Associations between medical school and career preferences in Year ...

making choices Associations between medical school and career preferences in Year 1 medical students in Scotland Jennifer Cleland,1 Peter W Johnston,2 Fiona H French2 & Gillian Needham2

OBJECTIVES Little is known about the relationship between the career preferences of medical students and the medical schools at which they are enrolled. Our aim was to explore this relationship early in students’ medical training. METHODS Year 1 (2009–2010) medical students at the five Scottish medical schools were invited to take part in a career preference questionnaire survey. Questions were asked about demographic factors, career preferences and influencing factors. RESULTS The response rate was 87.9% (883 ⁄ 1005). No significant differences were found among medical schools with regard to first-choice specialty. Surgery (22.5%), medicine (19.0%), general practice (17.6%) and paediatrics (16.1%) were the top career choices. Work–life balance, perceived aptitude and skills, intellectual satisfaction, and amount of patient contact were rated as the most important job-related factors by most

respondents. Few differences were found among schools in terms of the impact of jobrelated factors on future career preferences. Students for whom the work–life balance was extremely important (odds ratio [OR] = 0.6) were less likely to prefer surgery. Students for whom the work–life balance (OR = 2.2) and continuity of care (OR = 2.1) were extremely important were more likely to prefer general practice. CONCLUSIONS Students’ early career preferences were similar across the five medical schools. These preferences result from the interplay among demographic factors and the perceived characteristics of the various specialties. Maintaining a satisfactory work–life balance is very important to tomorrow’s doctors, and the data hint that this may be breaking down some of the traditional gender differences in specialty choice. Longitudinal work is required to explore whether students’ career preferences change as they progress through medical school and training.

Medical Education 2012: 46: 473–484 doi:10.1111/j.1365-2923.2012.04218.x Discuss ideas arising from this article at www.mededuc.com ‘discuss’

1

Division of Medical and Dental Education, Faculty of Medicine, University of Aberdeen, Aberdeen, UK 2 North of Scotland Deanery, National Health Service Education for Scotland, Aberdeen, UK

Correspondence: Jennifer Cleland, Division of Medical and Dental Education, University of Aberdeen, Polwarth Building, West Wing, Foresterhill, Aberdeen AB25 2AZ, UK. Tel: 00 44 1224 437257; Fax: 00 44 1224 550683; E-mail: [email protected]

ª Blackwell Publishing Ltd 2012. MEDICAL EDUCATION 2012; 46: 473–484

473

J Cleland et al

INTRODUCTION

Many factors influence the career decisions made by medical students. These range from the characteristics of individuals,1,2 to the perceived benefits of particular specialties,3–5 to factors associated with medical school curricula, such as experience of the chosen specialty.6–9 Recently, studies have suggested that quality of life has become a determinant in specialty selection criteria4,10–12 and has been found to be more influential than more traditional specialtylinked motivators, such as remuneration.5,10,11 It is also clear that demographic factors, such as gender, influence medical career preference.2,11,13 The majority of research into career preferences in medicine has tended to be carried out in US and Canadian populations,3–5,10,11,14,15 in students who are either near graduation16 or in graduates12,17–20 (see also the work of the UK Medical Careers Research Group [http://www.uhce.ox.ac.uk/ ukmcrg/]), or in students who have entered medical training as graduates.17,18,21–23 Alternatively, it has focused on specific career preferences, often for general practice.24–30 There is evidence, mostly from the USA,17,18,21–23 that some students have reasonably firm career preferences on entering their medical studies, although these do shift for a proportion of students.25 Although there may be some similarities, findings in US graduate-entry medical students on non-integrated degree programmes are unlikely to be directly applicable to other medical education settings, such as those in the UK, where most students enter medicine as undergraduates aged 17–20 years. Similarly, studies of graduating students and those who have already graduated are also unlikely to be directly applicable as these individuals can be viewed as having already, albeit if tentatively, committed themselves to a career pathway (i.e. they have applied for or commenced particular training programmes). Furthermore, there is a need to maintain up-to-date information on career preferences. This need is not unique to the UK, but changes in the structure of medical careers and progression resulting from the UK’s Modernising Medical Careers (MMC)31 initiative introduced in 2007 require junior doctors to make a definitive choice about a career pathway much earlier than they have had to in the past. (The reorganisation of UK medical training is explained later in the paper.) Furthermore, studies to date have not explored the relationship, if any, between career preferences and

474

choice of medical school, even when the opportunity to do so has been available.18 This is pertinent in the UK, where student demographics vary across medical schools,32 applicants to medicine rank medical schools preferentially,33,34 and graduate career paths appear to differ by school.35 Applicants may be attracted to different medical schools for different reasons – curriculum, reputation, size or geographical location – or perhaps students with particular career preferences choose to go to particular schools. It may be that differences in graduate career preferences among medical schools are related to student variables rather than to variations in medical school education provision and ‘habitus’.33,34 In short, little is known about career preferences in new-entry medical students on undergraduate degree programmes, or about the relationship between career preference and medical school. Why is this important? If UK medical students enter medicine with specific career preferences, knowing more about these early preferences, and the correlations between them and individual factors, is critical: the UK National Health Service (NHS) needs a supply of medical graduates who are willing to train in all specialties, in the right proportions and in the right places, if it is to meet the health care needs of all people, everywhere. Furthermore, careers advice can be better designed,16,36 in terms of both timing and content, to meet the needs of applicants for medical school, young doctors and the population if we know more about early career preferences. An understanding of the factors influencing early career preference could also be used to modify methods of medical school selection, medical school curricula and practice opportunities. The aim of this study was to explore students’ career preferences upon entry into undergraduate medical degree programmes in Scotland using a cross-sectional questionnaire survey.

METHODS

Setting and background population Students were surveyed at the five Scottish medical schools (at the Universities of Aberdeen, Dundee, Edinburgh, Glasgow and St Andrews), which together have approximately 1000 students in each year of study. Applicants to medical school in Scotland tend to study medicine as an undergraduate degree, progressing directly from secondary (high) school to


Career preferences of Year 1 medical students medical school. Each school has a greater number of female than male students (approximate ratio: 60 : 40). Student domicile (home address on acceptance to medical school) varies across the medical schools, but about half of those accepted to Scottish medical schools are domiciled in Scotland (http:// www.scotland.gov.uk/Publications/2002/07/15037/ 8376). The process for applying to medical school requires the candidate to apply through the UK Universities and Colleges Admissions Service (UCAS), a national forum for applications to many UK degree courses. Application is competitive and is based on the attainment of a certain standard in school examinations such as Scottish Highers, English A-levels and the International Baccalaureate, coupled with outcome on the UK Clinical Aptitude Test (UKCAT), a standardised admissions test used by most UK medical schools since its introduction in 2006 (http:// www.UKCAT.ac.uk), and performance at interview. Each of the Scottish medical schools differs in its admissions process in terms of the relative weightings given to UKCAT outcome, interview format and performance (Personal communication with J Dowell, Admissions, University of Dundee). Four of the schools offer 5-year degrees, with elective intercalating degree programmes; the fifth (St Andrews) offers a 3-year BSc degree, after which students complete their medical degree elsewhere (approximately half in Scotland and the remainder in England). Excluding that at St Andrews, the programmes are comparable with most UK medical degree programmes other than graduate-entry programmes. (At the time of writing, there were 16 graduate-entry and 31 undergraduate medical programmes available in the UK; the undergraduate programmes produce approximately 90% of medical graduates.) The five medical schools in this survey, like all UK medical schools, must deliver medical education to adhere to published guidance and standards of the General Medical Council (GMC) (http://www.gmc-uk.org/education/undergraduate. asp). Unlike, for example, schools in the USA, UK schools do not have reputations as leaders in particular clinical areas, probably as a result of the (mostly) undergraduate nature and national governance of medical education in the UK. The five schools in the study also differ in various important respects, including: curricula (e.g. problembased, case-based or traditional, lecture-based learning); student intake (ranging from 220 to 145 per year); geographical location; setting (which varies

from that of a large city in a heavily populated area to that of a relatively rural, coastal town), and age (Aberdeen has the oldest Chair of Medicine in the English-speaking world [1497], whereas Dundee became an independent university in 1967). It is relevant to state that at the time of data collection, fees were not charged to any student studying in Scotland. Medical training changed in the UK with the introduction of MMC in 2007.37 After graduating from medical school, prior to specialist training, young doctors now undertake a structured 2-year training programme called the Foundation Programme (FP). Before MMC, medical graduates often worked in a number of different specialties over a period of years before making a career decision (e.g.20,38), but this approach to learning about different specialties is not easy under MMC. Instead, medical graduates must decide on and apply for specialty training posts while they are on the FP. Because young doctors have gained less experience by the time they are required to make career decisions, early careers guidance is now even more important to help medical students make informed career choices. This contrasts with the previous system of training in which many freestanding junior hospital posts offered opportunities for experience and learning. These posts could count towards training in relevant specialties: for example, such a post in emergency medicine (accident and emergency) could count towards training in surgery, anaesthesia or general practice. The loss of these posts has denied many trainees the opportunity to spend a year or two exploring specialties before making a career decision. Participants Study participants included all Year 1 undergraduate medical students at the five Scottish medical schools in 2009–2010. Instrument The questionnaire was designed by the authors with reference to an advisory panel of undergraduate and postgraduate faculty staff, and the current literature on career choice and preference (Appendix S1, online). There is no consensus on the appropriate sample size for pre-piloting a questionnaire and therefore we used a small, relevant sample (six finalyear school pupils and six medical students in Years 1–3). These respondents were asked to think aloud as they worked through the questionnaire. Minor


475

J Cleland et al refinements (e.g. in wording and question order) were made on the basis of this pilot work. Forced- and free-choice questions were used. Forcedchoice questions were used to gain factual information and students’ opinions when the range of answers was predictable. Additional free text comments were requested when appropriate. Questions covered the following topics: schools applied to; whether students were at their first choice of medical school; specialty preferences; early career plans (if they planned to stay in Scotland for FP training and, if so, why, and where they saw themselves living after graduation), and demographics. Rather than providing a list of medical careers to respondents, in order not to inadvertently influence statements of preferences, the questionnaire asked students to give their top three and bottom three specialty choices in a free text format. Students were also asked to rate the importance of the following list of factors influencing career choice using a 4-point Likert scale: intellectual satisfaction; work–life balance; own aptitude and skills; potential earnings; amount of patient contact; continuity of patient contact; career prospects; spouse or partner’s career; location, and transport links. No definitions of these factors were provided and thus their interpretation was left to the individual. Demographic data included information on gender, age, ethnicity, socio-economic background and country of birth. Data collection

Data analysis Free text responses, such as, for example, reasons for choosing a particular medical school, were categorised into recurring themes using content analysis.39 When respondents provided more than one response, all responses were categorised. Answers with frequencies of > 30% were then recoded into dichotomous variables (mentioned = 1, not mentioned = 0). Specialty preferences, identified by asking students to list their top three choices of medical career, were categorised into main specialty groups, with the dichotomous variables of ‘top choice ⁄ not top choice’ and ‘bottom choice ⁄ not bottom choice’. Other than data on age, demographic data were nominal. Age was categorised into 17–20 years and ‡ 21 years (the standard definition of an ‘older’ student).32 Socio-economic status (SES) was defined using the UK Standard Occupational Classification, which assigns SES based on parental occupation (or the occupation of the person contributing the highest income to the household if the applicant is aged ‡ 21 years). Quantitative data were analysed using 15.0 (SPSS, Inc., Chicago, IL, USA).

SPSS

Version

Chi-squared tests (bivariate analysis) were used to identify significant differences among groups (gender, age group, country of birth, SES, medical school, factors influencing career choice, specialty choice). Chi-squared tests that produced significant results indicated which independent variables should be included in the regression analyses. The regression analysis used an enter model, not a stepwise model. The data from separate models predicting, for example, the importance of career-related factors in specialty preference are presented in tables. Odds ratios (ORs) are based on associations between the independent and dependent variable(s), as presented in each table, adjusting for relevant other variables (presented in parenthesis within each table).

Year 1 undergraduate medical students at the five Scottish medical schools in 2009–2010 were invited to complete a survey on career preferences within 2 months of commencing their studies (October– November 2009). Paper questionnaires were distributed at prearranged sessions at each school. Students were e-mailed details of the study 1 week before the data collection session. The purpose of the study was explained and a written information sheet was provided both by e-mail, in advance, and in the data collection session. Informed consent was implied by questionnaire completion; this protocol was deemed acceptable by the research ethics committee. Students were asked to complete the questionnaire within this session and to return it before leaving. No reminders were sent to students who did not attend the session or complete the questionnaire.

Because of the large number of statistical comparisons, Bonferroni correction40 was applied and statistical significance accepted at p < 0.01. Data are reported as significant at p < 0.01 unless otherwise stated.

No sample size calculation was required as the study was a survey of the career aspirations of the whole population of medical students in Scotland, at a particular point in time.

In view of space considerations and the number of different models in the analysis, only significant results are reported. The variables included in each model are presented in the accompanying tables.

476


Career preferences of Year 1 medical students Ethical review Ethical approval for this study was granted by the College of Life Sciences and Medicine Ethics Review Board (CERB), University of Aberdeen, and approved by the chairman of the University of Edinburgh Ethics Committee. These permissions were accepted as proof of review by the other medical schools.

RESULTS

Response rate The overall response rate was 87.9% (883 of 1005 potential respondents). Return rates differed significantly by school: St Andrews (96.7%), Aberdeen (95.6%) and Glasgow (92.1%) gave higher response rates than Edinburgh (81.9%) and Dundee (74.9%) (v2 = 61.1, d.f. = 4, p < 0.001).

among schools in terms of gender (v2 = 4.0, d.f. = 4) and SES (v2 = 12.5, d.f. = 4). Most students (77.6%) were from SES groups I and II (managerial and professional). Significant differences were found among medical schools for country of birth (v2 = 63.1, d.f. = 8, p < 0.001), age group (v2 = 17.3, d.f. = 4, p < 0.01) and ethnicity (v2 = 20.0, d.f. = 4, p < 0.01). Overall, 43.6% of respondents were Scottish-born, 35.0% were from other UK countries and 21.5% were from overseas. Dundee students were most likely (60.9%) and Edinburgh students were least likely (31.6%) to be Scottish-born. St Andrews had the highest proportions of overseas (38.1%) and ethnic minority (31.5%) students. Edinburgh had the highest proportion of students from UK countries other than Scotland (47.6%). Aberdeen had the highest proportion (20.8%) of older students (aged ‡ 21 years at time of entry to medical school). Choice of medical school

Demographic factors Table 1 outlines respondent demographics, presented by medical school. Over half of the students were female (57.6%). There were no differences

Table 1

Most respondents (82.3%, 727 ⁄ 883; data not shown) indicated that their first-choice medical school was in Scotland. A total of 70.2% (620 ⁄ 883) had obtained a place at their first-choice school. Most (90.1%,

Respondent demographics by medical school

Respondents Aberdeen

Dundee

Edinburgh

Glasgow

St Andrews

Total

(n = 174)

(n = 128)

(n = 213)

(n = 221)

(n = 147)

(n = 883) v2 = 4.0,

Gender, n (%) Female Male

102 (59.0)

80 (62.5)

119 (56.4)

117 (52.9)

89 (60.5)

507 (57.4)

71 (41.0)

48 (37.5)

92 (43.6)

104 (47.1)

58 (39.5)

373 (42.2)

‡ 21

p = 0.406 v2 = 17.3,

Age group, years, n (%) 17–20

d.f. = 4,

137 (79.2)

115 (89.8)

195 (92.4)

187 (84.6)

131 (89.1)

765 (86.6)

d.f. = 4,

36 (20.8)

13 (10.2)

16 (7.6)

34 (15.4)

16 (10.9)

115 (13.0)

p = 0.002 v2 = 63.1,

Country of birth, n (%) Scotland

83 (48.0)

78 (60.9)

67 (31.5)

105 (47.5)

51 (34.7)

384 (43.5)

d.f. = 8,

Other UK

56 (32.3)

29 (22.7)

101 (47.4)

82 (37.1)

40 (27.2)

308 (34.9)

p = 0.000

Non-UK

34 (19.5)

21 (16.4)

44 (20.7)

34 (15.4)

56 (38.1)

189 (21.4) v2 = 20.0,

Ethnic group, n (%) White

148 (85.1)

105 (82.0)

167 (78.4)

186 (84.2)

100 (68)

Other

25 (14.4)

20 (15.6)

45 (21.2)

34 (15.4)

46 (31)

706 (80)

d.f. = 4,

170 (19.3)

p = 0.001 v2 12.5,

Socio-economic status, class, n (%) I and II

128 (73.6)

90 (72.3)

182 (85.4)

173 (78.3)

107 (72.8)

680 (77)

d.f. = 4,

Other

43 (24.7)

34 (26.6)

30 (14.1)

48 (21.7)

39 (26.6)

194 (22)

p = 0.014


477

J Cleland et al 346 ⁄ 384) Scottish-born students had applied to three or four Scottish medical schools, as had 21.1% (65 ⁄ 308) of other UK and 22.2% (42 ⁄ 189) of overseas students (data not shown). Respondents were asked to give up to three reasons for wishing to study medicine at the school they were at. These open responses were categorised according to theme. Answers with frequencies of > 30% were then recoded into dichotomous variables (mentioned ⁄ not mentioned). The main themes were location (e.g. ‘like the city’, ‘near home’, ‘close to my family’), reputation of the school (e.g. ‘well-respected medical school’, ‘heard good things [about the school]’, ‘[the school] has an award for student satisfaction’), preference for a particular city (e.g. ‘amazing city’), curriculum (e.g. ‘good course’, ‘very high standards of teaching’) and facilities (e.g. ‘large hospital and teaching centre’, ‘fantastic facilities’) (Table 2).

Location was a statistically significant factor and was less important to overseas students compared with Scottish students (OR = 0.5), but more important to Glasgow students than Aberdeen students (OR = 1.9). The reputation of the school was more important to those born outside the UK than to Scottish students (OR = 2.2) and more important to Edinburgh and Dundee students but less important to Glasgow students compared with students at Aberdeen. Edinburgh students born outside Scotland placed more importance than their Scottish-born counterparts on reputation (p < 0.01). Aspects of the course were more important to those born outside the UK compared with those born in Scotland (OR = 0.5), to male compared with female students (OR = 0.6), and to Dundee and Glasgow students compared with those at Aberdeen (OR = 2.3 and OR = 2.0, respectively).

Table 2 Reasons for wishing to study at current medical school and associations with gender, age group, country of birth, socio-economic group and medical school

Dependent variable 1 Course and curriculum

Independent variable

OR (95% CI)

p-value

Male gender (ref. female)

0.6 (0.5–0.9)

p = 0.003

Born outside UK (ref.

0.5 (0.4–0.8)

p = 0.002

Dundee (ref. Aberdeen)

2.3 (1.3–3.9)

p = 0.003

Glasgow (ref. Aberdeen)

2.0 (1.3–3.1)

p = 0.003

Born outside UK (ref. born

0.5 (0.3–0.7)

p £ 0.001


1.8 (1.2–2.8)

p = 0.003

Age 17–20 years (ref. age

3.5 (2.1–6.0)

p £ 0.001

1.9 (1.4–2.7)

p £ 0.001

Edinburgh (ref: Aberdeen)

5.2 (3.2–8.2)

p £ 0.001

Glasgow (ref: Aberdeen)

2.1 (1.4–3.3)

p £ 0.001

Born outside UK (ref. born

2.2 (1.5–3.2)

p £ 0.001


1.9 (1.2–3.0)

p = 0.009

Edinburgh (ref. Aberdeen)

3.6 (2.3–5.6)

p £ 0.001


0.5 (0.3–0.8)

p = 0.004


0.2 (0.1–0.4)**

p £ 0.001

born in Scotland)

2 Location

in Scotland) 3 City or town

‡ 21 years) UK-born, not Scotland (ref. born in Scotland)

4 Reputation and prestige

in Scotland)

5 Facilities


0.1 (0.0–0.2)**

p £ 0.001


0.4 (0.2–0.7)**

p £ 0.001

St Andrews (ref. Aberdeen)

0.0 (0.0–0.1)**

p £ 0.001

OR = odds ratio; 95% CI = 95% confidence interval *p < 0.01; **p < 0.001

478


Career preferences of Year 1 medical students Career preference Students were asked to indicate the importance of certain job-related factors (work–life balance, perceived aptitude and skills, intellectual satisfaction, amount of patient contact, continuity of patient contact, career prospects, earnings, location, transportation links, spouse or partner’s career, carer responsibilities) when considering their future career preferences. The following factors were rated as extremely important by the majority of respondents: work–life balance (50.9%); perceived aptitude and skills (55.1%); intellectual satisfaction (51.1%), and amount of patient contact (58.9%). No significant differences were found across schools in terms of respondents’ ratings of intellectual satisfaction, work– life balance, career prospects, or (geographical) location of job. Earnings were less likely to be extremely important to Aberdeen students compared with Dundee students (OR = 0.5), but more likely to be extremely important to overseas students compared with Scottish students (OR = 1.8). St Andrews students (OR = 0.4) were less likely to consider amount of patient contact as extremely important (Table 3). Demographic differences were apparent (Table 3). Male respondents were less likely than female respondents to rate the following factors as extremely important: their perceived aptitude and skills (OR = 0.6); amount of patient contact (OR = 0.4);

continuity of patient contact (OR = 0.5), and transport links (OR = 0.7). Overseas students were less likely than Scottish students to consider amount of patient contact as extremely important (OR = 0.2), but more likely to rate transport links as extremely important (OR = 1.8). Students were asked to provide their top and bottom specialty choices using a free text format (data not shown). Surgery (22.5%), medicine (19.0%), general practice (17.6%) and paediatrics (16.1%) were most frequently mentioned as top choices. Medicine (20.7%), surgery (20.9%) and general practice (15.2%) were most likely to be given as bottom choices, followed by obstetrics and gynaecology (11.1%) and laboratory medicine (9.8%). No significant differences were found among medical schools with regard to first-choice specialty (data not shown; v2 = 47.750, d.f. = 28, p = 0.11). The analysis was adjusted for demographic and jobrelated preferences (Table 4). Specialty preferences differed by gender. Male students were more likely than female students to prefer surgery (OR = 2.4), but less likely to prefer paediatrics (OR = 0.4) or general practice (OR = 0.6). Students for whom a satisfactory work–life balance was extremely important (OR = 0.6) were less likely to prefer surgery. Students for whom work–life balance (OR = 2.2) and continuity of patient care (OR = 2.1) were extremely important were more likely than other students to

Table 3 Associations between career-related factors and demographic factors including gender, age group, country of birth, socio-economic group and medical school

Dependent variable


OR (95% CI)

p-value

Own aptitude and skills


0.6 (0.5–0.8)

p = 0.001

Potential earnings


0.5 (0.3–0.8)

p = 0.003


1.8 (1.2–2.7)

p = 0.000


0.4 (0.3–0.6)

p = 0.000


0.4 (0.3–0.6)

p = 0.000

born in Scotland) Amount of patient contact

born in Scotland) Continuity of patient contact Transportation links

St Andrews (ref. Aberdeen)

0.4 (0.2–0.6)

p = 0.000


0.5 (0.4–0.7)

p = 0.000


0.7 (0.5–0.9)

p = 0.004

Born outside UK (ref. born in Scotland)

1.8 (1.2–2.6)

p = 0.002

No significant differences were found for intellectual satisfaction, work–life balance, career prospects or location OR = odds ratio; 95% CI = 95% confidence interval


479

J Cleland et al

Table 4

Associations among demographic factors, job-related factors and specialty preference

Dependent variable


OR (95% CI)

p-value

Work–life balance extremely important

2.2 (1.5–3.3)

p £ 0.001

2.1 (1.3–3.2)

p = 0.001


2.4 (1.7–3.3)

p £ 0.001

Work–life balance extremely important

0.6 (0.4–0.8)

p = 0.001

Top choice or not General practice

(ref. not extremely important) Continuity of patient contact extremely important (ref. not extremely important) Surgery

(ref. not extremely important) Paediatrics


0.4 (0.3–0.6)

p = 0.000

Obstetrics and gynaecology


0.1 (0.0–0.5)*

p = 0.005

Bottom choice or not Emergency medicine


0.2 (0.1–0.6)*

p = 0.006

Psychiatry

Age 17–20 years (ref. age ‡ 21 years)

0.2 (0.1–0.5)

p £ 0.001

Surgery


0.6 (0.4–0.8)

p = 0.003

Continuity of patient care extremely

1.9 (1.2–3.0)

p = 0.004

important (ref. not extremely important) Obstetrics and gynaecology Pathology


4.2 (1.6–10.8)*

p = 0.004


5.0 (2.0–12.4)*

p = 0.001

Amount of patient contact extremely

3.3 (1.7–6.7)*

p £ 0.001

important (ref. not extremely important) * p < 0.01; p < 0.001 OR = odds ratio; 95% CI = 95% confidence interval

prefer general practice. The female preference for general practice was eliminated when these workrelated factors, or variables, were included in the analysis.

related qualities considered important. Surgery and general practice were represented as both most and least preferred choices of specialty. These choices were correlated with preferences for certain jobrelated factors, particularly work–life balance and continuity of patient care.

DISCUSSION

What this paper adds This work is the first major study of career aspirations following substantial changes in UK medical career organisation and structure. We found the Year 1 Scottish medical student corpus to be heterogeneous in terms of student origin (Scottish, other UK or overseas), ethnicity and age. By contrast, Scottish medical students are remarkably homogeneous in terms of specialty preference and the factors they view as important in a medical career. First-choice specialty preference did not differ significantly among students at different schools and there were only minor differences among schools in terms of the job-

480

Our data indicate that Year 1 medical student career preferences do not take into account the availability of training places and medical jobs in the UK. For example, far more students wish to train in surgery than would be possible, whereas far fewer people than the number required wish to pursue a career in general practice. It may be that these young students have not yet started working through the processes of circumscription (sense of personal fit) and compromise (what is feasible once practical considerations such as availability of posts are taken into account) in career choice.41,42 Early career guidance to help with these processes is required. Furthermore, less popular specialties (e.g. psychiatry,28 obstetrics and gynaecology30) may benefit from emphasising job


Career preferences of Year 1 medical students qualities such as patient contact and work–life balance that are important to today’s medical students. Of particular interest is the finding that a gender difference in preference for general practice was removed when preferences for factors such as continuity of patient contact and work–life balance were included in the analysis. It may be that the decreasing centrality of work to all doctors may be leading to changes in traditional gender patterns in medical careers. The data indicate that students born in Scotland wish to stay in Scotland, whereas those born in other UK countries and overseas are attracted to Scottish medical schools on the basis of their reputation and location, but plan to leave at some point after graduation. We do not know if this reflects patterns seen in other populations of medical students. Comparisons with findings in the existing literature Like students in previous studies, the students in this survey regarded the qualities of a specialty, patient contact43 and work–life balance4,10–12,44,45 as important factors in career preference. Students had definite preferences for and against some specialties, which, given the timing of data collection, they had probably formed prior to entering medical school. Although previous studies do suggest these preferences may change over time, with exposure to the specialties in question,6–9,25 this pattern reflects later problems in recruitment and is in keeping with other research.46,47 The homogeneity of student career preferences across the five medical schools is at odds with what is known about the ultimate career paths of Scottish medical students who trained in the years before medical training was restructured in the UK.35 Again, this suggests that medical school factors influence career destination.6–9 Longitudinal work is required to explore this phenomenon further. Traditional gender differences in specialty preferences were confirmed.19,48 The gender differences in specialty preferences expressed by the students in this study are evidenced in the current gender split in applicants for specialty training posts in Scotland,40 which suggests that early career preferences are pertinent to later career decision making. This reflects established findings in graduate medical students17,18,21–23 and hence these findings must be

taken into account in medical school selection, curricula and careers advice. Respondent demographics differed from those of the student body at UK medical schools as a whole in that our sample included higher proportions of women and White students.32 However, the proportions of female and White students in the survey are in keeping with those in the Scottish medical student population and in the general Scottish population.48 Strengths and weaknesses An important strength of this study is that it surveyed students before they had had much experience of medical school. The study achieved an excellent response rate compared with some other similar studies.19 This may have reflected the face-to-face nature of the data collection, which was time-consuming and expensive, but advantageous in terms of ensuring a high response rate. Differences in response rate among schools reflected differences in the timing and internal advertising of, and hence attendance at, the study sessions. Unfortunately, the ethical approval we obtained for this study did not enable us to request the demographic details of nonrespondents from the respective medical schools or to contact these individuals separately. However, the respondents do reflect the general demographic profile of Scottish medical students, which suggests they are representative of the target population. The content of the questionnaire was based on evidence in the literature, reviewed by appropriate groups and piloted with high school and medical students but, in retrospect, could have included further questions on topics such as the influence of financial considerations on choice of medical school and career plans. There are no data on the validity or reliability of our questionnaire. However, the purpose of the study was to collect descriptive data on the career aspirations and views of students at one time-point, not to develop a validated questionnaire. We may have identified more specific thoughts on career preferences by providing a list of medical careers rather than using free text responses, but decided not to do so in order not to inadvertently influence the expression of preferences. However, the study may have suffered some loss of data as a result of free text reduction and future researchers may wish to design their surveys using specific response options rather than free text to avoid this possibility. Some of the comparisons generated limited statistical significance and hence it is important to re-investigate our questions with further cohorts. An important


481

J Cleland et al weakness of this study is that differences in medical admissions and training mean the data are applicable only to the UK system. Implications for practice and research At first glance, the current system in Scotland appears to oversupply medical graduates for FP places (approximately 900 graduates per annum apply for 800 FP Year 1 posts). However, the present results indicate that this is not in fact the case: there is actually a potential undersupply of medical graduates who wish to stay in Scotland to train and work because non-Scottish students tend to wish to leave after completing their medical degree. Although the data reported here refer to a single study carried out in one country, these findings raise interesting general questions. Should the numbers of undergraduate and postgraduate medical training places be planned on the basis of the (predicted) medical care needs of the defined population? Could that health economy then assign posts to appropriately qualified students and trainees from the home nation (as is the case in other countries) and, particularly, target training to supply health professionals to staff (work in) remote and rural localities? Medical schools might supplement these home places by allocating a proportion of places to non-domestic students in the knowledge that when the members of this group leave, they will serve as a conduit for the export of expertise and will, it is hoped, also share their experiences and thus encourage future applicants. A robust, longitudinal study is required to explore whether and how these students’ chosen trajectories and career preferences change as they progress through medical school and training. This would provide more understanding of the influences of variables such as curriculum design and quality of the learning environment on training choice and outcomes.33 Furthermore, the current study must be repeated with other cohorts of UK medical students to ensure the data reported are not unique to one cohort at one time-point. This study is the first contemporary national cohort study of medical undergraduates following the restructuring of medical career pathways in the UK under MMC.37 It adds further evidence to the debate on the relative contributions of medical student characteristics (the people we select) and undergraduate medical education provision (the educational programmes they follow according to

482

defined outcomes in Tomorrow’s Doctors)49 to the differences in medical school output (the doctors we produce) and trainees’ career preferences (the careers they will follow). It raises some interesting questions regarding current policy and planning for medical student places and the design of postgraduate training programmes. At a time when UK Departments of Health are actively considering the shape (workforce planning and profiles) and structure (career pathways) of health care teams, this study offers some new evidence to inform decisions.

Contributors: all authors contributed substantially to the design of the study. PWJ, FHF and JC collected the data. FHF led the analysis, with support from PWJ and JC. GN contributed to data interpretation and the acquisition of comparative data. JC prepared the first draft of the manuscript. All authors contributed to the critical revision of the article and approved the final document. Acknowledgements: the authors thank Dr Neil Scott, Medical Statistics Team, University of Aberdeen, for his invaluable advice and guidance, and Dr Murray Lough, NHS Education for Scotland, for his encouragement and support. We also thank the Scottish Medical Deans Education Group (SMDEG) for supporting this project. Funding: this study was funded by NHS Education for Scotland. Conflicts of interest: none. Ethical approval: ethical approval for this study was granted by the College of Life Sciences and Medicine Ethics Review Board (CERB), University of Aberdeen, and approved by the chairman of the University of Edinburgh Ethics Committee. These permissions were accepted as proof of review by the other medical schools.

REFERENCES 1 McManus IC, Lefford F, Furnham AF, Shahidi S, Pincus T. Career preference and personality differences in medical school applicants. Psychol Health Med 1996;1:235–48. 2 Soethout MBM, Heymans MW, ten Cate OTJ. Career preference and medical students’ biographical characteristics and academic achievement. Med Teach 2008;30:15–30. 3 Arnold MW, Patterson AF, Tang AS. Has implementation of the 80-hour work week made a career in surgery more appealing to medical students? Am J Surg 2005;189:129–33. 4 Kiker BF, Zeh M. Relative income expectations, expected malpractice premium costs, and other determinants of physician specialty choice. J Health Soc Behav 1998;39:152–67. 5 Zinn WM, Sullivan AM, Zotov N, Peters AS, Connelly MT, Singer JD, Singer J, Block S. The effect of medical


Career preferences of Year 1 medical students

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

education on primary care orientation: results of two national surveys of students’ and residents’ perspectives. Acad Med 2001;76:355–65. Goldacre MJ, Turner G, Lambert TW. Variation by medical school in career choices of UK graduates of 1999 and 2000. Med Educ 2004;38:249–58. Maiorova T, Stevens F, Scherpbier A, van der Zee J. The impact of clerkships on students’ specialty preferences: what do undergraduates learn for their profession? Med Educ 2008;42:554–62. Ward AM, Kamien M, Lopez DG. Medical career choice and practice location: early factors predicting course completion, career choice and practice location. Med Educ 2004;38:239–48. Stagg P, Greenhill J, Worley PS. A new model to understand the career choice and practice location decisions of medical graduates. Rural Remote Health 2009;9:1245. Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA 2003;290:1173–8. Dorsey ER, Jarjouram D, Rutecki GW. The influence of controllable lifestyle and sex on the specialty choices of graduating US medical students, 1996–2003. Acad Med 2005;80:791–6. van der Horst K, Siegrist M, Orlow P, Giger M. Residents’ reasons for specialty choice: influence of gender, time, patient and career. Med Educ 2010;44:595– 602. Lambert EM, Holmboe ES. The relationship between specialty choice and gender of US medical students, 1990–2003. Acad Med 2005;80:797–802. Newton DA, Grayson MS, Thompson LF. The variable influence of lifestyle and income on medical students’ career specialty choices: data from two US medical schools, 1998–2004. Acad Med 2005;80:809–14. Zeldow PB, Preston RC, Daughertsy R. The decision to enter a medical specialty: timing and stability. Med Educ 1992;26:327–32. Mahoney R, Katona C, McParland MEA. Shortage specialties: changes to career intentions from medical student to newly qualified doctor. Med Teach 2004;26:650–4. Scott IM, Matejcek AN, Gowans MC, Nut Diet M, Wright BJ, Brennels FR. Choosing a career in surgery: factors that influence Canadian medical students’ interest in pursuing a medical career. Can J Surg 2008;51:371–7. Scott IM, Wright BJ, Brenneis FR, Gowans MC. Whether or wither some specialties: a survey of Canadian medical student career interest. BMC Med Educ 2009;9:57. Lefevre JH, Roupret M, Kerneis S, Karila L. Career choices of medical students: a national survey of 1780 students. Med Educ 2010;44:603–12. Goldacre MJ, Laxton L, Lambert TW. Medical graduates’ early career choices of specialty and their eventual specialty destinations: UK prospective cohort studies. BMJ 2010;341:c3199.

21 McGreevy J, Wiebe D. A preliminary measurement of the surgical personality. Am J Surg 2002;184: 121–5. 22 Kozar RA, Holcomb JB, Hassoun HT, Macaitis J, DeSoignie R, Moore FA. Pre-clinical students: who are surgeons? J Surg Res 2004;119:113–6. 23 Carline J, Cullen T, Dohner C, Schwarz R, Zinser E. Career preferences of first and second year medical students. J Med Educ 1980;55:682–91. 24 Henderson E, Berlin A, Fuller J. Attitude of medical students towards general practice and general practitioners. Br J Gen Pract 2002;52:359–63. 25 Sinclair HK, Richie LD, Lee AJ. A future career in general practice? A longitudinal study of medical students and pre-registration house officers. Eur J Gen Pract 2006;12:120–7. 26 Lambert TW, Turner G, Fazel S, Goldacre MJ. Reasons why some UK medical graduates who initially choose psychiatry do not pursue it as a long-term career. Psychol Med 2006;36:679–84. 27 Goldacre MJ, Willett K, Lambert TW. Career choices for trauma and orthopaedic surgery: 30 years of surveys. Ann R Coll Surg Eng 2008;90:134–8. 28 Rajagopal S, Rehill KS, Godfrey E. Psychiatry as a career choice compared with other specialties: a survey of medical students. Psych Bull 2004;28:444–6. 29 Turner G, Goldacre MJ, Lambert TW, Sear J. Career choices for anaesthesia: national surveys of graduates of 1974–2002 from UK medical schools. Br J Anaesth 2005;95:332–8. 30 Turner G, Lambert TW, Goldacre MJ, Barlow D. Career choices for obstetrics and gynaecology: national surveys of graduates of 1974–2002 from UK medical schools. Br J Obstet Gynaecol 2006;13:350–6. 31 Department of Health. Modernising Medical Careers. London: Department of Health 2004. http://www. dh.gov.uk/publications. [Accessed 23 March 2012.] 32 British Medical Association. Equality and Diversity in UK Medical Schools. London: BMA 2009. 33 Brosnan C. Making sense of differences between medical schools through Bourdieu’s concept of ‘field’. Med Educ 2010;44:645–52. 34 Cave J, Goldacre M, Lambert T, Woolf K, Jones A, Dacre J. Newly qualified doctors’ views about whether their medical school had trained them well: questionnaire surveys. BMC Med Educ 2007;7:38. 35 McManus IC, Elder AT, De Champlain A, Dacre JE, Mollon J, Chis L. Graduates of different UK medical schools show substantial differences in performance on MRCP(UK) Part 1, Part 2 and PACES examinations. BMC Med 2008;6:5. 36 Lambert TW, Goldacre MJ. Views of doctors in training on the importance and availability of career advice in UK medicine. Med Educ 2007;41:460–6. 37 Department of Health. Modernising Medical Careers: The Next Steps. London: DoH 2004. 38 Watmough S, Waddelove C, Jaeger L. First Year Medical Students’ Perceptions of a Career in Medicine – How can these inform Careers Support? Constructing the Future: Career


483

J Cleland et al

39 40 41

42

43

44

45

46

484

Guidance for Changing Contexts. Birmingham: Institute of Careers Guidance 2009. Glaser BG, Strauss AL. The Discovery of Grounded Theory. Chicago, IL: Aldine 1967. Cramer D. Fundamental Statistics for Social Research. London: Routledge 1998. Gottfredson LS. Circumscription and compromise: a developmental theory of occupational aspirations. J Couns Psychol 1981;28:545–79. Petrides KV, McManus IC. Mapping medical careers: questionnaire assessment of career preferences in medical school applicants and final-year students. BMC Med Educ 2004;4:18. Carline JD, Greer T. Comparing physicians’ specialty interests upon entering medical school with their eventual practice specialties. Acad Med 1991;66:44–66. Heiliger PJ, Hingstam L. Career preferences and the work–family balance in medicine: gender differences among medical specialists. Soc Sci Med 2000;50:1235–46. Wright B, Scott I, Woloschuk W, Brenneis F. Career choice of new medical students at three Canadian universities: family medicine versus specialty medicine. CMAJ 2004;170:1920–40. Maiorova T, Stevens F, van der Zee J, Boode B, Scherpbier A. Shortage in general practice despite the feminisation of the medical workforce: a seeming paradox? A cohort study. BMC Health Serv Res 2008;8:262.

47 Baldwin P, Dodd M, Buckley G, Macpherson S. The career plans of Scottish medical graduates. Health Bull 1991;56:488–97. 48 National Records of Scotland. Statistics on Population and Demographics in Scotland: Assessment Report 13. Edinburgh: NRS 2011. 49 General Medical Council. Tomorrow’s Doctors: Outcomes and Standards for Undergraduate Medical Education. GMC: London 2009.

SUPPORTING INFORMATION Additional supporting information may be found in the online version of this article. Appendix S1. Study questionnaire. Please note: Wiley-Blackwell is not responsible for the content or functionality of any supporting materials supplied by the authors. Any queries (other than for missing material) should be directed to the corresponding author for the article. Received 16 June 2011; editorial comments to authors 4 August 2011, 2 December 2011; accepted for publication 19 December 2011
