100%).

In terms of mentor influence on residency choice, only 13% of the students found their mentors had a “strong influence” on their career choices.

“General guidance” was the most important benefit students expected from their mentors, followed by “career counseling” and “professional support.” Providing “emotional support” and “assistance on research projects” was considered less important.

When asked whether they would be interested in a mentorship program in the future, the majority of student respondents (34/35) expressed interest.

Residents. Among the 44 responding residents, 20 had mentors prior to residency; however, this number dropped significantly during residency, to 11. When the residents were analyzed by speciality, 36% of internal medicine and 73% of surgery residents had mentors during medical school. During residency, only 27% of internal medicine residents and 18% of surgery residents had mentors.

Among those residents who had mentors prior to residency, only 15% found their mentors had a “strong influence” on their residency choices. 
For those residents who currently had mentors, 27.3% found their mentors “very helpful,” 27.3% “somewhat helpful,” and 45.5% found them “pretty helpful.”

“Career counseling” was ranked as the most important benefit residents expected from their mentors, followed by “professional support” and “general guidance.” Mentor roles that were considered less important were “assistance on research projects” and “emotional support.”

Despite the small number of residents with mentors, the majority of resident respondents (38/44) expressed their interests in a mentorship program in the future.

Physicians. Of the 39 physician respondents, 16 had had mentors during their residency. Among those who had mentors, 8 were strongly influenced by their mentors when choosing their careers.

As a physician and mentor, providing “general guidance” to the mentees was perceived as most important, followed by “career counseling,” “professional support,” “emotional support,” and “assistance on research projects.”

While 97.1% of student respondents and 86.4% of resident respondents were interested in a mentorship program, only 69.3% of physicians were interested, a statistically significant difference (P = .0079).

Study limitations
There were several limitations to this study. The sample size was small and the participant rate was low. The study relied on the respondents to self-report what influenced their career choices and these responses, especially in the case of residents and physicians, would be subject to recall or nondisclosure bias. Furthermore, this study looked at only seven career-choice selection factors; other factors such as marital status, level of educational debt, and desire to work with people, were not considered. Lastly, the study sample was drawn from students, residents, and physicians from a single Canadian province and may not be generalizable to other provinces and countries. To better understand the career-choice process, additional research involving input from other regions and residents from other specialty training programs would be needed.

Conclusions
The results of this study illuminate some key factors that influenced the career choices made by medical students, residents, and practising physicians. “Personal interests” and “previous positive clerkship experience” were the two most important factors for the students, residents, and physicians when selecting their specialty, while “lifestyle and financial rewards” and “geographical location” did not attain significance as predictors of a career choice. It was somewhat surprising to see that “lifestyle and financial rewards” had minimal influence on the career choices since previous studies[9,10] have shown that the odd ratios for selecting a residency other than primary care increased as the concern about student indebtedness increased. Moreover, comments in the Vancouver media have suggested that the decline in physician interest in primary care, especially family medicine, is in part due to income disparity between primary care physicians and specialists.[11,12]

The results of this study regarding mentorship were also somewhat surprising. Other studies have reported that role models or mentors influence a medical student’s selection of residency.[7,13] In our study, both the residents and physicians ranked “influence from a mentor” third, after “personal interests” and “previous positive clerkship experiences.” However, when asked about mentors specifically, very few respondents felt that mentors did not provide any influence. In fact, the perceived value of mentors appeared to be greatest among the practising physicians. This is in contrast to the responses of medical students, who perceived that having a mentor did not have any significant influence on residency selection. We concede that it is possible this finding may be due to the limitations of our study: the study looked only at third-year medical students from a single university and only 65.7% of these students had mentors. It may also be possible that students tend to meet their mentors after they have decided on a career path, and that the true value of mentorship is perceived only long after the mentorship has been completed and not immediately afterward or during the course of mentorship. Mentorship may in fact be of great benefit, even if those student respondents with mentors do not appreciate this right away. Another possibility is that the difference in the perceived value of mentorship in our study reflects a cohort or temporal effect. It may be that the generation of students we surveyed is less affected by mentorship than those of previous years. If this is true, then increasing exposure to mentors will be of limited benefit. Since there appeared to be a gradient in perceived value of mentorship from students to residents to practising physicians, and since the age gap between students and residents is not that great (i.e., most respondents within both groups were between 20 and 30 years of age), we do not feel that this was the reason.

Despite the limitations of this study, our findings suggest there might be ways to influence students to pursue careers in primary care. One way might be to increase exposure to primary care experiences during the first and second years of medical school, and to emphasize primary care ambulatory experiences during clerkship years. Another way to increase the number of primary care physicians might be through the medical student selection process. Explicit interest in primary care by a student applicant is a predictor for later generalist practice.[14,15] Therefore, selecting medical students who express an interest in primary care might be helpful.

Promoting interest in primary care will require substantial effort. Various strategies—including increasing exposure to primary care during training, selecting students who express interests in primary care, and improving satisfaction among family physicians—might encourage more trainees to pursue a career in primary care. However, all these will require a coordinated and interdisciplinary approach among the policymakers, physicians, and academics. Although this study provides some insight, studies that involve multiple centres and a larger sample are still needed to provide better understanding of the relative importance of various career-choice factors.

Acknowledgments
We thank Dr Jessica Mills for all her help with the distribution of surveys.

Competing interests
None declared.

Dr Ko is a gastroenterology fellow at the University of British Columbia. Dr Lee is the computer scientist for Cancer Control Research at the BC Cancer Agency, clinical assistant professor in Dermatology and Skin Science, UBC, and adjunct professor in Computing Science, Simon Fraser University. Dr Leung is a gastroenterology fellow at the University of Calgary. Dr Fleming is the associate dean for the MD Undergraduate Program at UBC. Dr Vikis is a senior general surgery resident at UBC. Dr Yoshida is an associate professor and head of the Division of Gastroenterology, UBC, and medical director of the Liver Transplant Program, BC Transplant Society.