MEDICAL SPECIALTY SELECTION INFLUENCES, SATISFACTION, AND
IDEALSIM WITHIN THE FRAMEWORK OF CAREER COUNSELING
JUDITH DAVIDSON HENNING
Bachelor of Arts in Psychology
Case Western Reserve University
May 1970
Master of Education
John Carroll University
May 1977
submitted in partial fulfillment of requirement for the degree
DOCTOR OF PHILOSOPHY IN URBAN EDUCATION
at the
CLEVELAND STATE UNIVERSITY
May, 2015
©Copyright by Judith Davidson Henning, 2015
We hereby approve the dissertation of
Judith Davidson Henning
Candidate for the Doctor of Philosophy in Urban Education degree
This Dissertation has been approved for the
Office of Doctoral Studies,
College of Education and Human Services
and
CLEVELAND STATE UNIVERSITY
College of Graduate Studies by:
______Dissertation Chairperson: Sarah Toman, Ph.D. Counseling, Administration, Supervision, and Adult Learning
______Methodologist: Karla Hamlen Mansour, Ph.D. Curriculum and Foundations
______Kathryn C. MacCluskie, Ed.D. Counseling, Administration, Supervision, and Adult Learning
______Aaron Ellington, Ph.D. Summit County ADM Board
______Constance L. Hollinger, Ph.D. Psychology
March 16, 2015 Student’s Date of Defense
ACKNOWLEDGEMENTS
Though I entered the doctoral program in 1999 and just completed my dissertation defense this spring I always knew I would complete the process and change my status from ABD to PhD. This could not have been accomplished without the support of my family and friends especially my daughter and husband to whom I cannot offer enough gratitude.
Secondly I would like to thank my chairperson, methodologist and committee members. My chairperson Dr. Sarah Toman was not only extremely supportive she was also very helpful in making edits and corrections and continued her commitment to my dissertation even after she retired from the university. My methodologist Dr. Karla
Hamlen Mansour, who graciously agreed to replace my original methodologist, was instrumental in retuning and refining my statistical skills. She reminded me of the importance of projecting confidence in my ability and skills. My other three committee members Dr. Aaron Ellington, Dr. Constance Hollinger, and Dr. Kathryn MacCluskie were also very helpful and provided meaningful suggestions and direction not only for this research but continuing with both research and work in this area of study and counseling.
Lastly I want to thank all those who made my quest easier including those who distributed my questionnaire and those physicians who took the time to complete the questionnaire, Wanda Pruett Butler who retyped and edited my document and was also very helpful when she was the graduate office administrative assistant, Rita Grabowski who as the current administrative assistant helped me complete required paperwork and
Grant Griffin who showed me how to use the SPSS program.
MEDICAL SPECIALTY SELECTION INFLUENCES, SATISFACTION, AND
IDEALSIM WITHIN THE FRAMEWORK OF CAREER COUNSELING
JUDITH DAVIDSON HENNING
ABSTRACT
Because of the amount of knowledge, cost of a medical school education, length of time specialty preparation requires, and the value of achieving career satisfaction, research into the specific area of career guidance assisting aspiring physicians choose a professionally rewarding area of medical practice is critically important.
Past studies in this area of specialty choice examined specific variables such as personality or gender, or specific specialty areas such as primary care, or specific populations, most often the medical students themselves. This dissertation adds to the research by asking practicing physicians to complete a questionnaire designed specifically for this study to identify their major influences in selecting a specialty, if they were satisfied practicing their area of specialty and how their idealism was related to specialty and satisfaction.
The mentor relationship emerged as a significant influence in the surgery/anesthesia physician group. Clerkship and high amount of patient contact were important for the primary care group while body system interest, high income potential, high demand for services, and interest in performing specific procedures were significant non-influences for this group. Interesting as well, was that the other influences of ability/skills and lifestyle expectations were not significantly different for any of the three groups which in addition to the two above included those in a medical specialist/subspecialty category.
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Primary care tended to be chosen by those who were older at graduation, those who graduated more recently and those who made their specialty decision earlier in their medical education. Medical Specialist/Subspecialty tended to be chosen by those who made a specialty choice later. Surgery/Anesthesia tended to be chosen by males and those who had higher debt.
No significant differences in satisfaction levels among the different groups of physicians were found. None of the demographic differences in gender, age at graduation, debt level, having a physician parent, time of specialty choice or being born in the U.S. predicted later satisfaction levels. Generally, most physicians were satisfied in the practice of their specialty, the amount of patient contact they had, the amount of intellectual stimulation and their collegial interaction and tended to be a little less satisfied with levels of compensation and lifestyle demands.
Physicians who saw themselves at the same level of idealism prior to medical school and after becoming a physician, were generally more satisfied with all aspects of their jobs. Those in the primary care groups rated themselves as being more idealistic compared to those in both surgery/anesthesia and medical specialties/subspecialties.
Those in surgery/anesthesia rated their idealism as being the same as when they first chose to become a physician, as compared to those in primary care who rated themselves as currently less idealistic than when they chose to become a physician.
The study further opens the door to additional research investigation in medical specialty selection.
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TABLE OF CONTENTS
ABSTRACT ...... v
LIST OF TABLES ...... xi
LIST OF FIGURES ...... xiii
CHAPTER
I. INTRODUCTION ...... 1
Definition of Terms ...... 7
Research Questions ...... 10
Clinical and General Implications ...... 11
Limitations ...... 11
Conclusion ...... 12
II. LITERATURE REVIEW ...... 13
From Generalization to Specialization ...... 13
Areas of Specialization, Skills, Training, and Responsibilities ...... 15
Available Resources ...... 16
Societal and Political Influences and Impacts ...... 21
Research Review of Variables in Specialty Selection...... 23
External Influences ...... 26
Training Influences ...... 35
Individual Characteristics ...... 38
Career Satisfaction ...... 54
Career success ...... 58
Change of focus...... 60
Including Values as a Variable and Examining the Concept of Idealism .... 61 vii
Conclusion ...... 69
III. METHODOLOGY ...... 71
Purpose of Study ...... 71
Research Questions ...... 71
Hypotheses ...... 72
Design ...... 72
Participants...... 74
Instrument ...... 74
Data Collection Procedures ...... 76
Ethical and Legal Considerations...... 76
Institutional Review Board ...... 76
Rights and informed consent ...... 76
Further approvals and communications ...... 77
Data Analysis ...... 77
Conclusion ...... 81
IV. RESEARCH FINDINGS ...... 82
Participants...... 82
Demographics ...... 84
The Independent Variable: Influences...... 87
Research Question 1 ...... 89
Research Question 2 ...... 101
Research Question 3 ...... 106
Research Question 4a ...... 109
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Research Question 4b ...... 111
Summary ...... 114
V. DISCUSSION ...... 116
Discussion of Results ...... 117
Research question 1...... 118
Research question 2...... 120
Research question 3...... 121
Research question 4...... 122
Research Questions Summary ...... 123
Limitations ...... 123
Implications ...... 124
Suggestions for Future Research ...... 126
Conclusions ...... 127
REFERENCES ...... 129
APPENDICES ...... 149
A. PHYSICIAN MEDICAL SPECIALTY QUESTIONNAIRE...... 150
B. INTERNAL REVIEW BOARD APPROVAL ...... 154
C. CONSENT TO PARTICIPATION FORM ...... 156
D. CASE WESTERN RESERVE MEDICAL SCHOOL APPROVAL ...... 158
E. UNIVERSITY HOSPITAL GRADUATE MEDICAL EDUCATION EMAIL ...... 160
F. EMAIL SOLICITATION ...... 161
G. CLEVELAND CLINIC EMAIL AGREEING TO INCLUDE LINK TO SURVEY IN
MONTHLY QUESTIONNAIRE ...... 162
ix
H. NEWSLETTER SOLICITATION REQUEST ...... 164
I. SPECIALTY, FREQUENCIES, MEDICAL CATEGORY CONVERSION ...... 165
J. “OTHER” RESPONSES CITING INFLUENCES ...... 168
K. PERSONAL EXPERIENCE IN CHOOSING A SPECIALTY...... 171
L. ADVICE TO OTHERS MAKING A SPECIALTY DECISION...... 184
x
LIST OF TABLES
1. External Influences ...... 52
2. Training Influences ...... 53
3. Individual Characteristics ...... 53
4. Connections between research questions, variables and analyses employed ...... 80
5. Medical Categories ...... 83
6. Professional Standing ...... 84
7. Gender ...... 84
8. United States Birth Status...... 85
9. Indebtedness ...... 86
10. Time of Specialty Selection...... 87
11. Influences: Number and Percentage Selected ...... 88
12. Mentor and Medical Categories Cross-Tabulation ...... 90
13. Chi-Square Tests for Mentor ...... 90
14. Clerkship and Medical Categories Cross-Tabulation ...... 91
15. Chi-Square Tests for Clerkship ...... 92
16. Ability/Skill and Medical Categories Cross-Tabulation ...... 93
17. Chi-Square Tests for Ability/Skill ...... 93
18. Body System Interest and Medical Categories Cross-Tabulation ...... 94
19. Chi-Square Tests for Body System Interest ...... 95
20. High Income Potential and Medical Categories Cross-Tabulation ...... 95
21. Chi-Square Tests for High Income Potential...... 96
22. High Rate of Patient Contact and Medical Categories Cross-Tabulation ...... 97
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23. Chi-Square Tests for High Rate of Patient Contact ...... 97
24. High Demand for Service and Medical Categories Cross-Tabulation ...... 98
25. Chi-Square Tests for High Demand for Services ...... 98
26. Specific Procedures and Medical Categories Cross-Tabulation ...... 99
27. Chi-Square Tests for Specific Procedures ...... 99
28. Lifestyle Expectation and Medical Categories Cross-Tabulation ...... 100
29. Chi-Square Tests for Lifestyle Expectation ...... 100
30. Correlation of Independent Predictor Variables ...... 103
31. Regression Model Summary ...... 107
32. ANOVAa ...... 108
33. Regression Coefficientsa ...... 108
34. Correlations between Satisfaction and Idealism ...... 110
xii
LIST OF FIGURES
Figure 1. Age at Graduation ...... 85
Figure 2. Physicians in my specialty are more idealistic compared to those in other
specialties ...... 113
Figure 3. “I am as idealistic as I was when I first chose to become a physician” ...... 113
xiii
CHAPTER I
INTRODUCTION
Career counseling is a significant specialty area in the field of counseling and exemplifies the practice of focusing on a person’s strengths, and identifying and assisting the client in reaching his or her career goals. Counseling of medical students who will choose a specific area of practice in the field of medicine is a further subspecialty of career counseling involving these same explorations and supports.
Pope (2000) identified six specific stages in the development of career counseling in the United States linked to major societal forces and environmental conditions. The first stage, starting at the end of the 1800’s and proceeding to the early 1900’s resulted from many confluences. These included the transformation of the country from an agrarian to an industrial economy, the demands and aftermath of World War I, the beginnings of psychological testing influenced by Galton, Wundt, Cattell, and Binet, and the initial social reform movements to end child labor and improve general working conditions. During this time Parsons founded the Vocation Bureau at Civic Service
House in Boston in 1908 to assist young people in learning about themselves, as well as what was required in the work place in different vocations, and how the interaction between self-knowledge and work knowledge resulted in successful job placement. The
1 second stage during the 1920’s and 30’s focused on educational guidance in the schools, fulfilling the requirements of the 1917 Smith-Hughes Act to provide vocational education training in response to the effects of the Great Depression and the growing labor union movement. World War II and the resultant cold war space race and scientific competition with Russia brought about stage three between 1940 to the end of the 1950’s. There was a focus on higher education and the formal training and development of counselor professionals to help returning veterans with personal and vocational problems and assist in development of a highly educated workforce. At this time, professional counseling organizations were growing. This later resulted in the formation of the American
Counseling Association and pertinent publications were emerging with one evolving into the Personnel and Guidance Journal. The fourth stage from 1960 to 1979 was marked by much government support through legislative action to further develop educational training, career and vocational guidance, and counseling. The 80’s decade, marked by an economic down turn and the beginning of the information/technology age, began stage five. In addition to legislation such as the Carl D. Perkins Vocational Education Act of
1984, this period was marked by professional development in the counseling area which led to several vocational guidance publications such as, A Counselor’s Guide to
Vocational Guidance Instruments in 1982 edited by Kapes and Mastie, and Adult Career
Development: Concepts, Issues, and Practices in 1988 edited by Leibowitz and Lea, both with subsequent revised editions. These all led to the further definition of vocational and career counseling as a separate specialty and independent practice with expansion outside of typical school and college settings to private practice. Pope identified the last and sixth stage as 1990 on and is marked by further refinement, such as multicultural
2 considerations, technological sophistication and working with skilled employees who were needing outplacement support and to career counselors working in corporate settings.
Robitchek and Woodson ((2006) posited three basic models in the area of vocational and career counseling. The first was the person-environment fit construct which includes Parsons’ (1909) original beliefs, Holland’s (1997) theory based on matching a person’s interests and characteristics to those who hold certain types of jobs, and Dawis and Lofquist (1984) work adjustment theory in which fit was between the person’s work values and those values required by the position. The best fit between the person and the work environment produced the most satisfaction and productivity.
Robitchek and Woodson identified the second model as developmental theory in which the various roles a person has, such as worker, spouse, parent, child, or community member and the person’s awareness of his or her stage of growth in that role and their interests and abilities are intertwined and impact that person’s satisfaction in life and work. Super (1980) is considered to be part of this framework. Their third model is that of Lent, Brown and Hackett’s (1994) social-cognitive career theory which incorporates developmental theory and adds how a person’s interests and career choices change over time as they become a more active agent of that change.
The development of career counseling in the field of medicine has also been affected by changes in the greater culture, such as the effects of war, governmental legislation and regulation, and advances in technology, as well as theoretical constructs such as matching individuals’ skills and interests as similar to those practicing certain specialties. Those who assist medical students explore their future positions and provide
3 career counseling and experiences are aware of both the general career counseling approaches as well as those unique to this population with its specific timelines, hurdles, requirements, decision making and eventual placement and satisfaction (Mellman and
Paquette, 2012). The vocational psychology constructs of Kitson’s (1942) creating interests, Holland’s (1980) vocational identity, and Savickas’ (1986) crystallization, specification, and implementation are especially important as related to developing physicians (Borges, 2007). The importance of developing and providing medical career counseling through comprehensive programming has been recognized by institutions, students and professionals (Zink, et al., 2007).
Choosing to become an allopathic physician requires a strong commitment, perseverance and personal sacrifice. Acceptance into medical school in the United States is very competitive. Nearly 44,000 applicants, with an average GPA of 3.5, applied for about 19,000 openings in 2011 (O’Reilly, 2011). Once in a program, students face tremendous amounts of academic rigor. It is reported that one out of five, or twenty percent of those starting medical school are not graduated four years later (Garrison, et al., 2007). In addition to this dedication to career attainment, future physicians must make several important decisions. Decisions which begin in their third year and are finalized in their fourth year of medical school are some of the most significant ones affecting their future practice—that is, which specialty area of medicine to pursue.
Physician training takes a commitment of many years of study. Completing undergraduate requirements takes three to four years, depending on whether the individual chooses to obtain a Bachelor’s Degree. Medical school participation is another four year program. Residencies are typically an additional three to five years,
4 depending on the area of specialization with sub-specialization adding up to five more years, again depending on the subspecialty and fellowship. As well, the training requires an assumption of a hefty financial burden. Eighty-six percent of allopathic physicians have an average medical school debt of $162,000 upon graduation, with the average cost of a four year medical school education in 2011 as $187,393 for public institutions and
$263,964 for private ones (Krupa, 2012).
Currently there are over 120 areas of specialization listed on the Association of
American Medical Colleges (AAMC) website (www.aamc.org, 2013). These areas can be dichotomized in various ways: surgical versus non-surgical; primary versus secondary contact; child versus adult; adult versus geriatric; high degree of patient interaction versus low degree of patient interaction; lengthy versus shorter post- graduation training; saturated versus less competitive areas; highly compensated versus less so; and so on. In
2011, 17,364 students were graduated from all allopathic or traditional U.S. schools granting an M.D. degree (Association of American Medical Colleges, 2012). In 2012,
38,377 doctors from around the globe applied for 22,934 first year residency assignments awarded in the United States (Krupa, 2012). The National Resident Matching Program
(NRMP, 2012) released the 2012 match results across several specialties. The results for the largest specialty group categories were 2,941 in internal medicine, 1,732 in pediatrics,
1,427 in medicine-preliminary (a one year hospital experience similar to a first year residency in internal medicine prior to going into another specialty such as dermatology or radiology), 1,335 in emergency medicine, 1,322 in family medicine, 1,122 in anesthesiology, 914 in surgery, 913 in obstetrics-gynecology, 831 in diagnostic
5 radiology, and 785 in transitional medicine (similar to medicine- preliminary but varies due to residency program).
It is estimated that there will be a shortage of 91,500 physicians by the year 2020 because of the ever growing and aging population and changes in health care availability
(O’Reilly, 2011). Medical schools are gearing up for this by steadily increasing the number of applicants accepted into professional training in existing medical programs. In addition both new allopathic (MD) and osteopathic medical schools are coming into existence. Eighteen allopathic medical schools across the United States have recently begun the accreditation process (Japsen, 2012). However the U.S. government has not increased the number of residencies it funds through Medicare, while many medical lobbying groups have requested that this increase be made in the federal budget (Krupa,
2012; MedPac, 2010). Certain specialty areas already have significant shortages which not only affects servicing patients but also recruiting residents and practitioners. Though there is a strong focus on the primary health care physician shortage, specialty shortages include cardiology, critical care, diagnostic radiology, oncology, orthopedic surgery, dermatology, general surgery, neurology, psychiatry, urology and vascular surgery (Dill and Salsberg, 2008; Harris, 2010).
It seems almost unthinkable that after all the efforts and sacrifices a student makes to become a physician, he or she might not find work satisfaction in that professional endeavor. However, a recent study of 7,288 practicing doctors between the ages of 29 to
65 reported that 47% exhibited at least one sign of burnout including emotional exhaustion, depersonalization, depression, or suicidal ideation thereby contributing to early retirement or even leaving clinical practice entirely (Krupa, 2012). Intense patient
6 caseloads with demands for paperwork start in residency. Though recent changes in maximum weekly assigned hours in U.S. hospitals during residency have been reduced to eighty per week with first year residences single shifts restricted to 16 hours per day, the hours are still considerably higher than in other countries practicing Western medicine.
For example in New Zealand the number of hours per a single shift is limited to thirteen.
Even so, the eighty hour work week rule is frequently broken in U.S. hospitals (Phalen,
2008).
These factors of personal and economic investment, competition, and potential dissatisfaction make it imperative that medical students have a solid sense of understanding when selecting their area of specialty practice. Many factors must be taken into account, including interests, personality characteristics, potential earnings, life style, skills, competitive standing, and geographic location. Moreover, there are many influences on a medical student and his or her decisions to take into consideration, such as mentors, specialty saturation/need, career counseling and guidance, results of personality and interest measures, and collegial compatibility.
The purpose of this dissertation investigation was to identify the significant factors to consider when selecting a medical specialty by analyzing responses about influences and satisfaction from physicians who are in various specialty practices.
Definition of Terms
The following definitions clarify the meaning and parameters of key terms in the current literature and research:
Specialist: “A medical practitioner whose practice is limited to a particular class of patients (as children) or of diseases (as skin diseases) or of technique (as surgery);
7 especially: a physician who is qualified by advanced training and certification by a specialty examining board to so limit his or her practice” (http://www.merriam- webster.com/medlineplus/specialist, 11/11/2012). There are currently 24 general certificated specialties (American Board of Medical Specialties, 2013).
Subspecialty: A subspecialty is a further branching off from a field of specialization, such as cardiology from internal medicine, requiring additional years of training due to the ever increasing amount of specificity of knowledge. Nineteen of the twenty-four specialties have an additional one hundred and twenty-three subspecialty certifications (American Board of Medical Specialties, 2013).
Residency: A period of advanced, supervised, and compensated training and instruction in a specialty area after medical school graduation and licensure. The training is provided in hospitals and its outpatient settings by hospital staff specialists over a number of years, depending on the area of specialization. For example, internal medicine requires three years, urology five years and neurosurgery eight years of residency. Most residencies are funded through the Medicare program and initial annual salaries are around $50,000.
Clerkship: Several weeks of medical training in a specialty area during the third and or fourth year of medical school.
The Match: A somewhat controversial but rigidly adhered to procedure using an algorithm created by Alvin Roth, for which he received the 2012 Nobel Prize in economics (Whelan, 2012). The process matches medical school graduates to approximately 24,000 open residency positions and is conducted by the National
Residency Matching Program (NRMP). The process integrates the graduates’ preferred
8 rankings of the residency positions and the hospitals’ ratings of the applicants and thereby generates a single match per applicant that must be accepted.
Match Day: A yearly assigned day in mid-March in which all fourth year medical students across the county open an envelope at noon EST containing a letter informing them of their match to a residency program and thereby where they will be living, working and training for the next few years.
Fellowship: Fellowship is a program for additional years of training in a subspecialty area after residency for which applicants also compete for acceptance.
Board Certification: This certification is recognition by the specific specialty board of the American Board of Medical Specialties that the physician has met the training requirements and passed the specific exams to practice in that area of medicine, to assure quality of care.
Primary Care Physician: This physician is one with whom a patient has long term and steady contact and who would refer, if necessary, the patient to a medical specialist for further treatment beyond the primary care physician’s scope of practice. These are often physicians in family medicine practice, or an internist, gynecologist, or pediatrician.
Surgical Specialty: These areas of practice require five to eight years of training, good eye hand coordination, strong manual dexterity, embracing of new technology and a combination of both decisiveness and flexibility (Freeman, 2007).
Lifestyle: Determining one’s lifestyle includes consideration of level of compensation, number of hours worked, level of autonomy, working independently or within a group, availability to patients, and the balancing of professional responsibilities and time for personal interests and family (Freeman, 2007).
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Medical Liability: Because the practice of medicine frequently includes some risks to patients, physicians can be held liable for their services. Many specialties are subject to malpractice law suits which can drive prospective and practicing physicians away from certain fields (such as anesthesiology or gynecology).
Idealism: This is defined as “The cherishing or pursuit of high or noble principles, purposes, or goals (Dictionary.com, 2012).” “In medicine, these aims traditionally include relief of suffering and improved quality of life for all humankind” (Smith &
Weaver, 2006, p. S32).
Research Questions
As previously stated, becoming a physician requires dedication, persistence, commitment of time, energy and money. What and how a physician will perform his or her professional duties depends on their chosen specialty area. Making the specialty area/subspecialty area decision depends on self-examination of professional interests, prior experiences and exposure, possessing required skills, and personality factors. This dissertation research focuses on the following questions:
1. What do practicing physicians identify as the most significant influences
on the selection of their area of specialty?
2. How are demographic characteristics and other factors (i.e., age at time of
medical school graduation, gender, amount of debt, physician parent, year
in medical school selected final specialty choice) related to specialty
decision?
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3. How does level of current job satisfaction relate to specialty decision,
demographic characteristics, level of debt, when specialty decision was
made, and identified influences on specialty selection?
4. How does idealism relate to job satisfaction and medical specialty?
Clinical and General Implications
There are several potential implications which could result from this investigation. Medical school counselors are encouraged to use tools and experiences which would be of most help to perspective medical practitioners in making a specialty decision and reduce anxiety in the process. The findings of this research support students making choices to maintain their career course and professional goals with the support of professionals in the counseling fields. Improved compatibility with specialty choice and lifestyle goals could increase job satisfaction, and could reduce physicians leaving the field of medicine and physician shortages or need for retraining in another specialty.
Limitations
Respondents in this study represent only a small percentage of practicing physicians. Increases in medical knowledge and technological advances may change the nature of future medical practices, requirements, and specialty choices. Changes in legislation may impact specialty decisions in terms of greater numbers of patients having access to health care, capping of malpractice claims, educational funding and dealing with projected shortages overall and in specific areas. These may all impact the specialty decision making process more than the research findings can account for in this dissertation study. Another limitation is the lack of a previously researched measure which assesses the variables necessary to answer this study’s research questions.
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Conclusion
This first chapter provides an introduction and overview of the research topic and how the findings would impact the guidance of medical students in selecting a specialty.
Four basic research questions were stated as well as the limitations of the study. The next chapter reviews the literature that reflects on the history of medical specializations, the areas of specialization and what skills, training and demands are consistent with each, what resources medical students currently have available to assist them in making a specialty choice, the impact of current political and societal issues, and finally what other researchers have concluded on this topic.
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CHAPTER II
LITERATURE REVIEW
The purpose of this chapter is six fold. One is to review the history of medicine from initially being a profession of largely general practitioners to one of specialists.
Next is to explore the major areas of specialization and the skills, training and responsibilities of each. Third is to identify what resources and tools are available to medical students to assist them in selecting a specialty. Fourth is to look at the current societal and political forces shaping the future of medical specialization. Fifth is to explore the literature regarding research on the variables involved in the specialty selection process and lastly to review the construct of idealism in medicine.
From Generalization to Specialization
Up to the first half of the 1900’s most physicians were general practitioners.
They provided non-invasive treatments as well as surgeries, delivered babies, and even made house calls serving children, adults and seniors. After completing medical school, graduates apprenticed with more experienced doctors by way of a one to two year internship (Freeman, 2007). Several factors brought a radical change to the provision of medical treatment. Today upon graduating from medical school, doctors receive anywhere from three to ten years of specialty training through residencies and post
13 residency fellowships. The most significant concurrent combination of reasons for this transformation were patient needs, differences in compensation in favor of specialists, exponential increases in knowledge about the body systems such as in endocrinology, expanding treatment options and pharmacological advances, and technology (Richmond
& Fein, 2005).
Obviously, similar to other areas of the modern information age, there is an ever increasing explosion of knowledge to acquire and learn in the areas of medicine and science, which requires the information to be broken down into smaller more manageable categories in order to gain expertise. In medicine, some investigators trace the beginnings of this phenomenon back to World War II as the result of the multitude of treatment needs of wounded soldiers and returning veterans (Freeman, 2007; Bynum,
2008). Prior to this time there were 10 recognized specialty areas: “general surgery, orthopedics, otolaryngology, internal medicine, pediatric, psychiatry, dermatology, urology, ophthalmology, and obstetrics-gynecology” which developed in the first half of the twentieth century (Freeman, 2007). While in the military service, general practitioners worked alongside their better paid, higher ranked, and more favorably assigned specialized colleagues. The returning GP’s having learned from the specialists during the war and able to benefit from the GI bill, pursued further training as residents in the above and emerging specialty areas themselves. At the same time, the government funded a tremendous amount of medical research which led to improved and specialized treatments and innovations in technology requiring increased medical expertise
(Freeman, 2007).
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Areas of Specialization, Skills, Training, and Responsibilities
Currently, the American Board of Medical Specialties (ABMS) recognizes 24 categories. These are allergy/immunology, anesthesiology, colon/rectal surgery, dermatology, emergency medicine, family practice, internal medicine, medical genetics, neurological surgery, nuclear medicine, obstetrics/gynecology, ophthalmology, orthopedic surgery, otolaryngology, pathology, pediatrics, physical medicine and rehabilitation, plastic surgery, preventive medicine, psychiatry/neurology, radiology, surgery, thoracic surgery, and urology. In addition to choosing one of these twenty-four areas, a fourth year medical student can instead choose one of fifteen combined residency programs and thus become licensed in two specialty areas. These include internal medicine-dermatology, internal medicine-emergency, internal medicine-family medicine, internal medicine-neurology, internal medicine-pediatrics, internal medicine-physical medicine and rehabilitation, internal medicine-preventive medicine, internal medicine- psychiatry, neurology-diagnostic radiology-neuroradiology, pediatrics-dermatology, pediatrics-emergency medicine, pediatrics-medical genetics, pediatrics-physical medicine and rehabilitation, pediatrics-psychiatry-child and adolescent psychiatry, psychiatry- family medicine, or psychiatry-neurology (National Resident Matching Program, 2012).
The current medical student now has to choose from a total of thirty-nine initial residency opportunities available after graduation. Some specialty areas have no subspecialties such as allergy/immunology, colon/rectal surgery, neurological surgery, nuclear medicine, or ophthalmology, while other specialties are rife with subspecialties such as internal medicine which has 19 from adolescent medicine to transplant hepatology. The
American Board of Specialties recognizes a total of one hundred and twenty-three
15 subspecialties. These subspecialties along with the twenty-four principal specialties equal one hundred and forty-seven career alternatives (American Board of Medical
Specialties, 2013).
Successful practice in one specialty over another may involve differing skills.
Surgical specialties require good eye hand coordination, manual dexterity, physical stamina, and quick reflexes. Internal medicine requires critical thinking, data analysis, problem solving, good listening and people interaction skills. Emergency medicine requires tolerance for the unexpected, quickly changing circumstances, and being pulled in multiple directions at one time. Some specialties, such as dermatology, require a high degree of expertise in one specific area. Some, such as obstetrics/gynecology, often require performance of certain routinized procedures. Many specialties, such as the two just mentioned along with ophthalmology, and otolaryngology, require both good medical and surgical skill sets (Freeman, 2007).
Available Resources
In a 1991 essay in the Journal of the American Medical Association (JAMA),
Iserson stated “a physician’s career opportunities are restricted only by interest, ability, and scope of vision. The key step in choosing a career path is to decide which elements of any specialty will lead to professional and personal satisfaction. Self-reflection and insight are the ideal ways of getting this information, but it is the lucky few who can, alone, understand their current desires, let alone clearly perceive future desires” (Iserson,
1991, p. 1190).
Medical students have a number of resources available to them both in vivo and on line to assist them with this major decision. The availability of career advisors or
16 counselors varies with the particular medical school but often students must do most of their specialty career exploration on their own (Freeman, 2007).
Part of all medical school education requires clinical rotations in the core specialties of internal medicine, pediatrics, surgery, obstetrics-gynecology, psychiatry, family practice and neurology. During these rotations students observe firsthand the day to day procedures involved in the treatment and care of patients and also observe practitioners of various specialties and subspecialties. These experiences may ignite the interest of some and extinguish it in others. The rotations do, however, begin to help students identify the types of patients they would interact with, be it children, adults, or one gender over the other, and what type of interaction, be it primary care, clinical, or surgery, and what their future colleagues may be like in addition to the skills needed, procedures performed, and technology used.
Other immersion experiences include choosing elective rotations in fields of interest, rotations in different geographic and practice settings, and summer externships in various specialties and locations or doing research in particular areas of interest with potential future colleagues. Mentorships can be both formal and informal. Some school programs assign mentors to an area of interest which can last throughout the school years while some mentorships are chance interactions through a rotation or other chance contacts. Schools also have lecture programs from in house specialists or national guest presenters who share their professional experiences and provide opportunities for further informal inquiry. There are also many local, regional, and national meetings of specialty and general medical concerns at which to explore different career prospects.
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Navarro (2010) defended the reasons for a career course in the second year of medical school and stated it should focus on understanding The Match, being aware of specialty candidate qualifications, writing a curriculum vitae, writing an effective personal statement, reviewing personal finances impacting career decisions, and considering the factors of personality, skills, values, interests and lifestyle.
Many national organizations, and their websites, not only offer their unique and critical service components, they also share useful data and exploration tools delineating requirements, competitive United States Medical Licensing Exam (USMLE) Step II scores needed, program profiles, and general information to assist both students and physicians. Among these organizations is the Association of American Medical Colleges
(AAMC) which appears to be the most comprehensive and useful organization having been “founded in 1876 and based in Washington, DC [as]... a not-for-profit association representing all 141 accredited U.S. and 17 accredited Canadian medical schools; nearly
400 major teaching hospitals and health systems, including 51 Department of Veterans
Affairs medical centers; and 90 academic and scientific societies... [ and thereby] 128,000 faculty members, 75,000 medical students, and 110,000 resident physicians”
(www.aamc.org, 10/10/2012). The AAMC features the Careers in Medicine (CIM) informational and interactive programs at www.aamc.org/students/medstudents/cim/. The site offers medical students career assessments to identify barriers to making a specialty selection (Specialty Indecision Scale, 2nd Edition; Richard, et al., 2007) ), as well as interests (Medical Specialty Preference Inventory-R, MSPI-R), values (Physician Values in Practice Scale), and skills identification through exercises based on Bolles’ (1976 )
What Color is Your Parachute? It also employs the 16 personality types of the Myers-
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Briggs (MBTI) (Myers & McCauley, 1985) to help identify specialty satisfaction profiles as well as decision assistance worksheets, and a preceptor interview questionnaire. The
CIM program also supplies a very useful timeline of recommended activities throughout medical school for self-evaluation beginning in year one, exploring options during year two, choosing a specialty for year three and getting into a residency program for year four and a bank for keeping one’s individual assessment and investigative results. The site also provides exhaustive specialty and subspecialty information for 132 categories with details about the nature of the work, personal characteristics with correlations to the
MSPI-R (Richard, 2005) and MBTI types (Myers & Mcauley, 1985), residency requirements in terms of prerequisites and length of training, match data for number of positions available, number filled, and applicant data on the United States Medical
Licensing Exam Step 1 and 2, workforce statistics, compensation ranges, and links and further readings for almost all of the categories. The CIM also has a resource component for medical school advisors and holds annual meetings for the advisors to promote relevant and current supportive practices.
Another major organization is of course the American Medical Association
(AMA) at www.ama-assn.org which supplies much valuable informative career guidance one of which is the Fellowship and Residency Electronic Interactive Database (FREIDA) at www.ama-assn.org/go/freida which describes itself as “a database with over 9,000 graduate medical education programs accredited by the Accreditation Council for
Graduate Medical Education, as well as over 100 combined specialty programs” allowing the user “to search for programs by specialty, state, institution, and optional criteria” and obtain guiding facts and figures on them. Other helpful sites include: the
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Accreditation Council on Graduate Medical Education (ACGME) at www.acgme.org which is responsible for the accreditation of post MD medical training programs in the
United States, i.e., residency and fellowships, and its site provides information on duty hours, labor rulings, guidelines for programs and institutions; the American Board of
Medical Specialties (ABMS) at www.abms.org is responsible for certificating and board licensing in most specialties and subspecialties; the Electronic Residency Application
Service (ERAS) at www.myeras.aamc.org centralizes the application components such as letters of recommendation, test scores, individual statement and program selections and rankings; the National Resident Matching Program at www.nrmp.org is responsible for matching applicants and programs; United State Medical Licensing Exam at www.usmle.org which provides the Step 1 and Step 2 exams and practice materials during medical school and the Step 3 exam near the end of residency measuring the progress of clinical knowledge at each developmental educational milestone; CareerMD at www.careermd.com which provides job postings and career fairs around the county; and the Internship and Resident Information Site (IRIS) at www.i-r-i-s.com is a commercial site offering access to many residency program brochures.
Some less formal sites include www.residentweb.com which provides links to other pertinent sites as well as on-line discussion groups; and lastly scutwork.com at www.scutwork.com which offers actual detailed frank reviews and ratings of residency programs throughout the United States by current residents, as well as links to important on-line resources including those mentioned above.
One additional resource is the Pathway Evaluation Program developed by the pharmaceutical company GlaxoSmithKline and Duke University in 1988 at which time it
20 was reported that 80% of medical students claimed not to have sufficient information to choose a specialty (Fowler, 1988). This three step self-guided program is now web accessible at www.smbs.buffalo.edu/RESIDENT/CareerCounseling/main_menu.htm, revised in 2003. It consists of self -assessments on interests and values and compares them with practicing specialists’ responses for 18 critical factors to advice on specialty compatibility.
Societal and Political Influences and Impacts
A recent summary of reports on physician shortages in the United Sates indicates that in addition to current shortages in already identified specialties continuing, there will be new areas of shortages in more specialties and also for primary care providers. This is not only due to the general population growth which was reported to have increased by nearly a third “between 1980 and 2005, the nation’s population grew by 70 million people (AAMC, 2008, p. 5)” but also the population growth of those over sixty-five years of age, predicted “to double from 35 million to 71 million” by the year 2030 (AAMC,
2008, p. 5) with all needing general, specific and long term care. Increases in the number of injured and disabled veterans from Iraq and Afghanistan will also contribute to the need for additional medical providers.
Differences in compensation across specialties and the need for medical malpractice reform are also noted as key reasons for shortages in specific less lucrative practice areas. The growing access to healthcare benefits through employment, government funding and newly passed and previous legislation will continue to spur increased demand for both primary and specialty physician care (AAMC, 2008).
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Many institutions have sought to expand minority representation in the profession to increase the physician workforce as well as to provide support to all medical students to reduce attrition rates for academic reasons (Garrison et al., 2007). Increasing minority representation in order to increase care to a more diverse population is recommended in addition to merely increasing the overall number of physicians (AAMC, 2008).
Several requests have been made by the various physician professional groups, medical colleges and hospitals to lift Medicare caps on the number of residency positions being funded by the government. These caps have stayed the same since 1998 (AAMC,
2008) in total discordance with projected population growth and anticipated physician workforce need.
A recent study by The Physicians Foundation (2012) divided physicians into two broad groups for the purpose of its study: those who provide primary care in the areas of family medicine, internal medicine, and pediatrics, making up about a third of the workforce and those who are specialists, being all other categories, making up the remaining two thirds. The Foundation distributed 100,000 questionnaires via email to a representative group of the American Medical Association and received 13,575 replies for a 13.5% response rate. Key findings of the overall responders showed 77.4 % of physicians were pessimistic about the profession’s future; 84% believed the medical profession is in a state of decline; 58% would not recommend a medical career to their children or others; over one third of physicians would select a different profession if they could do it over; and over 60% would retire if they could afford to do so. Though younger doctors, female doctors, employed versus those in private practice, and primary care doctors were more positive than those who were either older, male, private
22 practitioners, or specialists, physician job satisfaction seemed generally low for a profession that requires so much education and sacrifice. Of the forty four questions in the survey related to the key findings as well as other topics such as Medicare, number of hours worked, electronic medical records, compensation, health care costs, and others, interestingly no questions were related to a physician’s choice of specialty in relation to job satisfaction.
In June 2010 the Medicine Payment Advisory Commission (MEDPAC) sent a report to the two houses of Congress entitled “Aligning Incentives in Medicine” reviewing several aspects of Medicare’s service delivery including how it supports
Graduation Medical Education (GME). In 2009 this support totaled $9.5 billion. The report recommended that there should be more oversight and inherent reinforcement to support primary care, over specialization, in that there will be a great shortage in these areas and also to promote more socioeconomic diversity in the physician work force than currently exists. One specific recommendation was if Medicare provides the main financial support to pay for residency programs, it should have a greater impact and influence on the available residencies in order to change the future makeup of specialists in the workforce. This report echoed similar recommendations made by the 2008 AAMC report titled “Policy Priorities to Improve the Nation’s Health from America’s Medical
Schools and Teaching Hospitals.”
Research Review of Variables in Specialty Selection
Several studies (Aagaard, et al., 2005; Dorsey, et al., 2003; Nuthalapaty, et al.,
2004; Lefevre, et al., 2010; Lawson, et al., 2004; Weissman, et al., 2012; Wilder, et al.,
2010) examined different variables influencing specialty selection in isolation or in
23 combination with others, as well as differences in these influences among discrete groups, such as, by gender, age, or unlike personal experiences, both across the more common specialties or within one given specialty. Some (Borges, 2001, 2002, 2003,
2004, 2005, 2007, 2009; Elam, 1994; Glavin, 2009; Hartung, 2005; Leong, 2005; Maron,
2007; Merlo, 2009; Porfeli, 2010; Rogers, 2009) of these studies have been undertaken to provide students with guidance in making a specialty selection and some (Bindal, 2011;
Chang, 2005; Eidt, 2006; Hauer, 2008; Morra, 2002) with the broader intent of identifying factors that could be employed by medical schools and policy makers to help fill current and anticipated future shortages in various specialties so that medical care is readily available to all in need. These factors included both external -- life events, student experiences, teaching or curriculum practices, potential compensation, and non-monetary work aspects, e.g., lifestyle, and internal ones unique to individuals-- personality characteristics, interests, abilities, emotional intelligence, preferred learning styles, and values. In addition some studies not only explored specialty selection but also preferred residency program features.
Though published in 1995, a meta-analysis by Bland et al. (1995), addressed the following questions: what factors have been studied that predict a primary care specialty choice; the relationships between these factors and how they affect career decision making; and how medical schools can use this research to increase career choices for primary care specialties? After conducting literature searches for articles between 1930 and 1993 in the search engines of MEDLINE, ERIC, PsychInfo, Sociology Abstracts, and
Dissertation Abstracts, nearly 2,000 citations were further reduced to a little over 300 relevant studies for content and time frame and then further reduced by a rating measure
24 to 73 core articles published after 1987 for synthesizing into the review. Bland et al. proposed a model looking at three dynamics impacting the specialty choice: the characteristics of the medical school including mission, faculty composition, values, curriculum, etc.; the characteristics of the student including demographics, personality type, values, life experiences, etc.; and the medical specialty characteristics which included patient contact, income, and technical requirements. Accounting for differences in definitions of terms (for example did choice mean preference or eventual practice) and research methodology, the analyses did provide several conclusions. Public or state medical schools produced more primary care residents than do private schools. All schools that produced a large number of primary residents had departments of family medicine. Having more primary care full time faculty produced more students selecting primary care careers. Medical schools having “a curriculum providing experiences that are longitudinal, last more than six weeks, and occur in actual primary care offices . . . will have a higher proportion of students selecting primary care careers” (Bland, et al.,
629). Women, older students, married students, black students, Hispanic students, and those having low income expectations, non-physician parents, interest in diverse patients and health care problems and less interest in prestige, advanced technology, or surgery more often chose primary care careers.
Studies in the meta-analysis using various personality measures such as the Myer-
Briggs Type Indicator (Myers & McCauley, 1985), California Psychological Inventory
(Gough, 1990), and the Intolerance of Ambiguity Scale (Budner, 1962) have not found them to be useful instruments in predicting primary care specialty choice. Amount of financial obligation did not prove to be a predictor either. Studies also found that the
25 timing of choosing a specialty differs among the various specialties and that students often change their decisions as they have more experiences. The authors cited the
Savickas (1986) modification of the Career Decision Scale to indicate that medical students’ indecision in selecting a specialty are due mainly to lack of information about specialties, equal appeal of specialties, diverse interests, lack of support in making a decision, and lack of knowledge about one’s interests or abilities. The authors of this meta-analysis suggested many steps to increase the probability of medical students going into a primary care career including developing stronger departments of family practice, internal medicine and pediatrics, changing medical schools cultures to value primary care, recruit and select students who are more likely to choose primary care careers, provide primary care longitudinal experiences, provide instruction in societal health care needs and the characteristics of specialties, and obtain more dollars for training of primary care physicians.
External Influences
Aagaard et al. (2001) examined what factors were important to applicants in choosing an internal medicine residency program, especially women and underrepresented minorities. Of approximately the 3,000 applicants to residency programs at UCLA, UCSF, Massachusetts General and New York Presbyterian in 1999 who were sent surveys, nearly 37% responded but only 33% were included due to incomplete required demographic information or being an international medical school graduate. The researchers believed this study to be of value because unlike other studies that examined race and ethnicity factors on specialty choice, this study examined what factors were important to selecting a particular residency program. The broad factors
26 included location characteristics (such as: near spouse, spouse job opportunities, cultural activities, near family, ethnic diversity, etc.), program characteristics (such as, reputation, morale, variety of clinical experiences, patient ethnic diversity, on-call schedule, etc.), recruitment experience (positive interview, being wanted, prior experience in program, etc.), post residency plans (fellowships available in the area, desirable location to continue living in, and job opportunities in the area), and lastly advising availability of a role model, the dean and/or others. All applicants, using a five point Likert scale, rated staff morale, the program’s academic reputation and a positive interview experience as key selection factors. Women rated the following factors more highly than male counterparts: gender diversity of staff and faculty, nearness of spouse or spouse’s job, and emphasis on primary care. Minorities also valued the ethnic diversity of patients, staff and faculty, servicing the medically indigent, feelings of being wanted, and ethnic minority supportive academic environment more than the white applicant group. Though this study focused on a group of fourth year students who had already selected a specialty in internal medicine, it revealed important factors that can also be generalized to selecting a specialty area.
Dorsey, Jarjoura, and Rutecki (2003), examined the influence of the determinant of controllable lifestyle in the choice of medical specialty along with wage compensation and number of additional years of education required after medical school or graduate medical education (GME). Controllable lifestyle encompassed reasonable weekly work hours practiced, adequate amount of time for family/leisure pursuits, and perceived limited amount of night call duty. The 16 specialties that can be chosen by seniors for residency were rated by the authors as controllable, hyphenated by a “c” or
27 uncontrollable, hyphenated by a “u”. The specialties identified were anesthesiology-c, dermatology-c, emergency medicine-c, family practice-u, internal medicine-u, neurology- c, ob/gyn-u, ophthalmology-c, orthopedic surgery-u, otolaryngology-c, pathology-c, pediatrics-u, psychiatry-c, diagnostic radiology-c, general surgery-u and urology-u.
Upon examining the trends in the number of seniors who chose residencies in these specialties for the seven years between 1996 and 2002, the researchers found an increase in the selection of controllable lifestyle specialties over the uncontrollable ones and calculated that it accounted for 55% of the variability while higher income levels only accounted for 9% and less years of required GME only 4%. They cautioned these results were only a correlation not necessarily a cause/effect relationship because so many other factors contribute in the medical specialty selection decision.
In 2006, Bhattacharya, a professor at Stanford University in the department of medicine, categorized medical practice into the following five categories: General and
Family Practice or FP, Internal Medicine/Pediatrics or IM, Surgery, Internal Medicine and Pediatric Subspecialties or IM Subspecialties, and lastly Radiology and other specialties under Radiology. He collected data to determine how much each category earned and analyzed why some categories of physicians, such as those in Surgery earned significantly more than others, such as those in the category of FP by as much as double annually. He found that approximately half of the difference can be explained by expected factors like number of hours worked, increased length of training required, or level of skill differences. Though he postulated some reasons that might account for the other 50%, he speculated that there are definite barriers to entry into the highest earning specialties set by accreditation boards limiting the number of slots open. Even though
28 these barriers may limit the supply of specialists and thereby increasing demand for their services, he implied the wages still are highly inflated for a free market.
Morra, Regehr, and Ginsburg (2009) analyzed the responses of 560 out of 781 first through fourth year medical students attending the University of Toronto in the fall of 2002 and found that those students considering choosing to practice family medicine dropped significantly as they matriculated from 70% in year one to 30% in year four while those who indicated that low compensation was a consideration in not choosing to practice family medicine increased from 15% to 40%. When asked to rate factors in specialty selection including other factors such as residency length, daily duties, lifestyle in terms time, prestige, intellectual stimulation, patient population, 15% of fourth year students selected remuneration as most important as opposed to 0% of first years. The authors speculated that this view of family medicine not being a well-paid specialty area also devalues the worth of the specialty along with other lower paying primary care specialties and should be further studied to promote improving future recruitment in these specialties.
Nuthalapaty, Jackson, and Owen (2004) conducted the first study in identifying which of twenty factors, chosen from a review of literature of the 1980s through 1990s, were of most importance to medical students in selecting their top residency match. Of the 16,183 match participants, 7,143 rated the 20 factors as important or not and then how much on a Likert scale. The 20 factors were: satisfaction of current residents, how much the program cares about its trainees, how well they fit with the program, geographic location, how well the current residents work with each other, quality of hospital facility, faculty supervision in patient care, academic recognition of the residency, level of
29 responsibility for patient care, amount of faculty teaching on the wards, amount of conference/didactic teaching, case load size, on-call frequency, area cost of living, amount of clinical support, research emphasis, medical student interaction, employee benefits package, salary, and lastly supplemental income opportunities. The top reasons reported for residency selection were perceived regard for trainees (98%), satisfaction of current residents (98%), program fit (97%), geographic location (95%), and how well the current residents work with each other (94%). Nonsurgical residents rated geographic location, working with medical students, amount of clinical support services, frequency of on-call duty, types of benefits, salary, and opportunities for supplementing income as more important than did the surgical residents. The surgical residents emphasized the importance of research in the residency curriculum and how well the current residents worked together more than the nonsurgical resident group of match applicants.
Lefevre, Roupret, Kerneis, and Karila (2010) proposed that because most studies of medical specialty choice have been conducted in the United States and that data from other countries has not been collected, and because medical practice is becoming more similar across the world and the medical system in France has been recognized as being of high quality by the World Health Organization, the French population of medical students would be a good group to examine. The authors conducted an intense review of
1780 6th year students from a population of 2588 taking the National Practice Exam in
2008. They found that of the 87% that stated their medical specialty choice, only 20% chose general practice. More men chose specialties in surgery than women, and more women chose pediatrics (88%), gynecology (82%) and general practice (77%) than men.
Specialty choice was motivated by interest in particular diseases, private practice
30 opportunities, patient contact, and quality of life. They further observed that because women are steadily out numbering men in medicine and gender is one of the most significant factors in selecting certain specialties, more women in medicine will result in irreversible change in clinical practice and insufficient practitioners in critical areas.
Chang, Hung, Wang, Huang, and Chang (2005) chose to investigate factors that influence medical specialty selection of medical students in several medical programs in
Taiwan to identify what the government can do to provide incentives to future physicians to eliminate shortages in specific specialties such as surgery and ob/gyn. Since several factors influence specialty selection decision making, the researchers also defined the weights of each factor to better structure incentives. Younger medical students did not rate compensation as important a factor compared to more senior students and the researchers hypothesized that, in general, this factor was lower because families were now better off and students did not feel the burden of having to support their family as intensely as previously. Life-style was also an important incentive and was linked to increases in the specialties of residents applying for positions in ophthalmology, dermatology and rehabilitation. Highest reported influences were obtaining affirmation of personal ability and a sense of accomplishment as well as access to career opportunities.
Lawson, Hoban, and Mazmanian (2004) reexamined the Bland-Meurer (1995) career model as a preferable approach to looking at multiple variables affecting a primary care residency choice as well as looking at the specialties of pediatrics, internal medicine, and family medicine making up primary care separately as distinct specialty selection.
The Bland-Meurer specialty decision model consists of examining three areas-- student
31 characteristics, medical school characteristics and students’ perceptions of the medical specialty. This study looked at three areas contributing to the student characteristics component. The sample consisted of 555 of 832 (67%) medical school graduates of
Virginia Commonwealth University between 1998 and 2002 and used the university data base to gather information for the first area-- demographics, undergraduate major of science or non-science, highest degree held of bachelors, masters, doctorate or law, post baccalaureate work, Medical College Admission Test (Association of American Medical
Colleges, 1991) scores in physical science and biology; information from the Association of American Medical Colleges Graduate Student Questionnaire (AAMCGSQ, 1998,
1999, 2000, 2001, 2002) for the second area-- perceptions of clinical education quality, research activities and volunteer activities in medical school, influence of debt, actual debt figures, and scholarship figures; and for the third area other information from the
AAMCGSQ regarding anticipated experiences after medical school in research, working in underserved area, and perceptions of the medical practice environment. The research only showed gender to be a demographic predictor, in that women chose pediatrics four times more than men, the research model correctly predicted primary care over other specialties 72.4% of the time, as well as internal medicine at a rate of 70.6%, family medicine at 83.3% and pediatrics at 77.2%.
Weissman, Zisk-Rony et al. (2012) reviewed responses of 229 Israeli students in their fifth year of a six year medical program at two universities and found many similar results to other worldwide studies on medical specialty and residency program selection.
By their fifth year 66% of the students who had not yet considered a specialty were male; married students considered lifestyle as important with controllable hours in their
32 specialty decision; working conditions after residency were important to 52% while 42% considered working conditions during and after residency equally important; women preferred primary care specialties more than men especially if they were married; and males preferred residency programs that allowed for a high level of responsibility in clinical decision making and ability to do research; and both males and females considered residency programs based on good work place interpersonal relationships and a high level of teaching.
Wilder, Dodoo, et al. (2010) examined income as an influence on specialty choice. They found that since 1979 the disparities grew between the compensation of primary care physicians and specialists (such as radiologist and orthopedists). The number of medical students choosing primary care specialties dropped by 50% and choosing to work in a federally qualified health facility or in a rural area dropped by
30%. Concluding that potential income levels were such a strong determinant in specialty selections, the investigators asked that medical policies be revisited to avert further students from avoiding primary care careers resulting in continued specialty shortages due to compensation disparities.
Eidt (2006) examined trends in specialty selection as it affects mainly the area of vascular surgery which may be facing a critical manpower shortage in the years ahead based on applications to general surgery trending downward. He looked at what other researchers’ reasons for the selection of a specialty including “intellectual appeal of the specialty, projected income, manual dexterity, influence of role models, work hours, years of training and altruism among others” (p. 177). He reported that medical students cited “lack of autonomy, the brutal lifestyle, an unacceptable length of training,
33 inadequate debt compensation, and diminishing prospects for sustained long-term income growth” (p. 178) as their concerns in selecting surgery specialties. Though this downward trend in applicants may be due to an emphasis on lifestyle factors he felt that other factors do make surgery attractive like a grateful patient’s positive feedback for performing a “technically challenging and successful operation” (p. 178). He further stated the fact that more women have become physicians by almost seven fold from 1963 to 2003, 7.7% to 45.1%, and have therefore been credited with contributing to life-style emphases. Women, in fact, chose specialties (such as pediatrics and ob/gyn) with uncontrollable life-styles proportionately more than men. He believed the lack of female mentors, male-bias, and sexual harassment deter women from choosing surgical specialties.
Allen et al (1987) found that early clinical experiences in the area of family medicine at the University of Minnesota Medical School through either mentoring/tutoring by a family medicine practitioner or clerkships had no influence on medical students’ later selecting family medicine as their area of specialty even though the early exposure revealed positive attitudes similar to those who had experienced early exposures to other specialty areas (such as internal medicine) on the Family Medicine
Attitude Scale (Edward, et al., 1985). Based on their review of other earlier studies, researchers (Allen et al., 1987) concluded other factors (such as the population of a student’s home town being less than 50,000, the age of the student being 31 years or older, being married and having children, and being in debt after graduation) predisposed students to family medicine as a career choice much more so than did early exposure.
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Personal factors inherent to the student may impact choice more than externally contrived instructional ones.
Because of the predicted serious shortages in internal medicine (IM) due to less graduates choosing the specialty and the increase in the number of patients needing care, the Clerkship Directors in Internal Medicine (CDIM) Task Force on Enhancing Student
Interest in IM Careers, Hauer, Durning, Kernan, et al. (2008) studied 1177 (82%) members of the 2007 4th year class from eleven universities. Analyzing the results of a
78 item questionnaire composed of demographic information, perceptions of IM practice compared to other specialties, and items rating influences that either drew them to or away from IM specialty selection, the task force found that 274 (23.2%) of students planned to select an IM residency; the three strongest factors in selecting an IM specialty were educational IM experiences, IM patient care, and perceived lifestyle; more males, private medical school graduates, those rating IM educational experience as favorable chose IM; indebtedness, potential salary, prestige were not factors; intellectual challenge, commitment to patient care, IM role models, and personal/professional satisfaction were factors; residency and practice work load and hours, increased paper work and charting, drove others away from IM. One finding was that students were more likely attracted to other specialties than necessarily having had negative experiences as disincentives to selecting an internal medicine residency.
Training Influences
There are many differences in physician training and provision of patient care between the United States and the United Kingdom but concerns about physicians selecting specialties and contributing to shortages in provision of services cross
35 geographic boundaries. Bindal et al. (201l) investigated why students in the UK were avoiding selecting pediatrics as a medical career option. She indicated that although there had been a 57% increase in medical student enrollment to meet projected shortages, without any increase in the amount of graduates working in pediatrics. The study concluded that earlier exposure to a pediatric clerkship such as in the very first year of training, career advice, as well as exposure to healthy typical children during the training will influence those predisposed to working with children to select pediatrics as a specialty and thereby increase the number of practicing pediatricians. This recommendation however, contradicts the previous studies by Allen et al. (1987) and
Hauer et al. (2008).
Based on general career indecision theory, Borges (2007) hypothesized that a study of 91 first year medical students participating in a year-long course to provide experiences in various clinical settings (called the Ambulatory Care Experience) would demonstrate that assisting students gain information would result in crystallization of career identity and specialty choice. Pre and post course assessment using the Medical
Career Development Inventory (MCDI; Savickas et al., 1984) and the Specialty
Indecision Scale (Osipow et al., 1987) revealed that the students remained less likely to have a specialty preference or even to have formed a general preference for a medical career after participation in the course. She suggested that more analyses, including qualitative analyses, should further look at the process by which medical students go through the stages of selecting their specialty of practice and that career counseling along the way is critical. Borges referred to Kitson’s work from the 1940’s directing us to reframe our thinking from detecting interests to creating interests. Seventy years later
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Kitson’s proposition may be quite apropos and supportive of more focused exploration and development for this group as it relates to all the medical career decision making required along the way to eventual practice.
Stratton, Witzke, Elam, and Cheever (2005) examined the relationship between preferred learning styles, preferred instructional methods and specialty preferences among 912 medical school applicants and also to personality type as measured by the
Myers-Briggs Type Inventory (Myers & McCauley, 1985) for 160 students who were accepted to medical school. The seven learning preferences included applying information, discussing issues, problem solving, organizing concepts, digging out knowledge, memorizing facts, and spoon feeding. The four instructional methods included group discussion (GD), self-study (SS), lecture (L), and computers (C). There were nine traditional specialty choices. The study found modest associations of learning preferences with specialty preferences: surgery had a positive association with memorizing facts and a negative one for discussing issues; problem solving associated positively with internal medicine and negatively with ob/gyn. Gender differences indicated men preferred self-study while females preferred group discussion. Surprisingly the only statistically significant correlation between the learning preferences for computers was positive for extroversion and negative for introversion.
Leong, Hardin and Gaylor (2005) examined several issues by examining first, the perceived value and effects of participation in a career seminar class (intervention) on eventual specialty selection. They researched the usefulness of three measures—the
Gough Medical Specialty Preference Scale (GMSPS) for ten specialties (Gough,1979), the Myers-Briggs Type Indicator (MBTI) personality measure (Myers & McCauley,
37
1985), and the Values Scale (VS; Nevill &Super, 1989) with 117 workshop participants of which 112 became residents and thereby made a specialty choice, the correlation between pre and post class specialty selection, the correlation between pre and post class specialty selection and eventual actual selection and gender differences. Students generally rated the class as helpful in making a specialty decision with those not changing their specialty selection after the class, rating it as more helpful possibly because it confirmed their decision. The students rated the MBTI as the most helpful. The interactions between the three measures were different for men and women in choosing a specialty, meaning that the profile for selection of one of the ten specialties compared to either values or personality type were not consistent for men and women. For example, women interested in Anesthesiology rated higher in Achievement (VS) and men interested in the same specialty rated high in Risk (VS) and women interested in EENT rated higher in Thinking style (MBTI) while men rated higher in Feeling style (MBTI).
Most interestingly, student’s pre-participation specialty selections were better predictors at 32.1% of actual specialty selections in residency compared to post-class participation predictors at 21.4% and those that did not change their specialty selection after the workshop selected the same specialty in residency at a 42% rate while those who had changed their specialty selection after the workshop at only a 4.8% rate. The GMSPS only had an 11% prediction rate.
Individual Characteristics
Employing Holland’s (1977, 1985) codes of RIASEC ( Realistic, Investigative,
Artistic, Social, Enterprising and Conventional), Elam (1994) analyzed if a student’s undergraduate major in science or in a non-science field (the independent variable)
38 impacted that student’s later specialty choice (the dependent variable). Most medical students that graduated had majored in Investigative (I) disciplines in undergraduate school almost 10 times more than the next category of Social (S) in the sample of 13,871 medical students who graduated medical school in 1987. The highest frequency of graduating medical students (2324 out of the sample of 6997) selected specialties in the
IRS (Investigative, Realistic, Social) Holland Occupational Code. Results for three out of the seventeen specialties, namely psychiatry, surgery, and radiology indicated that the
Holland code of undergraduate choices failed to match predicted selection outcomes.
Based on her findings, she also suggested that the Holland occupational codes for the different specialties should be revisited and probably reconfigured with additional currently non-coded specialties and sub-specialties identified.
Borges, Savickas, and Jones (2004), looked at how interest surveys and the
Holland codes predicted either choosing a specific specialty or how they predicted patient versus technique-oriented specialty selection. Both medical school career counselors’ speculation and some empirical research have indicated that physicians are too homogeneous a group to fall into the different Holland three Career Code designation based on RIASEC. This study converted the interest scores from the Career Occupational
Preference System Inventory (COPS) (Knapp & Knapp, 1982) which focuses on job activity likes and dislikes in eight occupational clusters of Science, Technology, Service,
Arts, Communication, Clerical, Business, and Outdoor, to the six Holland Career Codes.
First year medical students were given the COPS and then their converted Holland Code was compared to their eventual specialty choices of family medicine, internal medicine, pediatrics, psychiatry, OB/GYN, surgery, and emergency medicine. Most groups were
39 found to have an ISR Holland Code with some differing outliers within their specialty. In addition to the Holland Code not predicting eventual specialty within this group it also did not predict between patient versus technique- oriented specialties when looking at
Social for patient-oriented specialties and Realistic for technique-oriented specialties being the second most frequent code. The study recommended that the Holland Career
Code for physicians (ISR) and that medical specialties should not have separate codes. It also proposed that those who had a significantly greater distance on the hexagon model between the first code of Investigative and the second code of either Social or Realistic were more technique-oriented in specialty choice than those whose second code was not so distant from the first one.
In a 2009 Australian study Rogers, Creed, and Searle used the principles of self- efficacy, outcome expectation, and goals of social cognitive career theory (SCCT) (Lent,
Brown, & Hackett, 1996) to develop a measure to assist medical students choose a medical specialty and to determine a practice location. Self-efficacy is judgment “of capabilities to organize and execute actions, outcome expectations are the expected consequences of actions, and goals are defined as intentions to engage in a certain activity” (Rogers et al., p. 325). The 25 items for the instrument were based on analyzing both the retrospective reporting of a small group of 34 practitioners on what gave them the confidence to select their specialty and practice location, the perceived advantages and disadvantages of their decision, and what steps they had taken to make their decisions, and the comments of 13 first year medical school students in a focus group discussing what would give them the confidence to make a specialty and practice location decision, what advantages and disadvantages did they expect regarding their
40 decisions, and what steps they were going to take to make their decisions. Two hundred and ninety three medical students participated in piloting the instrument for further statistical refinement and a second administration to 499 students to confirm validity. The authors believed their tool to be an important step in helping medical students select a specialty based on a theoretical foundation.
Glavin, Richard, and Porfeli (2009) investigated the predictive validity of the revised 150 item Medical Specialty Preference Inventory (MSPI; Zimny, 1979) to assess six major specialty choices of Family Medicine, Pediatrics, Internal Medicine, Surgery,
Psychiatry, and OB/GYN among 506 students who registered at the Careers in Medicine website. The overall predictive validity was 58% but differed among the six specialties from a low of 46.7% for family medicine and 74% for general surgery. The scale was more predictive for students whose second specialty choice had a gap of at least 3.5 points from their first choice.
Porfeli, Richard, and Savickas (2010) used several statistical methods in an empirical research model of the Medical Specialty Preference Inventory (MSPI) in contrast to the inductive measurement model used by Zimny to develop the original
MSPI (1979), as well as, by Sondano and Richard (2009) in their revision of the MSPI.
The inductive model examined the latent structure of interest items by clusters. The clusters then led to factors which led to scales. This study sought to use the empirical model to improve the predictive validity of the MSPI for the original six specialty areas of family medicine, internal medicine, ob/gyn, pediatrics, psychiatry, and surgery which accounted for only 45% of practicing physicians in 2009 according to the American
Medical Association, and expand the predictive validity to 16 specialty areas. They
41 analyzed the results of the 150 items and 18 interest factors of the MSPI completed by
2330 medical students and their eventual specialty selection as physicians in their 2nd year of post medical school education. The results of the study showed an increase in predictive validity of the MSPI to 53.6% in the empirical measurement model compared to 46% in the inductive measurement model. The empirical model yielded two discriminant functions: the first on the x axis ranged from biomedical-oriented to biopsycosocial and on the y axis from consulting services to direct patient care. For example radiology fell in the lower left quadrant (biomedical and consulting) and family medicine in the upper right quadrant (biopsycosocial and direct). They recommended that scores be reported using both empirical and inductive measures for more support in career choice.
Sodano and Richard (2009) supported the analysis of interests in helping medical students select a specialty and viewed most interest inventories such as The Self-Directed
Search (Holland, 1977) or the Strong Vocational Interest Blank (Strong, 1927) and the inventories later versions as better at general occupational selection than specialized fields within an occupation. The authors reexamined the validity of Zimny’s 150 item
Medical Specialty Preference Inventory (MSPI) with 1014 medical students and found the 38 factors within five general areas to be a poor statistical fit. In a further breakdown of the responses the authors constructed an 88 item version consisting of physician activities with three different factor models, but upon further examination of a second sample group of 1016 medical students, found the one with 18 factors was the best fitting model of the three using confirmatory factor analysis. The 18 factors obtained were community health, family history, psychosocial medicine, psychological services, home
42 health care, preventive health, reproductive health-counseling, comprehensive care, operative procedures, anatomy, emergency-critical care, laboratory tests, complex equipment and procedures, death and dying, immediate results, precise workups, systems knowledge, and complex problems. They recommended further investigation to examine the results of the 18 factors to more than the original traditional six specialty areas in the original 38 factor MSPI.
A 2001 study by Borges and Jones used the 16 Personality Factor Questionnaire
(Cattell, 1993) to determine if first year premed undergraduate students who later chose to practice family medicine shared any of the personality factors of already practicing family medicine physicians. Of the 16 primary factors of Warmth, Reasoning, Emotional
Stability, Dominance, Liveliness, Rule Consciousness, Social Boldness, Sensitivity,
Vigilance, Abstractedness, Privateness, Apprehension, Openness to Change, Self-
Reliance, Perfectionism, and Tension, both the students and the practitioners were within the average range for all factors except Reasoning on which the practitioners fell outside the average range being much more abstract than concrete in their thinking. Other differences between the students and physicians were in the additional five factors of
Emotional Stability, Liveliness, Rule Consciousness, Openness to Change, and
Perfectionism. “In general, these premedical students were more concrete thinkers; more reactive and emotionally changeable; more lively, animated and spontaneous, less conforming; less open to change; and more flexible and tolerable of disorder compared to family practitioners. These groups were similar with regard to the personality factors measuring Warmth, Dominance, Social-Boldness (or inhibition), Sensitivity, Vigilance,
Abstractedness (or imagination), Privateness, Apprehension, Self –Reliance, and
43
Tension” (Borges & Jones, p.8). The authors postulated that age and maturity might account for the differences between the two groups and a follow up administration of the questionnaire to the students who were later practicing Family Medicine, to compare if their personality profiles were now in more alignment with the original group of physicians, might prove informative.
Borges and Gibson (2005) examined personality factors as they differed among two groups of specialists: person oriented and technique oriented using both the
Personality Research Form (PRF; Jackson, 1984) based on Murray’s theory (1938) of personality and the Big Five-Factor Model (Digman, 1990) developed to provide a framework to quantify various personality measures and corresponding descriptors, factors, characteristics, or other subscales for research purposes. Of the 875 physicians who had taken the PRF as a first year medical student 244 (28%) agreed to participate.
Person-oriented specialists are those that focus on the entire patient and include internal medicine, psychiatry, and pediatrics and technique-oriented specialists focus on particular areas of the body and possess specific skills and include surgery, anesthesiology, and emergency medicine. The 20 PRF scales include Abasement,
Achievement, Affiliation, Aggression, Autonomy, Change, Cognitive Structure,
Defendence, Dominance, Endurance, Exhibition, Harmavoidance, Impulsivity,
Nurturance, Order, Play, Sentience, Social Recognition, Succorance, and Understanding.
The Big Five-Model personality dimensions are Agreeableness, Conscientiousness,
Extraversion, Neuroticism, and Openness to Experience. The results found differences between the two groups of physicians and also genders within each group. Borges and
Gibson (2003) also found the PRF a better discriminator at predicting affiliation between
44 the two specialty categories than the dimensions of the Five-Factor Model. The technique-oriented group scored higher on Defendence (more suspicious, having a chip on one’s shoulder, resisting of inquiries, justifying, defensive, and rationalizing) and
Social Recognition (greater seeking of respectability, approval, admiration, and wanting to make a good impression, be obliging and courteous) than the person-oriented group.
The person-oriented female physicians scored higher than male counterparts on
Nurturance (more sympathetic, helpful, benevolent, and caring), Order (more organized, consistent, planning, deliberate, and neat), Sentience (sensitivity, perception, awareness, sensuousness, and openness), Succorance (dependent, seeking help and support, trusting, and ingratiating) and lastly Understanding (curious, explorative, investigative, inquisitive, and analytical). The technique-oriented female physicians scored higher than males on
Change (flexible, wavering, and unpredictable), Exhibition (noticeable, expressive, demonstrative, and dramatic), Impulsivity (spontaneity, quick-thinking, impatience, impulsivity, and excitability), as well as Nurturance, Sentience, and Succorance. Though two of the Big Five Factors of Agreeableness and Neuroticism were found to differentiate between the person versus technique-oriented groups only Agreeableness was found to discriminate between them and was higher in the person-oriented group. The researchers postulated that physicians may share more common characteristics overall, regardless of being in either the person or technique-oriented group, within their profession and thereby requiring a more comprehensive discriminating measure like the PRF to be used for differentiation as opposed to a broader measure like the Five-Factor Model.
Borges, Roth, and Seibel (2004) examined Holland’s (1980) construct of vocational identity, Savickas’(1986) physician career development tasks of
45 crystallization, specification, and implementation in relation to personality factors and different career choice patterns. The 16 PF (Cattell et al., 1993) was used as the personality measure. The Medical Career Development Inventory developed by Savickas
(1984) which consists of 35 items, five in each of the seven vocational development tasks
(career crystallization, career specification, career implementation, occupational crystallization, occupational specification, occupational implementation, and stabilization) was used to categorize 155 first year medical students into four groupings differentiated by career choice patterns: the first group consisted of those who had crystallized a career preference but not specified a career preference; the second group consisted of those who had not crystallized but had specified a career preference; the third consisted of those who had done both; and the fourth was one in which they had neither crystallized nor specified a career preference. Crystallization means forming a general preference for a career and career specification means having a specific preference. Investigators found that those scoring higher on the Social Boldness (being thick skinned versus being shy and sensitive) personality factor fell into the groups that had coped with one or both tasks of crystallization or specification (groups one, two or three) and that those who had not coped with specification scored higher on the Tension factor (being tense, driven, and impatient versus relaxed and patient). Implications are for further “longitudinal studies to explore the impact of physician vocational identity development on satisfaction with medicine and specialty choice” (p.6).
Borges and Savickas (2002) undertook the tasks of quantifying the results of different personality assessments as related to medical specialists, transferring those findings into the Five-Factor Model of Personality (FFM; Digman, 1990), summarizing
46 the findings of the five personality factors and commonly studied specialties, and making recommendations for further research. The four most commonly used personality instruments included the Adjective Check List (ACL; Gough & Heilburn, 1983), the
California Psychological Inventory (CPI; Gough, 1990), the Sixteen Personality Factor
Questionnaire (16PF; Cattell et al., 1993), and the Myers-Briggs Type Indicator (MBTI;
Myers & McCauley, 1985). All of the resultant scores were converted to the FFM dimensions of Agreeableness, Conscientiousness, Openess to Experience, Neuroticism, and Extraversion. The specialty groups included anesthesiologists, family practitioners, internists, obstetricians and gynecologists, pediatricians, physiatrists, psychiatrists, surgeons, and support specialists of pathology and radiology. The reviewers found that the major specialties have been studied in inconsistent degrees with many other specialties being very limited or altogether excluded, creating large voids of groups for comparison; focus has been on differences between specialties or groups and not within specialties; assigning of specialties into groups has been inconsistent in the research; while one of the five factors, Neuroticism, is rarely found, two others, Openness to
Experience and Agreeableness, were present; and “stereotypes about the personalities of medical specialties were not supported by empirical research” (p. 374).
The most significant finding was that there is a greater variation within than between specialists and therefore more than one specialty can fit a particular medical student in terms of personality characteristics. Though the connection between personality characteristics and specialty are not as direct as some have proposed, use of personality assessments will help students with one tier of self-exploration, from which to then consider other factors, such as practice environment, compensation, and lifestyle in
47 making a specialty choice. The investigators suggested future research focus both on the students’ personality profiles rather than the specialty personality characteristics, as well as a shift from scale scores to score profiles that then form personality patterns and secondly examine how different personalities sustain in a particular specialty. Borges and Savickas (2002) also make the appeal to use one standard personality assessment, preferably one that aligns with the Five-Factor Model such as the revised NEO
Personality Inventory (NEO-PI; Costa & McCrae, 1992) for more consistency, since the study of personality and specialty is itself so specialized in the field of vocational and career study.
Hartung, Borges, and Jones (2005), in an effort to discover the utility of person to person profile matching versus person to normative group/environment matching, examined a reference group of 62 medical school graduates in the year 2000. The 16PF
(Cattell et al., 1993) primary and five global scores were gathered from a criterion group of 358 medical school graduates between 1995 and 1999. The 16PF primary and five global scores were then compared with how they matched in their specialty selections among the top highest five and also top seven profile matches. Results indicated better specialty matches when the top seven profile matches versus top five were selected. The
16PF primary factors were used in the profile match over the five global factors, comparing specialty choices as primary versus non-primary care rather than more specific specialties resulting in more corresponding selections. The authors speculated that follow ups of later sub-specializations and lifelong choices might reveal even more consistent validity. They argued that adding this type of career information to current counseling/intervention practices was useful, since those choosing the occupation of
48 medicine are a highly heterogeneous group which contradicts a prior premise of one of the authors (Borges, 2004) that medicine is a homogenous profession.
Maron, Fein, Maron, et al. (2007) proposed that since personality assessment had significantly improved over the past several decades and because the make-up of medical students had become more diverse with 50% of future physicians being women, it was important to again investigate personality as a predictor of medical specialty selection. One hundred and thirty seven eventual residency matches were compared to the students’ personality results of the Neuroticism-Extraversion-Openness Personality
Inventory Revised Test (NEO PI-R/Form S; Costa & McCrae, 1992) measuring the five traits of neuroticism, extraversion, openness, agreeableness, and conscientiousness as predictors for selecting one of nine specialty categories including psychiatry, internal medicine, surgery, family practice, anesthesiology, radiology, pediatrics, and ob/gyn. In general they found that personality traits before starting medical school were predictive of two specialty areas but not others. Psychiatrists scored significantly higher in the areas of neuroticism and openness while family practitioners scored relatively lower in neuroticism than others and surgeons were generally similar to clinical specialties and there was little difference among the seven other specialty categories in their personality profiles. Women scored higher than men in the positive attributes of extraversion, openness, agreeableness, and conscientiousness compared to men as beginning medical students.
Merlo and Matveeskii (2009) studied what cognitive skills and personality characteristics could predict competency in the specialty area of anesthesiology among the 13 highest rated versus 13 lowest rated residents among a pool of 80 residents. The
49 subjects’ performances on the four cognitive performance measures for fine motor dexterity, using finger tapping and pegboard tests, executive functioning, using the trail making test, processing speed, using the Wechsler Adult Intelligence III (Wechsler,
1997) symbol search and coding subtests, and sustained attention, using the Conners’
Continuous Performance Test (Conners, 2000) revealed no significant findings distinguishing the two groups. The two groups did show significant differences on personality factors measured by the 300 item International Personality Item Pool
Representation of the NEO-PI-R (Costa & McCrae, 1992). The high competency group scored higher on the three subscales of cooperation, self-efficacy, and adventurousness and scored lower on the four negative subscales of neuroticism, anxiety, anger and vulnerability than the low competency group. They concluded that personality factors measuring “confidence, conscientiousness, adaptive social skills, and mental well-being”
(p. e553) predicted success in this particular specialty and recommended personality as an adjunct in resident selection.
In addition to personality traits and vocational interests, Borges, Stratton, Wagner, and Elam (2009) reviewed how Emotional Intelligence (EI) might be different across specialists. They confronted traditional beliefs that primary care physicians demonstrate a greater ability to recognize one’s own and others’ emotions and feelings, to separate them, and then use the knowledge to shape one’s cognition and actions. Three separate groups of medical students one group in the fourth, one in the third and one in their first year at three different US medical schools were given three different EI measures respectively: the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT; Mayer et al., 2002) the Trait Meta-Mood Scale (TMMS; Salovey et al., 1995) and the Bar-On
50
Emotional Quotient Inventory (EQ-I; Bar-On, 1997). All three investigations found no significant differences between students who eventually entered primary care specialties, such as internal medicine, family practice, or pediatrics, and the other specialties, such as anesthesiology, emergency medicine, pathology, radiology, neurology, ob/gyn, ophthalmology and surgical fields in Emotional Intelligence and that their EI was generally comparable to other college-age adults.
Cienchanowski, Russo, Katon, and Walker (2004) investigated the effects of attachment style in selection of a primary care specialty versus non-primary care specialties using the combined results of two questionnaires and ratings of the top three specialty choices from a list of 36 specialty and sub-specialty options among 144 second year medical students. The two questionnaires administered were the Relationship Scales
Questionnaire (RSQ; Bartholomew & Horowitz, 1991) and the Relationship
Questionnaire (RQ; Griffin & Bartholomew, 1994) which then categorized the students into one of four categories: secure, cautious, support-seeking and self-reliant. They found those more secure in having close and trusting relationships did choose primary care in which practitioners typically do have longer term relationships with their patients, at a rate of 65%, while those identified in the other three combined relationship style categories of cautious, self-reliant, or support-seeking chose primary care options at a rate of 45%. Those students who were identified as more cautious or self –reliant in their relationship style more often chose future non-primary care options at a rate of 20% versus 7% and 25% versus 15% respectively. In general the relationship styles of the medical students were similar to the general population with 56% rating themselves as
51 secure in relationship style. However there is much to further investigate since 45% of those who were rated secure, did choose a non-primary care specialty.
To summarize the reviewed literature, the following tables offer a concise view of the variables important to this dissertation research. Table 1 is a summary of the research studies previously cited regarding external influences. Table 2 is a summary of studies of training influences. Table 3 is a summary of the research on the influences of individual characteristics. Positive findings or correlations are marked by “+” while lack of such are marked by “-” while mixed results are marked by “+/-” in the final column.
Table 1.
External Influences
Variable Researchers Findings Debt Level Budner (1962) - Allen et al (1987) + Hauer et al (2008) - Life Style/Quality Dorsey et al (2003) + Chang et al (2005) + Eidt (2006) + Hauer et al (2008) + Lefevre et al (2010) + Weissman et al (2012) + Compensation Dorsey et al (2003) + Chang et al (2005) + old/-young Eidt (2006) + Morra et al (2009) + Wilder et al (2010) + GME length Dorsey et al (2003) + Eidt (2006) +(away from) Hauer et al (2008) +(away from) Patient Contact Lefevre et al (2010) + Prestige Hauer et al (2008) - Paper work Hauer et al (2008) +(away from)
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Table 2.
Training Influences
Variable Researchers Findings Role Model Expsr Hauer et al. (2008) + Provate vs Public MS Hauer et al. (2008) +(males) Experiences Budner (1962) + Allen (1987) - Hauer et al. (2008) + Morra et al. (2009) + Bindal (2011) + Career Explo Class Leong et al. (2005) +/- Borges (2007) -
Table 3.
Individual Characteristics
Variable Researchers Findings Personality Budner (1962) - Borges & Jones (2001) - Borges & Savickas (2002) +/- Borges & Gibson (2003) +/- Borges et al. (2004) +/- Cienchanowski et al. (2004) + Hartung et al. (2005) +/- Stratton et al. (2005) - Maron et al. (2007) +/- Merlo & Matveeskii (2009) + Interests Elam (1994) - Borges et al. (2004) + Glavin et al. (2009) +/- Sodano & Richard (2009) + Lefevre et al. (2010) + Porfeli et al. (2010) +/-
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Table 3. Continued Learning Style Stratton et al. (2005) +/- Gender Lawson et al. (2004) + Lefevre et al. (2010) + Weissman et al. (2012) + Age Allen (1987) + Change (2005) + Emotional IQ Borges et al. (2009) -
Career Satisfaction
Duffy and Richard (2006), examined job satisfaction among 763 physicians in general and then within the six major specialties of family medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and surgery. They used the 18 critical factors developed by the collaboration of Duke University and the pharmaceutical firm of
GlaxoSmithKline (GSK) in 1989, to assist medical students in making decisions about their careers based on commonalities with practicing specialists. As a group, physicians were satisfied with their jobs and there were no significant differences due to gender, years of practice, or geographic location, but there were differences of satisfaction levels between specialties with differing critical factors accounting for satisfaction or dissatisfaction for different specialties. Of the 18 critical factors, the five most statistically significant predictors to overall job satisfaction were sense of accomplishment, creativity, income satisfaction, security, and autonomy. These were somewhat inconsistent with what the physicians believed to be important to their job satisfaction, with two factors, sense of accomplishment and autonomy, being the same, yet caring for patients, continuity of care, and personal time not the case, statistically.
Each of the six specialties had differing significant predictors: family medicine’s highest satisfaction predictors were sense of accomplishment, income satisfaction and creativity;
54 internal medicine’s significant predictors were sense of accomplishment, income satisfaction, pressure, and expertise; ob/gyn’s were creativity, income satisfaction, and security; pediatrics’ were sense of accomplishment, pressure, security and responsibility; psychiatry’s were security, autonomy, and sense of accomplishment; and lastly surgery’s significant predictors were creativity, responsibility, and pressure.
Gibson and Borges (2004) used a model based on social cognitive career theory
(Lent, Brown, & Hackett, 1996) evaluated 49 physicians who had graduated between
1990 and 1995. The participants completed the Personality Research Form (Jackson,
1984), the Myers-Briggs Type Indicator (Myers & McCauley, 1985), The Medical
Preference Inventory (Zimny, 1979), a Likert scale questionnaire about specialty choice and job satisfaction, and open-ended questions about expectations and actual practice.
The authors found no relationships between personality and specialty choice, no relationship between personality and job satisfaction, nor did entering a predicted or non- predicted one affect job satisfaction. However, comments about expectations matching actual practice of the specialty indicated a possible explanation for job satisfaction.
Following up on their earlier study, Gibson and Borges (2004) surveyed 300 physicians regarding job satisfaction consisting of demographic information, The Job
Satisfaction Scale (Price & Mueller, 1993) and qualitative questions about work expectations and the actual specialty work. Twenty one themes emerged from the study through qualitative analyses of responses. These themes concerned: Academic Medicine,
Advice, Balancing Personal and Professional Life, Business Side of Medicine, Clinical
Issues in Medicine, Dissatisfaction with Medicine, Expectations, Gender, Geography,
Match, Monetary Rewards, Personal Rewards and Satisfaction, Politics of Medicine,
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Practice of Medicine, Pressures and Demands Associated with Medicine, Switching
Specialty or Quitting Medicine, Time Commitments Associated with Medicine, Training
Issues, Working Full Time or Part Time, and Other circumstances which included issues of practicing in the military, Locum Tenums (program to practice in geographic area for specific time), specialty saturation or shortage, and research interest.
In a small study of 51 practicing physicians, Borges et al. (2005) using the
Medical Specialty Preference Inventory (MSPI; Zimny, 1977) and the Job Satisfaction
Scale (Price & Mueller, 1993) found that there was a significant difference in overall job satisfaction for those doctors who had chosen a specialty that was congruent with their
MSPI taken as a student as opposed to those doctors that had chosen a different specialty than recommended. The former having higher job satisfaction. Borges however examined many shortcomings in her research. Using the Medical Specialty Preference Inventory only allowed for medical students to choose a preference from six medical specialties: family practice, internal medicine, obstetrics and/or gynecology, pediatrics, psychiatry, and surgery, out of well over 100 available specialties; and the MSPI had not been updated to include even a few of the more popular specialties (such as emergency medicine, radiology or anesthesiology), thus limiting its predictive validity and use.
Leigh, Kravitz, Schembri, et al. (2002), using the 1996-1997 Community
Tracking Study Physician Survey (CTS; Kemper et al., 1996) with 12,474 physicians investigated the two dependent variables of satisfaction and dissatisfaction among several specialties, along with other independent variables. Like many previous studies, the investigators used the Eisenberg (1986) model to select the control variables arising from the categories of physician characteristics which in turn included age, gender, board
56 certification, and foreign medical school graduation; secondly the percentage of income from managed care; thirdly community factors such as residing in a small town of less than 200,000, their residency in 9 regions of the country; and lastly, type of practice which looked at six income levels from $50,000 to over $300,000, part or full practice ownership and number of weekly hours worked. They found that among the 33 specializations, family practitioners fell within the average range of satisfaction, geriatric internists, pediatricians and dermatologists were more satisfied and gynecologists, otolaryngologists, and ophthalmologists the least. In general, procedural specialists were among the least satisfied. Satisfaction was greatest among the youngest and the oldest groups and satisfaction increased with compensation.
Neither gender nor living in a rural area were significant indicators. Living in
New England was more satisfying than living in the Pacific. Those who worked longer hours than the mean of 52 hours were less satisfied and foreign medical school graduates were more dissatisfied. Authors believed this information may predict trends in future specialty shortages and also provide information for further investigation of the significance of some of the satisfaction or dissatisfaction among specialties.
In a follow up study using data from the 2004-2005 Community Tracking Study
Physician Survey (Kemper et al., 1996) with 6,590 participants from across the country,
Leigh, Tancredi, and Kravitz (2009) found fairly consistent results. This study had slightly different sample sizes and satisfaction and dissatisfaction were on a continuum rather than reviewed as two separate dependent variables. Geriatrics had the highest rate of satisfaction along with the specialties of dermatology, neonatal medicine, and pediatrics, obstetrics and gynecology the most dissatisfied rates. Ophthalmologists
57 increased in satisfaction. Lifestyle, meaning more control over number of hours worked and when, increased satisfaction in some specialties. With information in the new survey on race, satisfaction levels between whites and African Americans were found to be similar; also foreign medical graduates were more satisfied in this survey than in earlier studies. Income level was the most consistent predictor of satisfaction in both surveys.
Physicians employed in medical schools were also found to be highly satisfied and the authors speculated this was due to intellectual stimulation.
Studies by Meir and Yaari (1988) and Meir and Melamed (2005) reviewed past research in determining satisfaction within a broad professional occupation such as medicine as well as other occupations. They defined the work functions within the specialties of that occupation and using those results to assist in determining specialty selection and satisfaction. They argued that using work functions rather than university academic divisions, such as internal medicine or surgery, were more specific indicators of job congruence than other divisions. In an earlier study by Meir and Engel (1986) all medical specialties were categorized along the following three dimensions: degree of contact with people; use of instruments or equipment; and level of sensation or stimulation in terms of occurrence of dramatic events and need for immediate decisions.
Meir and Melamed’s (1986) study, which included their earlier unpublished data analysis of medicine along with other professions, resulted in correlations of .30 to .42 for specialty congruence and satisfaction. The 2004 study on engineers confirmed earlier study results of focusing on congruent specialty choice within occupations.
Career success. Pachulicz, Schmitt, and Kuljanin (2008) reviewed the meta- analysis study by Ng et al. in 2005 and indicated that there were objective and subjective
58 components to considering career success and that career success can be influenced by the four predictors of human capital (educational, personal and professional experience, organizational sponsorship which includes career opportunities to develop skills, being mentored and protected, socio-demographics which includes gender, race, marital status, and age, and lastly stable individual differences which includes personality factors, proactivity, locus of control, and ability). The authors also reviewed studies of physician satisfaction and found that the variables differed depending on the specialty. For example, longer weekly work hours was positive for surgeons but negative for psychiatrists, or that income was important for primary care providers but not as much for specialists. Pachulicz, Schmitt, and Kuljanin (2008) applied the meta-analysis findings to the practice of emergency medicine (EM) and determined the following results from a 38 page survey completed by 1269 emergency physicians: a) the four human capital indices of weekly work hours, years worked in EM, number of specialized certifications obtained, and level of work excitement were related to the objective component of work success; b) the socio-demographics variables of age, race and marital status were related to objective success; c) individual differences of planning, sociability, self-efficacy, health, leisure activity were related to subjective career success; d) organizational sponsorship variables including compensation, benefits, job security, educational opportunities, control over one’s work were related to subjective career success; e) career outcomes of leaving medicine, leaving EM or retirement were related negatively to objective career success; f) career outcomes of leaving medicine, leaving
EM or retirement are also negatively related to subjective career success; and g) gender impacted the variables.
59
Peskun, Detsky, and Shandling (2007) examined the predictability of academic and non-academic variables from admission to medical school to success in medical school to success in residency application rankings within the two specialty areas of family medicine and internal medicine. Of the 315 subjects in internal medicine (IM) and the 345 subjects in family medicine (FM) between 1999 and 2003, the researchers found the following: graduates applying to IM residencies had higher rankings on the
MCAT (AAMC, 1991), overall grade average, IM final grades, and IM clerkship, while
FM applicants had higher scores on the end of second year objective structured clinical examination (OSCE); IM residency ranking correlated with undergraduate GPA and pre medical school admission in non-cognitive assessment of factors such as the interview, essay and recommendations, and MCAT scores, while FM residency ranking correlated most with the non-cognitive factors, especially the interview; and GPA and MCAT scores predicted final medical school grades. The authors supported the use of non- academic measures in selecting medical school candidates along with the traditional academic measures, in that both lead to viable resident candidates.
Change of focus. Hartung and Leong (2005) reviewed past and new trends in vocational research/counseling across professional careers including medicine. Most career counseling focuses on the more general initial overall occupational selection-- medicine, law, business, engineering, or others with a lesser focus on specialty selection within that broader choice. Arguing that due to continuing increases in knowledge and requirements for more specialization and less generalization across professional careers, the authors called for a focus on research to assist those making a specialty choice.
Examining specialty career research, the authors go on to say that the research to assist in
60 career specialty decisions should move from person to environment normative matching to matching an individual’s profile to others who display the same profile across several variables such as interests, personality, abilities and work values and see what specialties those individuals have selected.
Including Values as a Variable and Examining the Concept of Idealism
A study by Schwarz, Cieiuch, et al. (2012) was not specific to medical specialty selection but reviewed the broad construct of values and value assessment. Schwartz,
Cieiuch, et al. (2012) revisited Schwartz’s (1992) original theory of human values in which he defined values as “trans-situational goals, varying in importance, that serve as guiding principles in the life of a person or group . . . organized into a coherent system that underlies and can help us explain individual decision making, attitudes and behavior”
(p.2). He further explained how these values are universal because they arise out of the three basic requirements for human existence to cope as biological beings, social interaction demands, and to maintain group welfare and ultimate survival. He originally envisioned his ten values as being on a continuum rather than being discrete variables, but has now expanded them to nineteen discrete variables and empirically confirmed them. Studies in ten countries using a revised 57 item assessment with three items per value were statistically analyzed and validated. The nineteen values were self-direction- thought (freedom to develop ideas and abilities), self-direction-action (determine own actions) , stimulation (excitement, novelty and change), hedonism (sensuous pleasure), achievement, power-dominance (over others), power-resources, [saving] face, security- personal, security-societal, tradition (preserving them), conformity-rules (compliance), conformity-interpersonal (not harming others), humility (recognizing ones limits in the
61 big picture), benevolence-dependability (reliability and trustworthy), benevolence-care
(welfare for group members), universalism-concern (equality and protection equally for all), universalism-nature (protecting nature), and universalism-tolerance (accepting others’ differences).
Rogers, Creed, Searle, and Hartung (2011) reviewed the benefit of examining values in medical specialty career choice citing the research that physicians whose values are consistent with their specialty are likely to be more satisfied. By conducting an item and factor analysis on 217 medical students’ responses to the 60 item version of the
Physician Values in Practice Scale (PVIPS; Hartung, 2004), the researchers developed a
30 item scale maintaining measurement of the six subscales of prestige, service, autonomy, lifestyle, management and scholarly pursuits. The authors cited research that personality traits and values are conceptually and empirically independent, in that personality traits are enduring dispositions and reflect behaviors while values are enduring goals that people consider important. The researchers validated the 30 item
PVIPS by analyzing gender correlations between the 30 and 60 item PVIPS and personality correlations by using the shortened version of the NEO Five-Factor Inventory
(Costa & McCrae, 1992). Though gender correlations were weaker in the 30 items scale, the personality factors generally showed no correlations to the six value factors among the 316 first year Australian medical student participants in support of the 30 item PVIPS construct validity.
Rogers, Searle, Creed and Ng (2010) undertook a multivariate study of the impact of personality factors, personal values, professional and life style expectations, psychological well-being, and demographics on medical specialty selection as opposed to
62 previous studies that analyzed only one or two of these variables on specialty selection.
One hundred and seventy nine fourth year Australian medical students chosen from 19 specialties (later reduced to three categories of surgical, medical and primary), took several questionnaires including the 20 item Mini-International Personality Item Pool
(Donnellan et al., 2006) to assess the five areas of extraversion, agreeableness, conscientiousness, neuroticism, and intellect, the 30 item Physician Values in Practice short form (Rogers et al., 2010), a questionnaire specific to this study regarding professional and lifestyle expectations for the specialties, the 12 item General Health
Questionnaire (Goldberg, 1978) for well-being, and a questionnaire designed for this study by the researchers indicating age, gender, urban/rural background, and partner background. Results indicated that values were not as strong an influence relative to personality and life style, surgical specialties were preferred by men and were associated with high professional/life style expectations of income and success, and primary care specialties were associated with quality life style of flexible working hours and leisure and a rural background, and the trait of agreeableness.
Taber, Hartung, and Borges (2011) examined the combined influences of values and personality traits in predicting medical specialty selection of 244 students and their subsequent residency selection using the 38 item Physicians Values in Practice Scale
(PVIPS; Hartung et al., 2005) and the 185 item16 Personality Factor Questionnaire, Fifth
Edition (16PF; Cattell et al. 1993). The six categories of work values were prestige, service, autonomy, lifestyle, management, scholarly pursuits. The sixteen personality factors were warmth, reasoning, emotional stability, dominance, liveliness, rule consciousness, social boldness, sensitivity, vigilance, abstractedness, privateness,
63 apprehension, openness to change, self-reliance, perfectionism, and tension. Results indicated that personality traits predicted specialty choices, but work values alone or combined with personality traits did not. Generally warm and sensitive personalities selected people-oriented specialties while dominant, impatient and skeptical types selected technique-oriented specialties.
An older study by Taggart, Wartman, and Wessen (1987) looked at institutional influences on medical specialty and residency choices. Using a questionnaire which asked 1631 seniors, a month after they were informed of their residency match, to rank the four most important influences and four least important influences in selecting their specialty the authors found twelve influences as important in their decision: faculty encouragement, role models observed, undergraduate courses taken in humanities and social sciences, social responsibility, specialty suited to ideal life, desire to reach aspired status, medical school class rank and grades, clerkship, size of community of origin, volunteer work, laboratory research, and spouse’s influence. After factor analysis, the two influences of sponsorship, consisting of faculty and senior physicians input, and the second of social responsibility emerged. Further evaluation indicated that those influenced by sponsorship tended to choose medical specialties rather than primary care, while those students influenced more by social responsibility, chose more often to become primary care providers. The students further ranked 15 criteria which they considered most important to the residency program/hospital selecting them as a candidate which resulted in five categories of academic standing, letters of recommendation, personal characteristics, the interview, and students’ expressed opinions about the program. They also ranked the residency program on 15 variables
64 which also resulted in the five categories of geographic/ecologic preferences, prestige of the hospital, and character of the teaching program, working conditions, and interpersonal factors. Students in the sponsorship group rated letters of recommendation and academic honors as most important in how the programs ranked candidates and the prestige of the hospital as how they would rank the program. While students in the social responsibility group ranked the social interactional quality of the interview as most important in the programs’ selections and house-staff morale and quality of life as important to them in program choice. To combat shortages in primary care and other specialties, the researchers recommended that medical schools need to examine these results in their practices.
Geller, Faden, and Levine (1990) studied 386 first through fourth year medical students and found that students who were female, non-white or older when they entered medical school measured more tolerant on a modified version of the Tolerance For
Ambiguity Scale (Norton, 1975) in which intolerance was defined as “the tendency to perceive situations that are novel, complex, or insoluble as sources of threat” (p.620).
Students’ tolerances for ambiguity did not change depending on year of medical education and that those that were more tolerant were also more involved in treatment of ambiguous conditions such as alcoholism and also chose specialties that dealt with more ambiguity, such as psychiatry rather than surgery. Researchers suggested that taking these characteristics into account may assist students select a more compatible specialty.
Gorenflo, Ruffin, and Sheets (1994), cited many previous studies that generally examined single factors like income/debt, demographics, personality, attitude, tolerance for ambiguity, influence of other people, and academic performance on the choice of a
65 medical specialty. In their study with 822 medical students, the authors examined the effects of the multiple factors of demographics, attitudes, social influence and expected income in choosing a primary care specialty (family practice, internal medicine, medicine/pediatrics, or pediatrics) over a non-primary specialty. They found that
“attitudes toward general practice issues and the influence of other people have the most impact on a student’s preference for a primary care specialty” (p.7) and that “little can be done to change these variables once a student is in medical school” (p.7).
Eliason and Schubot (1995) studied 273 family physicians who had been nominated for the Family Doctor of the Year award of the American Academy of Family
Physicians from 1988 to 1993 as a representative group of exemplary primary care providers. Responses to the 56 item Schwartz Value Questionnaire (Schwartz, 1992) and a satisfaction query indicated that the physicians chose the value of honesty as most important and social power as least important and the value category of Benevolence as the most important with the general category of Power as least. Those who had indicated
Benevolence as the most important value were also rated as the most satisfied while those who had chosen Power were less satisfied in their work. The researchers concluded that in order to recruit more primary care physicians the values of caring, honesty, loyalty, and responsibility should be nurtured and emphasized in medical education.
Manson (1994) proposed that idealism in modern medicine is no longer what
William Osler (considered the greatest clinician of the 20th century) envisioned. Osler viewed the ideal physician as sacrificing himself for his profession, extremely hard working, having high moral character and displaying restraint and always striving to improve his character by learning from other exemplary role models. Osler warned that
66 the idealism of medical practitioners would be eroded by their own successes, specialization, and monetary reward turning medicine into a business regulated by governmental bureaucracy (Osler, 1926).
MacNab, Malloy, et al. (2011) substantiated, through the use of confirmatory factor analyses of responses by 1,109 physicians to Forsyth’s Ethics Position
Questionnaire (Forsyth, 1980), the incidence of the two ethical dimensions of idealism and relativism across six culturally and religiously diverse countries-- Canada, China,
India, Ireland, Japan, and Thailand. Forsyth’s idealism dimension relates the extent to which the world is seen as positive having the potential for goodness by an individual.
The dimension of Relativism measures how much an individual believes in absolute, permanent, universal principles.
In line with Osler’s view that idealism can be fostered by working among those with high moral character, Smith and Weaver (2006) also believed that a volunteer experience among those in a poor underserved developing country like Nicaragua with experienced physicians and medical personnel would act to strengthen and maintain medical students’ idealism, i.e., the pursuit of moral goals. In medicine this is traditionally accomplished by relieving others’ suffering and improving their quality of life and is further evidenced by volunteering, working with underserved populations, and trying to improve peoples’ overall health and wellness.
Sixty-six medical students, who had just completed their first year of medical studies at the University of Texas between 1997 and 2005, spent three weeks in a small town community health center in Nicaragua providing support to a group of physicians and nurses with the intent of expanding knowledge of global health issues and increasing
67 interest in primary care specialties. At the end of the experience, students completed a course evaluation form that included the following four open ended questions: “(1) What was the single most important thing you learned in this elective? (2) What did you like most about this elective? (3) What did you like least about this elective? and (4) Do you think this elective will have an impact on your further medical education and career choice, and if yes, in what ways?” (p. S34). The two authors and an independent third analyst categorized the responses into three subsets—attitudes, awareness, and skills.
Attitudes included compassion, humility and idealism which were gauged by responses that mentioned volunteering, humanitarian efforts, or empathy for the underserved.
Students also responded that the experience strengthened or initiated an interest in a primary care specialty. Many students followed up the experience with volunteering in local community centers at home. To increase primary care specialty choices and retain idealistic attitudes, the authors believed similar electives need to be incorporated in all medical school programs early in the school curriculum.
Canadian researchers tested their hypotheses that medical students lose their positive attitude of idealism as they progress through medical school and that there is a difference in this attitudinal change between male and female students (Woloschuk,
Harasym & Temple, 2004). A total of 178 students attending the University of Calgary medical program between 1999 and 2001 completed two questionnaires, the Attitudes
Toward Social Issues in Medicine (Parlow & Rothman, 1974) and the Medical Skills
Questionnaire (Woloschuk et al., 2004), three times, at the beginning of medical school, two years later, and at the end of school. Results indicated that students’ idealistic
68 attitudes declined persistently over the three years and that females had an initial higher positive attitude than males and as their training progressed but still indicated a decline.
In two separate studies by Griffith and Wilson (2001, 2003), found downward trends in positive attitudes in both students and residents. Before and after a 16 week clerkship in their third year of medical school at the University of Texas, 88 students completed an author designed 17 item questionnaire about certain groups of patients and also the medical profession. The students were less idealistic about the elderly and saw more of them as being demented than initially and also were more cynical about a chronic pain group and saw more of them as seeking drugs than they did prior to the four month clerkship. In a later study, 61 internal medicine residents completed a similar 15 item questionnaire on initiating their residency in June, a few months later in November, and almost three years later at the end of their training. The authors found similar negative changes in attitudes toward the elderly and those complaining of chronic pain and also toward additional patient groups of smokers, alcoholics, the poor and the disabled. They noted that the greatest decline came within the first six months of residency and mainly held steady. Both groups’ attitudes toward the profession of medicine declined as well, indicating a growing cynicism. The researchers recommended further study to determine what contributed to the loss of idealism as individuals progressed in their medical careers and what interventions, such as stress management or changes in workload, could diminish these outcomes.
Conclusion
The literature review addressed several aspects of medical specialty selection.
These included the history from medical generalization to specialization, the categories of
69 specialization and corresponding skills and training and job responsibilities, resources available to medical students to make a specialization choice, socio-political influences on medical specialties, research on the medical specialty selection process and the state of idealism in the practice of modern medicine. The research on the medical selection process was generally limited to few specialty areas, did not address physicians identifying major influences regarding their specialty selection or later satisfaction with their decision and the relationship of those influences, at what stage of training the decision was made and correlations between idealism and specialty selection and satisfaction, The next chapter describes the distinction of this dissertation research to further investigate the relationships between types of influences and medical specialty selection, demographics and specialty selection, job satisfaction and specialty practice, and idealism and medical specialty selection. Information obtained by this research could be used by medical school counselors to determine appropriate exploratory career tools and encourage student exposure to experiences which can be influential in making specialty decisions. Information could also help to increase job satisfaction due to improved compatibility with specialty choice and lifestyle goals. Such research could assist to reduce physicians leaving their practice or need for costly and time consuming retraining to pursue a different, more compatible specialty. More medical providers, as well as more vocationally satisfied providers, ultimately benefit patients.
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CHAPTER III
METHODOLOGY
This chapter describes the research design and methodology used to examine the research questions of this dissertation. The research participants, data collection procedures, the measure, and the data analyses are presented.
Purpose of Study
The purpose of this study was to examine some of the major influences and experiences that may relate to medical specialty selection and extent to which specialty selection relates to idealism and job satisfaction.
Research Questions
1. What do practicing physicians identify as the most significant influences
on the selection of their area of specialty?
2. How are demographic characteristics and other factors (i.e., age at time of
medical school graduation, gender, amount of debt, physician relative(s),
year in medical school selected final specialty choice) related to specialty
decision?
3. Does specialty choice decision and demographic characteristics and other
factors relate to level of current job satisfaction?
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4. Does idealism relate to job satisfaction and medical specialty?
Hypotheses
The following hypotheses were derived from the existent literature which was mainly based on medical student participants to further study medical specialty selection but with practicing physician participants. There is a significant relationship between types of influences, such as potential earnings, life style expectations, skills or length of additional training required and medical specialty selection (Dorsey et al., 2003;
Freeman, 2007; Nuthalapaty et al., 2004). It is expected that a significant relationship exists between the demographics (age, gender, debt, physician relative, year in medical school made specialty decision) and the specialty selection (Hauer et al., 2008; Lefevre et al., 2010; Morra et al., 2009; Wilder et al., 2010;). A significant relationship exists between job satisfaction, demographics and medical specialties (Laubach & Fischbeck,
2005; Swanson, 1997; The Physicans Foundation, 2012). A significant relationship exists between (a) idealism and satisfaction and (b) idealism and medical specialty
(MacNab et al., 2011; Williams & Skinner, 2003; Schwartz et al., 2012).
Design
The design of this survey research investigation consists of the analysis of self- report data obtained through an online survey. Survey research, in some ways similar to other research, encompasses several components including purpose, research questions/concerns, sample/respondent selection, survey items/questionnaire design, validity, reliability, pilot study, distribution method, and data analysis procedures
(Hutchinson, 2004). The purpose and research questions of this study were investigated by surveying practicing physicians. The participants were practicing physicians in
72 different specialties obtained through convenience samples of physicians working within hospital settings, large practice sites, or through the network selection sample approach
(snowballing) of physicians forwarding the questionnaire to other physicians. The questionnaire was constructed of forced choice items, Likert scaled items and open ended responses. The questionnaire is four pages long and took less than ten minutes to complete. Content validity was demonstrated through reviewers’ assessment and similarity to items from other validated instruments. Feedback on the length of administration and clarity of questionnaire items was provided by a small group of physician reviewers prior to the sending of the survey to participants. The distribution method was through electronic mail. The data collected through the survey questionnaires provided descriptive statistical results, as well as correlational analyses between variables, analysis of variance, and multivariate analysis of variance. With forethought and planning given to the above constructs Hutchinson (2004) supports survey research.
Rea and Parker (2005) also promote the use of survey research to assist in understanding individuals’ interests, concerns, preferences, and characteristics. Surveys with study specific questionnaires have been used to measure abstract constructs such as job satisfaction in physicians (Swanson, 1997; The Physician’s Foundation, 2012).
Diemer (2008) not only endorsed survey research for career development exploration, but recommended it as a strong method to do longitudinal studies in vocational subject areas including that of job satisfaction.
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Participants
The participants were practicing physicians mainly in Ohio whose email addresses were provided by the individual physician to the researcher or the researcher already had available or who were contacted by a blanket email forwarded by the graduate medical education office of University Hospitals of Cleveland and through a notice in the monthly “Professional Staff Update” blanket e-newsletter of the Cleveland
Clinic. The researcher had contacted representatives of the two hospitals by phone and followed up with emails to the representatives as each requested with the information about the questionnaire and the link to the on-line survey. Physicians, upon reading the intent of the research consented to participate and then completed the on-line Survey
Monkey questionnaire. The physicians who participated in the study were asked to provide information that may assist medical students make decisions about selecting a medical specialty. In consideration of effect size, the goal was to obtain 150 survey responses; the actual response number of initiated responses was 201 with 183 surveys totally completed, 193 partially completed and 8 left blank.
Instrument
The questionnaire, designed for the purposes of this dissertation, contains five components derived from the review of previous research investigations cited in Chapter
2 and from revisions of sample questions piloted with physicians, a clinical researcher, and a college career counselor . The first component consisted of demographic information. The second component consisted of items related to the vocational influences. The third component consisted of items regarding satisfaction with medical specialty selection and includes the separate variables of overall satisfaction, satisfaction
74 with amount of patient interaction, collegial interaction, professional duties, financial compensation and lifestyle conditions. The fourth component consisted of items regarding idealism as a physician and was prompted by the Physician Values in Practice
Scale, 2nd Edition (Hartung, 2012) and the Ethics Position Questionnaire (Forsyth, 1980).
The last component has two open ended questions asking the respondents to describe how they finalized their medical specialty decision and to advise medical students who are making specialty decisions. A copy of the questionnaire is included in Appendix A.
The content validity of the survey was obtained by consulting with specialists in the fields of educational research, medicine, and vocational guidance whose evaluations of questionnaire items confirmed they measured the intended concepts. Items relating to satisfaction were modeled on items used in A Survey of America’s Physicians: Practice
Patterns and Perspectives by The Physicians Foundation in 2012. The foundation reported that all items including those regarding job satisfaction met the reliability criterion of a margin of error or MOE at 99% confidence at +/- 2% or less. Items regarding idealism were modeled on the questions in the “Ethics Position Questionnaire” developed by Donelson Forsyth (1980) and used in recent research (MacNab, et al.,
2011). Forsyth reported a p-value < .05 for the construct of idealism for concurrent validity when compared to previous validated scales.
The survey was piloted with six physicians in various specialties to ensure that the questions were understandable, choices appropriate, length acceptable, etc. Split-half reliability calculations for idealism and job satisfaction were performed on the entire sample. The reliability coefficient for idealism was .535 and for satisfaction was .801
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Data Collection Procedures
The questionnaire was electronically distributed to physicians who were asked to link to the survey in the email. Participants were not asked their names on the questionnaires and were instructed not to put their names in their responses to an open ended question. Completing the questionnaire online provided anonymity of responses.
All collected data was copied from the online form into a word file and maintained in a locked, secure location. In an effort to elicit as many responses as possible, participants were given the opportunity to enter a random drawing at a separate website for a $300
Amazon gift card to be awarded after 200 questionnaires were successfully completed.
Only 183 questionnaires were successfully completed within the 5 weeks the survey was open. The opportunity to participate was closed after no responses were received for five days and also in order to initiate the analysis. As a result no gift card was awarded.
Ethical and Legal Considerations
Institutional Review Board. To insure compliance with Federal, State, and
University rules and regulations, an application for research conducted with human subjects was submitted to the Cleveland State University, Institutional Review Board
(IRB). The CSU IRB permission to conduct research is in Appendix B.
Rights and informed consent. Participation in this research was strictly voluntary and participants could choose not to participate without penalty. The purpose of the research was provided in the email or within the newsletter to the link requesting participation. Consent was acquired on the first page of the online questionnaire. A copy of the Consent for Participation document is in Appendix C.
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Further approvals and communications. Approval to proceed with contacting physicians at University Hospitals of Cleveland from the CWRU Medical School IRB director through email is documented in Appendix D. A copy of the email survey solicitation is in Appendix E. Appendix F contains the email verifying that a mass email was forwarded from the Graduate Medical Education Office. The Cleveland Clinic email agreeing to include a notice about the survey in an electronic newsletter is in Appendix
G and the newsletter solicitation is in Appendix H.
Data Analysis
The following quantitative analyses were performed to test the hypotheses and answer the research questions. Research question one asked what do practicing physicians identify as the most significant influences on the selection of their area of specialty? Descriptive statistics were used to identify influential factors in specialty choice by examining responses to items 1 and 2 in section 1 and items12 and 13 in
Section 2. The first two asked for the specialty name (open-ended response) and then for a classification of that specialty (closed-ended choice).
Item 12 in section 2 asked the respondent to check all items from a list of a possible 22 that influenced the specialty selection decision, such as a mentor, body system interest, income potential, etc. that apply with one open ended additional response and item 13 asked the respondent to rank his or her top five influences from first to fifth from the responses in question 12. This related to the hypothesis that there is a significant relationship between types of influences and specialty selection.
Research question two asked how are demographic characteristics and other variables (i.e., age at time of medical school graduation, gender, amount of debt,
77 physician relative, year in medical school selected final specialty choice) related to specialty decision? A bivariate logistic regression was the data analysis method used.
The specialty chosen was the independent variable and the continuous variables of age, when graduated, level of debt, and time the specialty decision was made, and the categorical variables of gender and whether or not the physician had one or more physician relatives were the dependent variables. The responses to survey questions 1 through 9 provided the data for these analyses. Open ended question one provided the specialty and closed choice question two the category of specialty. Questions 3 through 6 and 8 and 9 provided forced choices regarding age, gender, year of graduation, having physician relative(s), time of specialty decision and debt amount, while question 7 is open ended, regarding the physician relative(s) relationship. The obtained data for question two related to the hypothesis that there is a significant relationship between the selected specialty and demographic categories.
Research question three asked how do specialty choice decisions and demographic characteristics and other factors relate to level of current satisfaction? A multiple linear regression analysis was employed between the independent variable of chosen specialty obtained in survey questions 1 and 2, as well as other demographic information (age, gender, debt, etc.) contained in survey questions 3 through 9 and the continuous dependent variable of satisfaction. Responses from items 12 and 13 in
Section 3 of the survey were used for the calculations for the dependent variables of satisfaction. Responses to overall specialty selection, question 12 and specific areas of job satisfaction, question 13, including amount of patient contact, intellectual stimulation, collegial interaction, professional duties, financial compensation, and life style are
78 through a Likert scale with one being highly dissatisfied to five being highly satisfied. In addition question 14 asked the respondent to reflect on the specialty decision on a Likert scale from “it would be highly likely” (1), to “highly unlikely” (5) to have selected another specialty and question 15 asked for a forced yes or no response if he or she has actually changed specialties. Research question three is related to the hypothesis that there is a significant relationship between job satisfaction, demographics and medical specialties.
Research question number four asked how idealism relates to both job satisfaction and medical specialty? A correlation analysis was performed between the continuous independent variable of idealism and the continuous dependent variable of satisfaction.
Responses to survey questions in Section 4 were used for the variable idealism which included the initial statement “Idealism is a complex concept but is defined by many dictionaries as the ‘cherishing or pursuit of high or noble principles, purposes, or goals’”
(Random House, 2014, http://www.dictionary.reference.com). Questions 16 through 20 asked the respondent to rate items regarding individual and group idealism via a Likert scale of 1-9 from strongly disagree to strongly agree, respectively. A multivariate analysis of variance (MANOVA) was conducted between the independent variable of specialty selection and the five continuous dependent variables relating to idealism using the survey questions identified above. Research question four relates to the hypotheses that a significant relationship exists between both idealism and satisfaction and idealism and medical specialty.
The following table summarizes the connections between the research questions, the variables, and the analyses employed.
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Table 4.
Connections between research questions, variables and analyses employed
Question Independent Variables Dependent Variables Analysis One Influences: mentor, clerkship, medical school advisor, personality Specialty choice Descriptive statistics measures, ability/skills, body system interest, on line information /tools, (Chi square tests) income potential, malpractice, patient contact, demand, specific procedures, technology, self -investigation/literature, influence of physician relative, life style, length of additional training, other Two Demographics/characteristics: year graduated medical school, age Specialty Choice Bivariate logistic graduated, gender, physician relative(s), time made specialty decision, debt regression
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amount Three Specialty/demographics and characteristics: year graduated medical school, Satisfaction Multiple Linear age graduated, gender, physician relative(s), time made specialty decision, Overall Regression debt amount Patient Interaction Colleague Interaction Duties Compensation Lifestyle Four a Idealism Satisfaction Correlational statistics Four b Specialty Idealism MANOVA
Gpower calculations (Faul et al., 2009) for effect size required for the multiple
linear regression and the MANOVA were performed and results reported in Chapter 4.
Lastly, the optional open ended questions in Section 5 of the survey, “Please share your personal experience in selecting a medical specialty” and “What advice would you offer a medical student in selecting a medical specialty?” provided qualitative information to assist in interpreting the quantitative results.
Conclusion
In order to have sufficient numbers of respondents for data analyses, specialty practice areas were grouped together by category. The primary care category included family practice, internal medicine, and pediatrics; the medical specialty/subspecialty category included practices such as, cardiology, allergy and endocrinology; the surgical category included areas such as, anesthesiology, orthopedics, ENT, OB/GYN; and lastly the technical category included the specialties of radiology, pathology, and research. These groupings were generated from responses provided by the respondents choices of “primary care/non-surgical specialty,” “medical specialty/subspecialty,”
“surgical specialty,” “technical/little patient contact specialty,” “or other (please specify)” to question 2, “Please identify your specialty category.” The sample group consisted of
193 physicians. Of these, 183 completed the entire questionnaire while ten only completed part of the questionnaire. The results of the data analyses and further rationale for the category combinations are reported in Chapter 4.
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CHAPTER IV
RESEARCH FINDINGS
The results of the quantitative analyses conducted to investigate what practicing physicians identify as the most significant influences on the selection of their area of specialty, how demographic characteristics are related to specialty decision, how current job satisfaction relates to specialty decision and demographics, and how idealism relates to job satisfaction and medical specialty are reported in this chapter.
Participants
The sample group consisted of 193 physicians. Of these, 183 completed the entire questionnaire while ten only completed part of the questionnaire. The sample of respondents was obtained through direct email contact with known physicians, a group email distributed from the Graduate Medical Office at University Hospitals of Cleveland and a newsletter via a staff email at the Cleveland Clinic. The physicians identified themselves to be within 53 specialties. The six most frequent specialties reported were pediatrics (46), internal medicine (20), family practice (15), anesthesiology (7), radiology
(6), and urology (6). All the other specialties had an incidence of 5 or less. Appendix J lists all the specialties reported and their frequencies.
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These 53 specialties were grouped into the four categories of primary care, medical specialties/subspecialties, surgery/anesthesiology, and technical/research based on self- report and criteria from the American Board of Medical Specialties (2013) and the American Academy of Family Physicians (2014) and reported in Appendix J. The four categories are reported in Table 5. Primary care which included internal medicine, family medicine and pediatrics contained the largest grouping of 82 physicians for a total of 42.5% of the sample; the medical specialty/subspecialty grouping had 61 physicians for a total of 31.6%; the surgery/anesthesiology grouping had 39 physicians for 20.2%; and the technical research grouping had 11 physicians for 5.7%. A listing of the specialties and their medical category conversion is listed in Appendix G.
Table 5.
Medical Categories
Frequency Percent
primary care 82 42.5 medical specialty/subspecialty 61 31.6 surgery/anesthesiology 39 20.2 technical/research 11 5.7
Total 193 100.0
Physicians’ professional standings reported in Table 6 included 102 residents in graduate medical education, 31 fellows in subspecialty training and 60 practicing/attending.
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Table 6
Professional Standing
Frequency Percent
resident 102 52.8 fellow 31 16.1 attending 60 31.1
Total 193 100.0
Demographics. The gender composition of the respondent sample was 107 females and 86 males (see Table 7). The Association of American Medical Colleges
(2012) reported 30.4 % of active physicians in the U.S. are female and 69.6% are male.
Table 7
Gender
Frequency Percent
Female 107 55.4
Male 86 44.6
Total 193 100.0
Approximately 75% of the sample was born in the United States and 25% was not
(see Table 8).
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Table 8
United States Birth Status
Frequency Percent
yes 145 75.1
no 48 24.9
Total 193 100.0
Respondents graduated from medical school beginning in the year 1961and continued through 2013 with a median graduation year of 2010. The sample consisted of
57.5% being recent graduates within the four year period from 2010 to 2013.
Age at graduation ranged from 21 to 38 years in this sample of 193 physicians with 27.07 being the mean age and 26 being the median age and is displayed in Figure1.
Figure 1. Age at Graduation
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Indebtedness upon graduation ranged from less than $50,000 to over $200,000.
The largest percentage, 39%, had the least amount of debt at less than $50,000, a little more than 8% had between $50,000 but less than $100,000, about 24% had between
$100,000 to $200,000, and almost 29%, the second largest group had over $200,000 of debt (see Table 9).
Table 9
Indebtedness
Frequency Percent less than $50,000 75 38.9
$50,000 to less than $100,000 16 8.3
$100,000 to less than $200,000 47 24.4
$200,000 or more 55 28.5
Total 193 100.0
The majority of the respondents, nearly 60%, reported they had no family members who were physicians. Of the overall sample, 22% reported they had at least one parent who was a physician and 18% reported they had family members other than a parent who were physicians.
The majority of physicians, a little more than a third, selected their specialty during the third year of medical school, about 21% decided after medical school graduation, 18% in their 4th year, 17% prior to medical school, and less than 10% in years one and two of medical school combined (see Table 10).
86
Table 10
Time of Specialty Selection
Valid Frequency Percent prior to medical school 33 17.1
1st year 6 3.1
2nd year 12 6.2
3rd year 66 34.2
4th year, or 35 18.1 after medical school 41 21.2
Total 193 100.0
The Independent Variable: Influences
The most frequent influence selected was Clerkship with 116 responses and the least frequently selected was Parental Expectation/Family Obligation with 3 responses.
Table 11 lists the rate of responses and their percentages. The “Other” response was selected 45 times and a list of the accompanying answers along with the corresponding physician’s specialty is provided in Appendix K. Some of the “Other” responses included the type of patient population served, i.e., children, research opportunities, opportunity for variety in concerns and patients, community needs as influencing factors in the specialty decision.
87
Table 11
Influences: Number and Percentage Selected
N Percent a. Mentor 105 52.2% b. Clerkship 116 57.7% c. Medical School Advisor 13 6.5% d. Personality Measures 17 8.5% e. Ability/Skills Required 95 47.3% f. Body System Interest 72 35.8% g. Online Information/Tools 7 3.5% h. High Income Potential 33 16.4% i. Low Malpractice Rate 6 3.0% j. High Rate of Patient Interaction 111 55.2% k. Low Rate of Patient Interaction 3 1.5% l. High Demand for Services 56 27.9% m. Specific Procedures Employed 41 20.4% n. High Use of Technology 28 13.9% o. Self-Investigation through Literature 28 13.9% p. Influence of Physician Relatives 10 5.0% q. Lifestyle Expectations 78 38.8% r. Less Additional Training Required 20 10.0% s. Prestige 15 7.5% t. Parent Expectation/Family Obligations 5 2.5% u. Other 45 22.4%
88
Research Question 1
What do practicing physicians identify as the most significant influences on the
selection of their area of specialty?
Chi-square analyses were conducted with “Influences” as the independent categorical variable and specialty choice within the three medical categories of primary care, medical specialty/subspecialty, and surgery/anesthesia as the dependent categorical variable. The top nine most popular influences, which included mentor, clerkship, ability/skills, body system interest, high income potential, high rate of patient contact, high demand for services, specific procedures, and lifestyle expectation, were selected for these analyses because of sufficient number of responses to meet the chi-square test cell minimum case number assumption of at least five cases per cell. Conversely the technical/research specialty group was omitted from the analyses because the number of the respondents’ selections within this group did not satisfy the minimum chi-square cell case number requirements.
The Chi-Square test of independence was significant χ2 (2, n = 179) = 6.58, p =
.037 for the relationship between mentor influence and specialty category choice. There was a small effect size of Cramer’s V =.192. Specifically, the group of surgery/anesthesia was more likely to say that a mentor was an influence in their choice of specialty, as compared to the primary care or medical specialty/subspecialty groups (see Tables 12 and
13).
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Table 12
Mentor and Medical Categories Cross-Tabulation
medical specialty/ surgery/
primary care subspecialty anesthesia Total
Mentor – Yes: 43 27 28 98
% within medcategories1-3 53.1% 45.8% 71.8% 54.7%
% of Total 24.0% 15.1% 15.6% 54.7%
Mentor – No: 38 32 11 81
% within medcategories1-3 46.9% 54.2% 28.2% 45.3%
% of Total 21.2% 17.9% 6.1% 45.3%
Total: 81 59 39 179
% within medcategories1-3 100.0% 100.0% 100.0% 100.0%
% of Total 45.3% 33.0% 21.8% 100.0%
Table 13
Chi-Square Tests for Mentor
Value df Asymp. Sig. (2-sided)
Pearson Chi-Square 6.588a 2 .037
Likelihood Ratio 6.781 2 .034
Linear-by-Linear Association 2.329 1 .127
N of Valid Cases 179
Note: 0 cells (.0%) have expected count less than 5. The minimum expected count is 17.65.
90
The test of independence was significant χ2 (2, n = 179) = 6.95, p = .031 for the relationship between clerkship influence and specialty category choice. There was a small effect size of Cramer’s V =.197. Specifically, the primary care physicians were more likely to identify clerkship as an influence in their choice of specialty compared to either the medical specialty/subspecialty group or the surgery/anesthesia group of physicians (see Tables 14 and 15).
Table 14
Clerkship and Medical Categories Cross-Tabulation
medical specialty/ surgery/
primary care subspecialty anesthesia Total
Clerkship – Yes: 60 32 22 114
% within medcategories1-3 74.1% 54.2% 56.4% 63.7%
% of Total 33.5% 17.9% 12.3% 63.7%
Clerkship – No: 21 27 17 65
% within medcategories1-3 25.9% 45.8% 43.6% 36.3%
% of Total 11.7% 15.1% 9.5% 36.3%
Total: 81 59 39 179
% within medcategories1-3 100.0% 100.0% 100.0% 100.0%
% of Total 45.3% 33.0% 21.8% 100.0%
91
Table 15
Chi-Square Tests for Clerkship
Value df Asymp. Sig. (2-sided)
Pearson Chi-Square 6.950a 2 .031
Likelihood Ratio 7.061 2 .029
Linear-by-Linear 4.942 1 .026 Association
N of Valid Cases 179
Note: 0 cells (.0%) have expected count less than 5. The minimum expected count is 14.16.
The test of independence for the influence of ability/skill was not significant among any of the three specialty categories χ2 (2, n = 179) = 5.48, p = .065 (see Tables 16 and 17).
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Table 16
Ability/Skill and Medical Categories Cross-Tabulation
medical specialty/ surgery/
primary care subspecialty anesthesia Total
Ability/Skill – Yes: 36 28 26 90
% within medcategories1-3 44.4% 47.5% 66.7% 50.3%
Ability/Skill – No: 45 31 13 89
% within medcategories1-3 55.6% 52.5% 33.3% 49.7%
Total: 81 59 39 179
% within medcategories1-3 100.0% 100.0% 100.0% 100.0%
% of Total 45.3% 33.0% 21.8% 100.0%
Table 17
Chi-Square Tests for Ability/Skill
Value df Asymp. Sig. (2-sided)
Pearson Chi-Square 5.480a 2 .065
Likelihood Ratio 5.566 2 .062
Linear-by-Linear 4.463 1 .035 Association
N of Valid Cases 179
Note: 0 cells (.0%) have expected count less than 5. The minimum expected count is 19.39.
93
The test of independence was significant χ2 (2, n = 179) = 17.72, p < .001 for the relationship of body system interest influence and specialty category choice. There was a medium effect size of Cramer’s V =.315. It was however an inverse relationship in that the primary group was less likely to choose body system interest as an influence in their specialty decision compared to the other two groups of surgery/anesthesia and medical specialty/subspecialty (see Tables 18 and 19).
Table 18
Body System Interest and Medical Categories Cross-Tabulation
medical specialty/ surgery/
primary care subspecialty anesthesia Total
Body System Interest – Yes: 18 31 21 70
% within medcategories1-3 22.2% 52.5% 53.8% 39.1%
Body System Interest – No: 63 28 18 109
% within medcategories1-3 77.8% 47.5% 46.2% 60.9%
Total: 81 59 39 179
% within medcategories1-3 100.0% 100.0% 100.0% 100.0%
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Table 19
Chi-Square Tests for Body System Interest
Value df Asymp. Sig. (2-sided)
Pearson Chi-Square 17.728a 2 .000
Likelihood Ratio 18.295 2 .000
Linear-by-Linear 14.305 1 .000 Association
N of Valid Cases 179
Note: 0 cells (.0%) have expected count less than 5. The minimum expected count is 15.25.
Similarly the test of independence was significant χ2 (2, n = 179) = 36.01, p < .001 for the relationship of high income potential and specialty category choice with a medium effect size of Cramer’s V = .449. Again the primary care group was less likely to choose it as an influence compared to the other two categories (see Tables 20 and 21).
Table 20
High Income Potential and Medical Categories Cross-Tabulation
medical specialty/ surgery/
primary care subspecialty anesthesia Total
High Income Potential – Yes: 2 10 18 30
% within medcategories1-3 2.5% 16.9% 46.2% 16.8%
High Income Potential – No: 79 49 21 149
% within medcategories1-3 97.5% 83.1% 53.8% 83.2%
Total: 81 59 39 179
% within medcategories1-3 100.0% 100.0% 100.0% 100.0%
95
Table 21
Chi-Square Tests for High Income Potential
Value Df Asymp. Sig. (2-sided)
Pearson Chi-Square 36.012a 2 .000
Likelihood Ratio 35.547 2 .000
Linear-by-Linear 34.350 1 .000 Association
N of Valid Cases 179
Note: 0 cells (.0%) have expected count less than 5. The minimum expected count is 6.54.
The Chi-square test of independence was significant χ2 (2, n = 179) = 15.83, p <
.001 for the influence of a high rate of patient contact/interaction. There was a small effect size of Cramer’s V =.297. In this case, the primary care group was more likely to say that the high rate of patient contact and interaction was an influence in their decision of specialty practice compared to either the surgery/anesthesia group or the medical specialty/subspecialty groups (see Tables 22 and 23).
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Table 22
High Rate of Patient Contact and Medical Categories Cross-Tabulation
primary medical specialty/ surgery/
care subspecialty anesthesia Total
High Rate of Patient Contact – Yes: 63 30 18 111
% within medcategories1-3 77.8% 50.8% 46.2% 62.0%
High Rate of Patient Contact – No: 18 29 21 68
% within medcategories1-3 22.2% 49.2% 53.8% 38.0%
Total: 81 59 39 179
% within medcategories1-3 100.0% 100.0% 100.0% 100.0%
Table 23
Chi-Square Tests for High Rate of Patient Contact
Value Df Asymp. Sig. (2-sided)
Pearson Chi-Square 15.832a 2 .000
Likelihood Ratio 16.294 2 .000
Linear-by-Linear 13.770 1 .000 Association
N of Valid Cases 179
Note: 0 cells (.0%) have expected count less than 5. The minimum expected count is 14.82.
The test of independence was significant χ2 (2, n = 179) = 6.06, p = .048 for the influence of high demand for services. There was a small effect size of Cramer’s V =.186.
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The primary care group compared to the other two categories was less likely to choose it as an influence in deciding in which specialty area to practice (see Tables 24 and 25).
Table 24
High Demand for Service and Medical Categories Cross-Tabulation
primary medical specialty/ surgery/
care subspecialty anesthesia Total
High Demand for Service – Yes: 18 20 17 55
% within medcategories1-3 22.2% 33.9% 43.6% 30.7%
High Demand for Service – No: 63 39 22 124
% within medcategories1-3 77.8% 66.1% 56.4% 69.3%
Total: 81 59 39 179
% within medcategories1-3 100.0% 100.0% 100.0% 100.0%
Table 25
Chi-Square Tests for High Demand for Services
Value Df Asymp. Sig. (2-sided)
Pearson Chi-Square 6.063a 2 .048
Likelihood Ratio 6.050 2 .049
Linear-by-Linear 6.012 1 .014 Association
N of Valid Cases 179
Note: 0 cells (.0%) have expected count less than 5. The minimum expected count is 11.98.
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The test of independence for the influence of specific procedures was significant χ2 (2, n
= 179) = 48.80, p < .001. There was a large effect size of Cramer’s V = .522. The primary care group was not likely to recognize it as an influence compared to the surgery/anesthesia and medical specialty/subspecialty groups (see Tables 26 and 27).
Table 26
Specific Procedures and Medical Categories Cross-Tabulation
medical specialty/ surgery/
primary care subspecialty anesthesia Total
Specific Procedures – Yes: 4 12 24 4
% within medcategories1-3 4.9% 20.3% 61.5% 4.9%
Specific Procedures – No: 77 47 15 77
% within medcategories1-3 95.1% 79.7% 38.5% 95.1%
Total: 81 59 39 179
% within medcategories1-3 100.0% 100.0% 100.0% 100.0%
Table 27
Chi-Square Tests for Specific Procedures
Value df Asymp. Sig. (2-sided)
Pearson Chi-Square 48.804a 2 .000 Likelihood Ratio 46.758 2 .000 Linear-by-Linear 44.926 1 .000 Association N of Valid Cases 179 Note: 0 cells (.0%) have expected count less than 5. The minimum expected count is 8.72.
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The last test of independence for the influence of lifestyle expectation revealed no significant differences among any of the three specialty groups χ2 (2, n = 179) = 5.73, p =
.057 (see Tables 28 and 29).
Table 28
Lifestyle Expectation and Medical Categories Cross-Tabulation
medical specialty/ surgery/
primary care subspecialty anesthesia Total
Lifestyle Expectation – Yes: 25 30 16 71
% within medcategories1-3 30.9% 50.8% 41.0% 39.7%
Lifestyle Expectation – No: 56 29 23 108
% within medcategories1-3 69.1% 49.2% 59.0% 60.3%
Total: 81 59 39 179
% within medcategories1-3 100.0% 100.0% 100.0% 100.0%
Table 29
Chi-Square Tests for Lifestyle Expectation
Value df Asymp. Sig. (2-sided)
Pearson Chi-Square 5.735a 2 .057
Likelihood Ratio 5.749 2 .056
Linear-by-Linear 2.213 1 .137 Association
N of Valid Cases 179
Note 0 cells (.0%) have expected count less than 5. The minimum expected count is 15.47.
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Research Question 2
How are demographic characteristics and other factors which include gender,
being born in the United States, having a physician relative, amount of debt, age
at time of medical school graduation, year graduated medical school, and year in
medical school made final specialty choice, related to specialty decision?
This was examined using three separate binary logistic regression analyses, one for each of the three specialty categories of primary care, medical specialty/subspecialty, and surgery/anesthesia. For each of these, whether or not the participant chose the specialty was the dichotomous dependent variable and the categorical variables of gender, physician relative, and being born in the United States, and the continuous variables of debt amount, when made specialty decision, year graduated from medical school and age at time of graduation were the independent or predictor variables.
The three major assumptions required for binary logistic regression as described by Warner (2013) were met. The first assumption required that the outcome variables be dichotomous. Each respondent was coded as “1” for belonging to one of the three groups of primary care, specialty/subspecialty, or surgery/anesthesia, or was coded as “0” for not belonging to one of the three groups. The second assumption that the predictor variables were independent of each other was examined and reported in the correlation matrix in
Table 30. All the significant correlations ranged from an r of -.261 to .486 and a further review of the corresponding significant correlations’ scatter plots indicated that none were linear relationships. The third assumption that the outcome or dependent variable for each of the possible categories was exhaustive and mutually exclusive was substantiated in that each participant in the survey belonged to only one of the three
101 groups and all were included in the analysis. In addition the continuous variables of debt, when specialty decision was made, year graduated medical school and age at graduation were transformed using natural logs due to the sample normality properties and Warner’s recommendation for conducting a binary logistic regression analysis (2013).
102
Table 30
Correlation of Independent Predictor Variables
Physician Family When Chose Born in Year Grad. Age at
Gender12 Members Specialty Debt U. S. Med. School Graduation
Gender12 Pearson Correlation 1
Sig. (2-tailed)
N 193
Physician Family Members Pearson Correlation -.175* 1
Sig. (2-tailed) .015
103 N 193 193
When Chose Specialty Pearson Correlation .092 -.066 1
Sig. (2-tailed) .202 .360
N 193 193 193
Debt Pearson Correlation -.054 .319** -.246** 1
Sig. (2-tailed) .455 .000 .001
N 193 193 193 193
Born in United States Pearson Correlation .087 -.235** .184* -.241** 1
Sig. (2-tailed) .228 .001 .010 .001
N 193 193 193 193 193
Table 30. Continued
Year Graduated from Pearson Correlation -.132 .194** -.261** .486** .024 1
Medical School Sig. (2-tailed) .068 .007 .000 .000 .738
N 193 193 193 193 193 193
Age at Graduation Pearson Correlation .055 .039 -.091 .174* -.180* .091 1
Sig. (2-tailed) .451 .592 .208 .016 .012 .210
N 193 193 193 193 193 193 193
*. Correlation is significant at the 0.05 level (2-tailed).
**. Correlation is significant at the 0.01 level (2-tailed).
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The binary logistic regression analysis for the choice of primary care was performed and revealed that the model was statistically significant, χ2(7) = 38.196, p =
.000. Nagelkerke’s R2 = .241 indicating that about 24% of the variance between selecting a primary specialty or not can be predicted by this model. Three variables in the model were statistically significant predictors. These included age at graduation, p = .016, what year graduated, p = .03, and when the decision was made, p = .000. Primary care tended to be chosen by older students, those who had graduated at a later date, and those who had made a decision earlier in their training.
The binary logistic regression analysis for the choice of medical specialty/subspecialty was performed and revealed that the model was statistically significant, χ2(7) = 21.083, p = .004. Nagelkerke’s R2 = .145 indicating that about 15% of the variance between selecting a medical specialty/subspecialty or not can be predicted by this model. One variable in the model was a statistically significant predictor, when the decision was made, p = .007. The category of medical specialty/subspecialty tended to be chosen by those who had made a decision later in their training.
The binary logistic regression analysis for the choice of surgery/anesthesia was performed and revealed that the model was statistically significant, χ2(7) = 18.420, p =
.010. Nagelkerke’s R2 = .143 indicating that about 14% of the variance between selecting surgery/anesthesia or not can be predicted by this model. Two variables in the model were statistically significant predictors, gender, p = .006 and debt, p = .035. The category of surgery/anesthesia tended to be selected by males and those with more debt.
105
Research Question 3
Does specialty choice decision and demographic characteristics of age at
graduation, gender, and being born in the United States and the factors of year
graduated medical school, having physician family members, time chose
specialty, and debt level relate to level of current job satisfaction?
This research question was examined using a multiple linear regression. The four assumptions for employing this type of analysis (Warner, 2013) were reviewed.. The first assumption required that the outcome or dependent variable of satisfaction be quantitative and approximately normally distributed. The satisfaction composite variable consisted of seven responses to questions regarding satisfaction and all were rated on a
Likert scale from one to five for a possible range of scores from seven to thirty-five. The seven items were related to satisfaction regarding amount of patient contact, amount of intellectual stimulation, amount of collegial interaction, type of professional duties, amount of financial compensation, and manageable lifestyle. The satisfaction composite and the quantitative predictor variables were converted to natural logs to improve normality and reduce the effect of outliers. The predictor or independent variables were both quantitative and dichotomous. The second assumption of linearity among all pairs of variables was evaluated through scatterplots and relations between the variables were found to be generally linear with the exception of debt which was therefore removed from the analysis. The third assumption called for no interactions among the independent variables on the dependent variable, such that the regressions were not homogeneous.
This was reviewed through using the dichotomous variable of gender to divide the three continuous variables of year graduated, age at graduation, and when chose specialty, into
106 female and male. The resultant scatter plots and slopes for each pair of the split groups were found to be similar relative to the dependent variable. The fourth assumption of homogeneity of variance for satisfaction for each of the independent variables was again visually examined through scatter plots and was found to be relatively similar. In addition the independent variable of having a physician family member was removed from the model because it reduced the model’s adjusted R2 value.
In this regression model the collective independent variables significantly predicted about 9% of the variance for which the satisfaction composite score was the dependent variable, R2 = .09, F (8, 179) = 2.32, p = .022, Tables 31 and 32. However none of the individual independent variables were found to be significant on their own,
Table 33. There was a small effect size of Cohen’s f 2 = .10.
Table 31
Regression Model Summary
Model R R Square Adjusted R Square Std. Error of the Estimate
1 .306a .094 .053 .24528 a. Predictors: (Constant), Lnwhench, surgery/anesthesia, Lnagegrd, lnyrgrad, Born in United States, Gender12, medical specialty/subspecialty, primary care
107
Table 32
ANOVAa
Model 1 Sum of Squares df Mean Square F Sig.
Regression 1.115 8 .139 2.317 .022b
Residual 10.769 179 .060
Total 11.884 187
a. Dependent Variable: lnsatisfaction composite b. Predictors: (Constant), Lnwhench, surgery/anesthesia, Lnagegrd, lnyrgrad, Born in United States, Gender12, medical specialty/subspecialty, primary care
Table 33
Regression Coefficientsa
Unstandardized Standardized
Coefficients Coefficients
Model 1 B Std. Error Beta t Sig.
(Constant) -18.943 23.674 -.800 .425
Gender12 .054 .038 .106 1.411 .160
Born in United States -.070 .043 -.119 -1.614 .108 primary care -.087 .082 -.171 -1.055 .293 medical specialty/subspecialty -.018 .082 -.033 -.222 .825 surgery/anesthesia -.007 .085 -.011 -.083 .934
Lnyrgrad 3.085 3.120 .074 .989 .324
Lnagegrd -.352 .200 -.130 -1.755 .081
Lnwhench .057 .032 .139 1.806 .073 a. Dependent Variable: lnsatisfaction composite
108
Research Question 4a
Does idealism relate to job satisfaction?
Correlational analyses were conducted between the satisfaction composite and the idealism composite as well as each of the five idealism questions because of the low idealism composite reliability coefficient of .53 to answer this question. The rationale for analyzing the relationship between these two constructs was discussed earlier in chapters two and three. The four assumptions for conducting a Pearson’s r (Warner, 2013) were reviewed and met. The first was that all the scores for job satisfaction, as well as the scores for the variables of idealism, were independent of each other. There were seven separate questions for the variable of satisfaction with a choice of answers on a Likert scale from one to five for a total possible score of thirty-five, and five questions for idealism with a choice of answers on a Likert scale from one to nine for a total possible score of forty-five. The five items regarding idealism were: “A person or institution should never knowingly perform actions or promote policies that could harm an individual; Physicians in my specialty display more idealism compared to those in other specialties; Compared to others in my specialty area I have more idealism; Sometimes idealism must give way to pragmatism; I am as idealistic as I was when I chose to become a physician.” The second assumption was that the scores for both were quantitative and normally distributed. The scores were quantitative, as related above, and the distributions for the satisfaction composite, the idealism composite and each of the five idealism questions were examined by a review of their histograms. The idealism composite was approximately normally distributed and all the other variables were transformed using their natural logs to improve for normality which also tended to reduce
109 the effect of outliers. The third assumption addressed linearity between the variable of satisfaction and the variables of idealism. Review of scatter plots for these indicated relative linearity between them. The last assumption was that there be homogeneous variance between the satisfaction composite and each of the idealism variables.
No significant correlations resulted between the satisfaction composite or the idealism variables except for one. The idealism variable of “I am as idealistic as I was when I first chose to become a physician” was significant, r (181) = .24, p = .001 (see
Table 34) indicating a weak strength for the correlation.
Table 34
Correlations between Satisfaction and Idealism
lnsatisfaction composite lniamasid lnsatisfaction composite Pearson Correlation 1 .239**
Sig. (2-tailed) .001
N 188 183
Lniamasid Pearson Correlation .239** 1
Sig. (2-tailed) .001
N 183 183
**. Correlation is significant at the 0.01 level (2-tailed).
Those respondents who saw themselves as having the same level of idealism as when they first chose to become a physician tended to be more satisfied.
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Research Question 4b
Does idealism relate to specialty?
A MANOVA was conducted, with specialty choice consisting of the three specialty categories of primary care, medical specialty/subspecialty, and surgery/anesthesiology as the categorical independent variable and each of the five idealism questions as the continuous dependent variables.
The four assumptions for conducting a MANOVA (Warner, 2013) were reviewed.
The first assumption of independent observations was met in that there were different participants in each group and no participant was in more than one group. The second assumption of having quantitative outcome variables was met in that each variable regarding an aspect of idealism consisted of responses from one to nine. Each variable was also transformed to a natural log to improve normality and reduce the effect of outliers. The third assumption of linear associations among the five idealism variables was reviewed through a correlation matrix and a matrix scatterplot. The five idealism variables had significant correlations with each other but were not measuring the same concept. In addition the normality for the variable of a composite of all the five idealism responses was examined in relation to each of the three categories. In addition as mentioned the natural logs of the five idealism variables was used to enhance normality.
The fourth assumption of homogeneity of variances for the three groups was also examined and supported through the Levene Test of Equality of Error Variances, F(1,
181) = .760, p = .384.
There was a statistically significant difference in idealism based on the specialty category, F(10, 330) = 3.51, p < .001; Wilks Λ = 0.817, partial η2 = .10 indicating a large
111 effect size. Specialty category had a statistically significant relationship to two of the five idealism values: “Physicians in my specialty display more idealism than those in other specialties” [F(2, 169) = 7.69; p = .001; partial η2 = .08] indicating a medium effect size and “I am as idealistic as I was when I first chose to become a physician” [F(2, 169)
= 2.31; p = .031; partial η2 = .04] also indicating a medium effect size. The Tukey’s
HSD post-hoc tests further reported which category’s mean score differences were statistically significant for the two idealism variables. For “Physicians in my specialty display more idealism than those in other specialties” the means were statistically significantly different between the primary care category and the surgery/anesthesia group (p < .001). The primary care category mean scores were higher indicating that those in the primary care field were reporting their perception of their own specialty area.
For “I am as idealistic as I was when I first chose to become a physician” the mean was statistically significantly different again between the primary care and the surgery/anesthesia category (p = .023). The surgery/anesthesia mean scores were higher than the primary care category. These mean differences can be seen in Figures 2 and 3.
This model was also examined with gender included as an independent variable, but because there was no significant main effect for gender, as well as no significant interaction between gender and specialty choice on idealism, gender was removed from the model.
112
Figure 2. Physicians in my specialty are more idealistic compared to those in other specialties
Figure 3. “I am as idealistic as I was when I first chose to become a physician”
113
Summary
In conclusion, there were some significant findings for the relationships between influences and specialty choice, demographics and specialty choice, idealism and satisfaction, and specialty choice and idealism.
The surgery/anesthesia physicians identified having a mentor as influential in selecting their area of specialty. The primary care physicians identified clerkship and high patient contact as significant influences in selecting their specialty while body system interest, high income potential, high demand for services, and specific procedures as not having been significant influences. Primary care tended to be chosen by those who were older at graduation, those who made their specialty decision earlier in their training, and were graduated at a later date, i.e., more recent graduates. The category of medical specialty/subspecialty tended to be chosen by those who made a specialty choice later.
The category of surgery/anesthesia tended to be chosen by males and those who had higher debt. Those in the primary care group saw themselves as having more idealism than those in surgery/anesthesia. Those in surgery/anesthesia saw themselves as being as idealistic as when they chose to become a physician compared to those who were in primary care. This does not indicate that they had an initial higher level of idealism but only that they maintained their initial level of idealism.
Ninety-two respondents, almost half of the sample of those who completed the entire survey, chose to provide a response to relaying their personal experience in choosing a specialty. Some responses included: interested in technology, changed initial choice, concern that medical students have to make a choice during third year of school before have been fully exposed to all options, influenced by mentor or relative role
114 models, level of patient contact, type of duties, positive lifestyle, and expected compensation. All responses paired with specialty are reported in Appendix K.
One hundred and nineteen respondents, almost two thirds of the sample, responded to the open ended question regarding their advice to those having to choose a specialty. Many recommended choosing a specialty that employed their skills, do what is enjoyable, consider lifestyle and family needs, don’t consider compensation, consider the market or demand, don’t go into medicine, fit your personality type, follow your heart, as well as there are no bad choices. A full list of the responses paired with specialty can be found in Appendix L.
Chapter five will further discuss these results, the implications of the findings, the limitations of this research study, and future focus of such study.
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CHAPTER V
DISCUSSION
Along with learning a plethora of information about the human body and medical interventions, medical students must also learn how to navigate through a maze of career experiences and decisions. Because of the amount of knowledge, cost of medical school, length of time specialty preparation requires, and the value of achieving career satisfaction, research into this specific area of career guidance is critically important to help aspiring physicians choose specialty practice areas that will be professionally rewarding Medical students have access to multiple career exploration opportunities, including elective courses along with the required clerkships, attending guest lecturer presentations on the difficulties and rewards of practicing in a particular specialty, have meaningful mentor relationships during training, and often receive guidance from advisors or college counselors. As well, they may have a parent or relative who, as a physician, has familiarity with what certain specialties encompass or they may have explored available literature and online resources on their own. Some graduates enter a residency in a specialty and remain within that area of practice throughout their career.
Some choose a further specialty or sub-specialty after initial residency. As with all
116 important decisions, specialty selection may have had many influences along the way that eventually led to an informed choice.
This dissertation adds to the research by asking practicing physicians to identify their major influences in selecting a specialty, if they were satisfied practicing their area of specialty and how their idealism was related to specialty and satisfaction. Chapter V concludes this investigation with a review and discussion of the results of each of the four research questions, information from the open ended questions, the limitations of the study, the implications for practical application, and suggestions for future research in this important area of career development.
Discussion of Results
Past studies in this area of specialty choice, as reviewed in Chapter II, examined specific variables such as personality or gender, or specific specialty areas such as primary care, or specific populations, i.e., current medical students. Recently, the online advisor section in the “Careers in Medicine” website reported that fourth year medical students in the graduating class of 2010 identified the following top ten influences in choosing a specialty: “Fit with personality, interests, and skills,” “Content of specialty,”
“Role model influence,” “Work/Life balance,” “My future family plans,”
“Advising/Mentoring,” “Options for fellowship training,” “Income expectations,”
“Length of residency training,” and “Competitiveness of specialty” (Association of
American Medical Colleges, 2013, para. 1). However the influences were not further broken down relative to the students’ specialty choices at the time.
In contrast, this dissertation focuses on practicing physicians who have experience in the day to day practice of a specialty, as well as satisfaction levels and the value of
117 idealism in reference to their specialty area of practice. The results of this dissertation provide further information about the most significant influences on the selection of their areas of specialty. Though 193 physicians initiated participation in this dissertation research, 183 physicians completed the entire questionnaire. The sample did not include sufficient numbers for each specialty or subspecialty to be represented as an independent group for analysis. Consequently, the respondents were grouped into the four categories of primary care, medical specialty/subspecialty, surgery/anesthesia, and technical/research based on self- report and criteria from the American Board of Medical
Specialties (2014) and the American Association of Family Physicians (2014) (Appendix
G). Due to the required minimum number of respondents required for some of the quantitative analyses, the technical/research group was not included because the numbers were not sufficient and it could not logically be grouped with any of the other subspecialties. Using the three general physician categories of primary, surgery, and medical specialties was also employed in a study by Rogers, Searle, Creed and Ng
(2010).
The next sections of this fifth chapter include discussions of the results for each of the four research questions of this dissertation study.
Research question 1.
What do practicing physicians identify as the most significant influences on the
selection of their area of specialty?
The physicians’ responses were grouped into the general specialty categories of primary care, medical specialty/subspecialty, and surgery/anesthesia. Research question 1 sought to reveal if there were differences among the specialty groups as to what each
118 identified as the major influences in choosing their specialty. The results did, in fact, indicate some differences among two of the categories.
The mentor relationship was selected as a significant influence in the surgery/anesthesia group. Clerkship and high amount of patient contact were important for the primary care group while body system interest, high income potential, high demand for services, and interest in performing specific procedures were significant non- influences for this group. Interesting as well, was that the other influences of ability/skills and lifestyle expectations were not significantly different for any of the three groups and the remaining non-influences were consistent across the three research groupings. These results did not match those reported in a study by Dorsey, Jarjoura, and
Rutecki (2003), who found controllable lifestyle and to a lesser degree wage compensation to be important influences in selecting a specialty. The importance of the clerkship experience found in this study was consistent with Bindal’s conclusion in a
2011 study. Bindal reported that exposure to a pediatric clerkship in the early years of training, career advice, as well as exposure to healthy typical children during the training will influence those predisposed to working with children to select pediatrics as their future specialty.
In this dissertation, another influence was reported by forty-five respondents who selected “other” with the explanation of the type of patient. Wanting to work with children was often reported as a major influence and, not unexpectedly, was reported by those in pediatric specialties. Exposure to and experiences with children supports the potential influence of hands on learning.
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The responses indicating that mentorship and clerkship influences were important experiential influences, even among this small sample, supports the importance of providing these hands on learning experiences and exposure in medical settings. Medical students learn their trade through a variety of methods and these results support the importance of the extensive experiential learning required to select a specialty and to be a physician.
Research question 2.
How are demographic characteristics and other factors of age at time of medical
school graduation, year graduated medical school, gender, amount of debt,
physician parent, when selected final specialty choice, and place of birth related
to specialty decision?
Research question 2 revealed differences in the above variables resulted in different specialty choices. Primary care tended to be chosen by those who were older at graduation, those who graduated more recently and those who made their specialty decision earlier in their medical education. Medical Specialty/Subspecialty tended to be chosen by those who made a specialty choice later. Surgery/Anesthesia tended to be chosen by males and those who had higher debt. Lefevre, Roupret, Kerneis, and Karila
(2010) also found that males tended to select a surgical specialty more often than women.
Primary care may have been chosen by those who were older at graduation because of the relatively shorter three year residency as compared to the other areas which require longer residencies and may also require additional years of fellowship training. The fact that primary care was chosen by the respondents who made specialty choice decisions earlier, may be because they were obligated to begin the residency selection and application process in their third year prior to experiencing clerkships in
120 specialty areas outside of primary care. This type of information, however, was not a variable explored in this study.
Choosing a medical specialty/subspecialty later may be due to exposure during a primary care residency to more areas of medical specialties and subspecialties, giving the student the opportunity to apply to fellowships in those areas in the latter stages of the initial primary care residency. Surgery is currently reported as a male dominated specialty and perhaps the mentorship experience, reported as a significant influence, fosters the gender stereotype from both the mentor’s position as well as the student’s, which is consistent with Eidt’s (2006) findings. Surgery also tends to be a higher paying specialty which would coincide with having a higher level of debt burden. Some of these results were consistent with Bland’s et al. 1995 meta-analysis review which reported women, older students, married students, black students, Hispanic students, and those having low income expectations, non-physician parents, interest in diverse patients and health care problems and less interest in prestige or advanced technology, often chose primary care careers.
Research question 3.
How does level of current job satisfaction relate to specialty decision; how are
demographic characteristics of age at time of medical school graduation, year
graduated from medical school, gender, amount of debt, physician parent, when
selected final specialty choice, and place of birth related to satisfaction?
The results of this research did not find any significant differences in satisfaction levels among the different groups of physicians. Gibson and Borges (2004) also did not find any differences in job satisfaction among different specialists. None of the demographic differences in gender, age at graduation, debt level, having a physician
121 parent, time of specialty choice or being born in the U.S. predicted later satisfaction levels. A study by Leigh, Kravitz, Schembri, et al. (2002) also found no differences in satisfaction among physicians in relation to gender. Generally, most physicians were satisfied in the practice of their specialty, the amount of patient contact they had, the amount of intellectual stimulation and their collegial interaction and tended to be a little less satisfied with levels of compensation and lifestyle demands.
This finding of job satisfaction among physicians was consistent with two recent survey findings of high levels of over-all job satisfaction among U.S. employees in general (McCafferty, 2014; Adams, 2014). Similar to the physicians in the study, the workers surveyed tended to be less satisfied with issues of compensation and lifestyle, such as length of hours worked and allotted vacation time.
Research question 4.
How does idealism relate to job satisfaction and medical specialty?
For the purposes of this research, the concept of idealism was measured and modeled on the questions in the Ethics Position Questionnaire developed by Donelson
Forsyth (1980) and used in recent research (MacNab, et al., 2011). The results of this research indicated that physicians who saw themselves at the same level of idealism prior to medical school and after becoming a physician, were generally more satisfied with all aspects of their jobs. Those in the primary care groups rated themselves as being more idealistic compared to those in both surgery/anesthesia and medical specialties/subspecialties. Those in surgery/anesthesia rated their idealism as being the same as when they first chose to become a physician, as compared to those in primary care who rated themselves as currently less idealistic than when they chose to become a physician.
122
In interpreting the results of research question #4, it cannot be said that any one physician group was more idealistic than either of the others at the start of their career decisions, but if their level of idealism did not decrease, they did seem to be more satisfied later in their career selection. Other researchers have found declines in the levels of idealism as medical students and residents progressed in their training
(Woloschuk, Harasym & Temple, 2004; Griffith and Wilson 2001, 2003).
Research Questions Summary. There were several significant differences among the specialty categories even in this small study. Experiences such as mentorship and clerkship appeared to have a strong influence on later specialty selection. Desire for high patient contact, level of debt, and gender, may also be indicative of later specialty selection. Though most categories of physicians did not differ in levels of satisfaction those who had the same level of idealism as when they began their career path tended to be more satisfied and those in primary care specialties did see themselves as more idealistic than those in the other specialties. These differences validate the importance of further investigation and exploration for both individual career counseling and program development.
Limitations
This research study, similar to most research, had several limitations. In terms of the sample size the number of respondents was relatively small. All specialty areas were not represented and therefore not included. Those responding were grouped into four categories, and though not arbitrary, may have blurred significant differences among them. The category of technical/research was often not included in the analyses because it did not contain a sufficient number of respondents. Most responses were obtained from
123 physicians in the Midwest and may not be representative of responses obtained from a national sample.
In terms of the instrument, the questionnaire was intentionally brief so as not to discourage physicians from participating. The instrument was created specifically for the study and does not have a history of use. The component which assessed idealism did not have a high degree of internal consistency and perhaps more items in this area would have increased the reliability coefficient so the relationship between the constructs of idealism and of satisfaction could have been more meaningfully assessed. A larger sample group and more representation in not only each of the categories but for actual individual specialties might prove to be more differentiating between the influences.
Another limitation was the lack of standardization in the questionnaire’s administration. Some physicians may have responded in a quiet office setting in contrast to those who responded on their IPad during a meeting. Some may have taken their time and were more contemplative while others did not. Though online survey research has steadily increased in use, it is not as controlled as experimental research using different test groups for comparison. Perhaps an experimental research design in lieu of the survey could better assess the influences on the individuals as they occurred.
In addition a qualitative approach using personal interviews may have recorded the nuances regarding the differences between the various specialists and specialties that a questionnaire was unable to capture.
Implications
The findings of this dissertation research have implications for both medical education counseling and program development. Though the influence of mentorships
124 and clerkships is critical in career decision making, this type of exposure in all specialty and subspecialty areas may not be feasible in current medical education preparation programs due to time constraints. Some rotations, both required and elective, do not occur until the fourth year of medical training. Interestingly some of these experiences occur after some important decisions regarding specialty post graduate training intensions have already been initiated by third year students in quest of residency positions.
Further exploration of the mentorship experiences might be revealing in terms of the specific influences contained in the mentor relationship. Does the mentor in a surgical specialty observe potential in the student and foster it to a greater extent than mentors in medical or technical specialties? Do medical students who have already decided on surgery seek out a strong mentorship relationship in this category? Are there inherent gender biases in surgery mentorships?
Since most clerkships are predetermined components of the medical school curriculum, guidance in choosing the elective clerkships is critical and might prove to be very influential in later specialty selection. These opportunities should be carefully explored with each student as part of their medical school education and provided as early as possible.
Review of the career counseling opportunities for medical students was not assessed in any depth in this dissertation research, other than including the choice of
“medical school advisor” as a choice which respondents could select as one of the influences in choosing their specialty. The advisor response choice was, in fact, only selected 6.5% of the time in this study. Two recent studies cited the need for redesigning medical college guidance programs (Sweeney et al., 2012; Sastre et al., 2010). They also
125 reported the improvements made at Vanderbilt’s medical school through the expansion of their career counseling services as a model for changes to current career counseling programs (Sastre et al., 2010; Sweeney et al., 2012). These improvements involved an increase in career related events, participation in an elective career course, creation of student groups based on interest in exploring specific specialties, and expanded faculty involvement including greater numbers of staff, as well as more staff time devoted to program planning and program review in place of the typical one advisor model providing career guidance. Certainly expansions of such career counseling programs in other medical colleges would assist medical students in making more informed choices in eventual specialty practice selection. The results of this study add to their recommendations by identifying the importance of clerkships and mentorships on specialty choice selection. In addition, creating the ideal medical school counseling program would be a worthwhile continuing undertaking.
Suggestions for Future Research
Reviewing the results of this investigation and its limitations supports expanded examination of the medical specialty decision process in future research studies.
Continuing this line of research can assist those in medical education who support, coach, council, mentor and develop programming for medical students.
In addition to the influences examined in this study the aspects of age of patient clientele, diversity of problems presented, and severity of problems presented could also be assessed as related to specialty selection. Physicians who changed their specialty area could be surveyed to examine if different experiences or guidance would have influenced current specialty selection earlier in their training. Those individuals who chose to leave
126 medical school can be evaluated at the time of their departure as well as later in their lives to determine which interventions would have helped them continue their studies.
Those physicians who would advise others not to go into medicine could also be interviewed and their reasoning explored in a qualitative study.
Medical schools could conduct longitudinal studies to investigate influences, level of specialty choice certainty, satisfaction, and idealism at critical times in medical training and medical practice among their specialist graduates. Required versus elective clerkships influences on medical specialty selection could be compared. The differences between surgery mentorships and other specialty mentorships and how they influence medical students’ specialty decision could be examined.
Studies to assess programmatic differences in the career counseling of medical students in different U.S. medical institutions could be conducted to examine resultant differences in specialty selection and later job satisfaction. Medical education models across countries could be reviewed to determine when and how decisions are made when choosing a medical specialty.
Conclusions
Research in the area of medical specialty career selection is important not only to the individual having to make such a decision but also to medical colleges and hospital graduate medical education programs, as well as the general population who rely on skilled practitioners for medical care. Such research may help reduce medical school dropout rates, burnout and early retirements, or future specialty area shortages, promote continued physician satisfaction and inform government policy makers regarding medical education funding and support. In addition, as changes in insurance for Americans
127 expand coverage it is important to continue to research the educational experiences of our doctors and their satisfaction in their careers.
128
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APPENDICES
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APPENDIX A
PHYSICIAN MEDICAL SPECIALTY QUESTIONNAIRE
Section 1
1. What is your specialty? ______
2. Please identify your specialty category ______primary care/non-surgical specialty ______surgical specialty ______technical/low patient contact specialty (e.g., radiology, pathology) ______other: ______3. I am currently a
___resident
___fellow
___attending
4. What year did you graduate from medical school? (four columns of drop down boxes 0 to 9) 5. How old were you when you graduated? (two columns of drop down boxes 0 to 9) 6. What is your gender? ______Male ______Female 7. Do you have any physicians in your family?
______No _____Yes
8. If yes please list all relationships (mother, father, aunt, grandfather, brother, etc.) ______9. When did you decide to practice in your current specialty (check one of following): ______prior to medical school ______1st year ______2nd ______3rd ______4th, or ______later?
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10. How much debt did you incur upon medical school graduation? ______less than $50,000 ______$50,000 or less than $100,000 ______$100,000 or less than $200,000 ______over $200,000
Section 2
11. What influenced your specialty selection? Check all that apply: a. _____Mentor b. _____Clerkship c. _____Medical school advisor d. _____Personality Measures (e.g. Myers-Briggs, 16 Personality Factor) e. _____Ability/Skills required (fine motor, communication, social) f. _____Body system interest (e.g., renal, cardiology) g. _____On line information/ tools (Careers in Medicine, Match information, AAMC) h. _____High income potential i. _____Low malpractice rate j. _____High rate of patient contact k. _____Low rate of patient contact l. _____High demand for services m. _____Specific procedures employed n. _____High use of technology o. _____Self-investigation through literature p. _____Influence of physician relative q. _____Life style expectation r. _____Less additional training required after medical school s. _____prestige t. _____Other (explain)______
12. Rank order your top five choices as most influential from above list by placing the corresponding alphabet letter in the blanks below: ______top choice ______second choice ______third choice ______fourth choice ______fifth choice
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Section 3
13. How satisfied are you in practicing your specialty? (highly dissatisfied) ______1______2______3______4______5 (highly satisfied)
14. How satisfied are you with each of the following factors in your practice: Amount of patient contact? (highly dissatisfied) ______1______2______3______4______5 (highly satisfied)
Amount of intellectual stimulation? (highly dissatisfied) ______1______2______3______4______5 (highly satisfied)
Amount of collegial interaction? (highly dissatisfied) ______1______2______3______4______5 (highly satisfied)
Types of professional duties? (highly dissatisfied) ______1______2______3______4______5 (highly satisfied)
Amount of financial compensation? (highly dissatisfied) ______1______2______3______4______5 (highly satisfied)
Manageable life style conditions (e.g., hours worked, schedule flexibility)? (highly dissatisfied) ______1______2______3______4______5 (highly satisfied)
15. Upon reflection would you have selected a different specialty area initially?
(Very unlikely) ______1______2______3______4______5 (highly likely)
16. Have you changed specialty practice after initiating residency? (This does not include further fellowship specialization if this was your initial professional goal.) ______yes ______no
If yes, from what specialty ______?
Section 4
Idealism is a complex concept but is defined by many dictionaries as “the cherishing or pursuit of high or noble principles, purposes, or goals” (Random House, 2014)
17. A person or institution should never knowingly perform actions or promote policies that could harm an individual. (strongly disagree) ___1___2___3___4___5___6___7___8___9 (strongly agree)
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18. Physicians in my specialty display more idealism compared to those in other specialties. (strongly disagree) ___1___2___3___4___5___6___7___8___9 (strongly agree)
19. Compared to others in my specialty area I have more idealism: (strongly disagree) ___1___2___3___4___5___6___7___8___9 (strongly agree)
20. Sometimes idealism must give way to pragmatism:
(strongly disagree) ___1___2___3___4___5___6___7___8___9 (strongly agree)
21. I am as idealistic as I was when I chose to become a physician: (strongly disagree) ___1___2___3___4___5___6___7___8___9 (strongly agree)
Section 5 (Optional)
Please share your personal experience in selecting a medical specialty:
______
What do you advise current medical students who are making a specialty decision?
______
Thank you for your assistance.
153
APPENDIX B
INTERNAL REVIEW BOARD APPROVAL
4/7/14 Sheila M Patterson
to me , sarah , Karla
Dear Investigators,
Thank you for your efficient revisions to your research protocol entitled "Medical Selection Influences, Satisfaction and Idealism" [research protocol 30032-TOM-HS]. I am pleased to inform you that all areas have been addressed and you are approved to collect your data as of April 7th, 2014. You will also soon receive written confirmation of this approval via campus mail.
Best wishes for a successful research project.
Sheila M. Patterson PhD Chair, Health & Human Performance
From: jujuhenni
Hi Dr. Patterson, I have revised and added the documentation as you advised. Thank you for all your efforts and guidance. Sincerely, Judith Henning
On Sun, Mar 30, 2014 at 6:43 PM, Sheila M Patterson < [email protected]> wrote:
Dear Investigators Tomann and Henning,
154
The CSU IRB on Human Subjects has reviewed your research protocol entitled "Medical Selection Influences, Satisfaction and Idealism" [research protocol 30032-TOM-HS]. Please make these revisions and scan the revised application packet to this reviewer [email protected] and a final decision will be provided within 48 hours of receipt.
1. Investigator Henning is encouraged Encourage to complete the CITI course for Human Subjects Research and attach verification to the application. 2 In IIIe. indicate that the data must be stored for three years (indicate specific building and office number)and that the data will be shredded after three years. 3. Introduction to Questionnaire: describe briefly the research study in this paragraph. 4. Consent Form: a. Include both researches' information beginning paragraph and that the project is for dissertation/degree requirements.. b. CSU letterhead would or information at the top of consent form.
Again, please revise the application/consent form and scan directly to me. Thank you
Sheila M. Patterson Primary IRB reviewer
155
APPENDIX C
CONSENT TO PARTICIPATION FORM
Medical Specialty Selection Study/Consent Form
My name is Judith Henning and I am a doctoral candidate in the Department of Graduate Education in Counseling at Cleveland State University. I want to invite you to participate in a research study which is for my dissertation/degree requirements. If you have any questions, you can contact me at [email protected] or at (216) 214-2608, or contact my advisor, Dr. Sarah Toman, at [email protected] or at (330) 607-1560.
With this research study I would like to learn more about influences in the physician specialty selection process in that it is such a major decision in one’s medical career and how this relates to later career satisfaction, the value of idealism, and what advice you have for future physicians who will have to make a specialty decision.
If you would be so kind to be a participant in this study, you will be asked to provide informed consent before you begin. You are welcome to quit at any time. The items should not take more than 10 minutes to complete. You will not be asked to give your name, so your answers will remain anonymous. In addition the survey site uses SSL encryption, which will keep your answers private when you submit them online.
Answering the questions should not be uncomfortable for you. If at any time you feel uncomfortable answering any questions you can always choose not to respond or you can stop taking the survey. There are no foreseeable risks associated with participation and at most are no risks greater than those experienced during the course of everyday life. The benefits of participating include an entry into a drawing for one $300 Amazon gift card. The gift card will be given by randomly selecting one participant who provided an email address. The selection will be made two weeks after 200 physicians have provided viable survey responses. The winner will receive an email notification. If the winner does not respond within 7 days another recipient will be selected.
This study will be anonymous and your name will not be recorded at all. Your email address will be used only to notify you if you are the winner of the gift card. This study has been approved by the Cleveland State University Institutional Review Board. If you have any questions about your rights as a research subject you can contact the CSU Institutional Review Board at (216) 687- 3630.
156
If you agree to participate in this study, please click “I Agree” below. By clicking on “I Agree” below you are indicating that you understand the purpose, procedures, risks, and benefits of the study and are providing your consent to participate. You are indicating that you are over 21 years of age.
[ ] I Agree/Want to complete the survey and participate in the study. I understand that if I have any questions about my participation I can contact the CSU Institutional Review Board at (216) 687-363
[ ] I Disagree/Do not want to complete the survey and/or do not want to participate in the study.
157
APPENDIX D
CASE WESTERN RESERVE MEDICAL SCHOOL APPROVAL
On Mon, Feb 17, 2014 at 9:04 PM, jujuhenni
Hello Isabel, Thank you so much for your response. I cannot tell you how much I appreciate your attention and assistance in helping me complete my research, Judy
On Feb 17, 2014 4:53 PM, "Isabel Sanchez-Cummings"
Isabel
On Wed, Feb 5, 2014 at 4:40 PM, jujuhenni
Thank you for helping me navigate through this IRB process.
I am currently a doctoral candidate in Cleveland State University's Counseling Education Program. My research focuses on what influences practicing physicians identify in their decision to choose a particular specialty and if they are currently satisfied with their choice. The subjects of my research would be physicians including those who are attending, in fellowship, or residency. My questionnaire would be accessed through a link provided in a newsletter or through email distribution by a staff member at the University Hospitals or Case to the physicians. Of course all respondents would be anonymous.
I will also be working through the IRB at Cleveland State but they require either prior approval by the institution such as UH or Case allowing me to distribute the questionnaire or a letter indicating that IRB approval through them would not be required.
Please let me know if you need any additional information.
Thank you again for your assistance.
Sincerely,
Judy Henning, 216-214-2608
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--
Isabel A. Sánchez-Cummings, MSSA, LSW, MPA
CWRU SBER IRB Director
Office of Research Administration
Case Western Reserve University
2083 Martin Luther King, Jr. Drive
Sears Library Building, Room 660
Cleveland, OH 44106-7230 [email protected]
PH: 216.368.6993
FX: 216.368.4679
159
APPENDIX E
UNIVERSITY HOSPITAL GRADUATE MEDICAL EDUCATION EMAIL
4/28/14 Rebello, William
to me
I just forwarded it.
Will Rebello, MBA Manager, Graduate Medical Education Ph: 216-844-3889 Fax: 216-844-1949
From: jujuhenni [mailto:[email protected]] Sent: Sunday, April 27, 2014 9:50 PM To: Rebello, William Subject: Fwd: follow up on physician questionnaire
Hi Will,
You may recall our earlier emails regarding distributing a questionnaire to the physician residents, fellows and attendings through your office email listings once I received approval from Isabel Sanchez. I am forwarding her email to you giving me the go ahead to proceed indicating that I did not need CWRU IRB approval for this. I had to wait for Cleveland State IRB approval as part of the dissertation process before I could forward it to you and recently received that.
I will be forwarding the questionnaire to you from my Cleveland State University email address.
Please let me if you have any questions.
I truly appreciate all your help.
Sincerely, Judith Henning, CSU doctoral candidate 216-214-2608
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APPENDIX F
EMAIL SOLICITATION
Dear Physician,
I need your assistance to complete an important research study being conducted through Cleveland State University, College of Education and Human Services, investigating how you and other physicians decided on their particular area of medical specialty. Your participation is especially critical to me in that it would ensure that an adequate number of physicians in your specialty area and age groups are represented.
With this research study I would like to learn more about influences in the physician specialty selection process in that it is such a major decision in one’s medical career and relates to later satisfaction and idealism. I would also like to know what advice you have for future physicians who will have to make a specialty decision.
If you would like to participate in this study you will be asked to provide informed consent before you begin. You are welcome to quit at any time. The items should not take more than 10 minutes to complete. You will not be asked to give your name, so your answers will remain completely anonymous. In addition the survey site uses SSL encryption, which will keep your answers private when you submit them online.
Please consider this request. I know your time is very valuable and you have many demands on your time but I would be very grateful if you could help make a contribution to the specialty selection research by linking to the survey below. As a thank you for your participation you have the option to also enter a drawing for a $300 Amazon gift card after you complete the survey. Further drawing details are on the consent form.
Feel free to forward this email to other physicians or groups of physicians as well.
Sincerely,
Judith Henning, CSU Ph.D. candidate, Department of Education, Counseling [email protected]
Sarah Toman, Ph.D. Emeritus Faculty, Cleveland State University [email protected]
Please link to survey here XXXXXXXX
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APPENDIX G
CLEVELAND CLINIC EMAIL AGREEING TO INCLUDE LINK TO SURVEY
IN MONTHLY QUESTIONNAIRE
4/28/14 Heines, Marjie
to me
I will add a box to the May issue of Professional Staff Update, which will go out around the 15th of May. Thanks!
From: jujuhenni [mailto:[email protected]] Sent: Sunday, April 27, 2014 10:49 PM To: Heines, Marjie Subject: Re: Your request
Hi Marjie,
It took me awhile to get all my CSU committee and review board approvals to proceed with distributing my questionnaire. I have attached the draft of a newsletter announcement with the link to the physician survey. Please let me know if you have any questions or if you need anything else. Feel free to modify the draft as you see fit. Having this in your newsletter is a tremendous help to me.
I truly appreciate all your assistance.
Sincerely, Judith Henning, CSU doctoral candidate 216-214-2608
On Sat, Dec 28, 2013 at 1:35 PM, jujuhenni
Ok, thanks
On Dec 28, 2013 12:45 PM, "Heines, Marjie"
Sent from my mobile device
On Dec 28, 2013, at 12:32 AM, "jujuhenni"
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Dear Marjie, Thank you so much for your assistance on my research project. I think the newsletter would be a great way of reaching the physicians. I need to get through a few more reviews with my dissertation committee members before I can distribute the survey. Can we go with the February or March issue?
Again I can't thank you enough,
Judith Henning
On Fri, Dec 27, 2013 at 1:30 PM, Heines, Marjie
======
Please consider the environment before printing this e-mail Cleveland Clinic is ranked as one of the top hospitals in America by U.S.News & World Report (2013). Visit us online at http://www.clevelandclinic.org for a complete listing of our services, staff and locations. Confidentiality Note: This message is intended for use only by the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please contact the sender immediately and destroy the material in its entirety, whether electronic or hard copy. Thank you.
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APPENDIX H
NEWSLETTER SOLICITATION REQUEST
ATTENTION ALL PHYSICIANS
I need your assistance to complete an important research study being conducted through Cleveland State University, College of Education and Human Services, investigating how you and other physicians decided on their particular area of medical specialty. Your participation is especially critical to me in that it would ensure that an adequate number of physicians in your specialty area and age group are represented.
With this research study I would like to learn more about influences in the physician specialty selection process in that it is such a major decision in one’s medical career and relates to later satisfaction and idealism. I would also like to know what advice you have for future physicians who will have to make a specialty decision.
If you would like to participate in this study you will be asked to provide informed consent before you begin. You are welcome to quit at any time. The items should not take more than 10 minutes to complete. You will not be asked to give your name, so your answers will remain completely anonymous. In addition the survey site uses SSL encryption, which will keep your answers private when you submit them online.
Please consider this request. I know your time is very valuable and you have many demands on your time but I would be very grateful if you could help make a contribution to the specialty selection research by linking to the survey below. As a thank you for your participation you have the option to also enter a drawing for a $300 Amazon gift card after you complete the survey. Further drawing details are on the consent form.
Feel free to inform other physicians about participation in this study.
Sincerely,
Judith Henning, CSU Ph.D. candidate, Department of Education, Counseling [email protected]
Sara Toman, Ph.D. Emeritus Faculty, Cleveland State University [email protected]
Please link to survey here XXXXXXXX
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APPENDIX I
SPECIALTY, FREQUENCIES, MEDICAL CATEGORY CONVERSION
Medical Categories
medical
primary specialty/sub- technical/
care specialty surgery/anes-thesiology research Total
What is your addiction 0 1 0 0 1 specialty? psychiatry
anatomic and 0 0 0 1 1 clinical pathology
anesthesiology 0 0 7 0 7
anesthesiology 0 0 1 0 1 and critical care
cardiology 0 1 0 0 1
cardiothoracic 0 0 1 0 1 surgery
child and
adolescent 0 2 0 0 2
psychiatry
child neurology 0 1 0 0 1
child psychiatry 0 5 0 0 5
clinical cancer 0 1 0 0 1 genetics
dermatology 0 5 0 0 5
emergency 0 5 0 0 5 medicine
endocrinology
diabetes and 0 1 0 0 1 metabolism
family medicine 15 0 0 0 15
fetal diagnosis and 0 0 1 0 1 therapy
general surgery 0 0 5 0 5
gi 0 2 0 0 2
165 hematology and 0 3 0 0 3 medical oncology hospice and palliative 0 2 0 0 2 medicine infectious disease 0 1 0 0 1 infectious diseases 0 1 0 0 1 pediatrics internal medicine 20 0 0 0 20 internal medicine - 0 1 0 0 1 hematology internal medicine 1 0 0 0 1 pediatrics internal medicine 0 1 0 0 1 pulmonary medicine pulmonary critical 0 1 0 0 1 care neonatology 0 2 0 0 2 neurology 0 4 0 0 4 neurology 0 1 0 0 1 neurocritical care neurosurgery 0 0 2 0 2 ob/gyn 0 0 3 0 3 ophthalmology 0 0 3 0 3 oral and maxillofacial 0 0 1 0 1 surgery orthopaedic 0 0 2 0 2 surgery otolaryngology 0 0 1 0 1 pathology 0 0 0 4 4 pediatric critical 0 3 0 0 3 care pediatric epilepsy 0 1 0 0 1 pediatric gi 0 2 0 0 2
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pediatric
hematology 0 1 0 0 1
oncology
pediatric 0 1 0 0 1 pulmonology
pediatrics 46 0 0 0 46
physical medicine 0 4 0 0 4 and rehabilitation
plastic surgery 0 0 1 0 1
psychiatry 0 2 0 0 2
radiation oncology 0 3 0 0 3
radiology 0 0 0 6 6
reproductive
endocrinology and 0 0 2 0 2 infertility
rheumatology 0 2 0 0 2
urology 0 0 6 0 6
urology oncology 0 0 1 0 1
vascular medicine 0 1 0 0 1
vascular surgery 0 0 2 0 2
Total 82 61 39 11 193
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APPENDIX J
“OTHER” RESPONSES CITING INFLUENCES
QUESTION 13
RESPONDENT SPECIALTY OPEN ENDED RESPONSE 4 Urology, oncology Research opportunities in the field 5 pediatrics and child Psychiatry enjoyed working with children 19 Ob/Gyn extracurricular interests: did a lot of work in women's health via clubs 20 pediatrics research topics 21 Pathology research 24 Internal Medicine ability to help others 40 Child Psychiatry 2 week elective I signed up for on a whim and I feel in love 45 pediatrics interest in working with children and their families 51 Emergency Medicine Variety of patients seen, everything from stubbed toe to heart attacks or gunshot wounds 52 Internal Medicine Personal life medical experience 59 Anesthesiology Treatment of patients with acute issues (as opposed to chronic) 66 internal medicine broad spectrum of service provided 67 Child Psychiatry personal interest 73 Pediatrics intellectual stimulation 75 Pediatrics patient population 90 pediatrics positive interactions with colleagues and advisors 91 family medicine I wanted to do something that would allow me to provide a needed service in underserved communities. 94 Pediatrics Ability and skill to work with/interact with children, and the enjoyment I get from it. 99 Family Medicine Most challenging, most flexible career choice, role models happiest 105 internal medicine/pulmonary mentor in residency training 111 family practice started in general sugery, did not work out for me. Was able to continue training without
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any delay by doing family pracatice. 114 Pediatrics I love working with kids.I picked it because I enjoy doing it. 116 Pediatrics Patient population (specifically pediatric population) 125 pediatrics interest 127 Pediatrics Happiness (everyone in pediatrics is happy) 134 Pediatrics My Pediatrician 136 Pediatrics Love of pediatrics above all other rotations! 147 Family practice The need of the community 148 Internal Medicine uncertain on specialty. self perceived highest income potential attainable lower tier step scores 154 Family med Fam med is one specialty ' invented ' by ordinary people not by allopathic medicine's logic of compartmentalization; also a fascination with combining scientific and humanistic valued 156 Family Medicine interest in helping medically underserved populations 158 Pediatric Critical Care Interest, satisfaction at the end of day (working as a student/ trainee in the specialty) and perceived contribution. 159 Anatomical and Clinical Interest in all specialties- Pathology pathology encompasses everything 163 pediatrics It's fun, especially the children. You can prevent problems before they happen 164 Clinical cancer genetics I wanted to put genetics and oncology together and created, together with a handful of colleagues, the new subspecialty of clinical cancer genetics 173 Pathology I started a residency in internal medicine and was miserable 174 Otolaryngology Ability to take care of children and adults of all ages within a surgical specialty 175 Internal Medicine Need to pay back loans. 177 Family Medicine board scores
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178 Pediatrics I like the pediatricians in Medical School 179 Infectious Diseases Pediatrics I loved inpatient practice and ID is the heart of pediatrics 182 Physical Medicine and ability to diversify practice Rehabilitation after training 188 Obstetrics and Gynecology variety of office and OR and delivery services 195 Family medicine personal experiences prior to entering medical school 199 pediatrics working with children
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APPENDIX K
PERSONAL EXPERIENCE IN CHOOSING A SPECIALTY
RESPONDENT SPECIALTY PERSONAL EXPERIENCE 3 Reproductive I was very interestd in the new technology that was Endocrinology and occurring Infertility 4 Urology, oncology My cousin was going into the field of Urology and was very excited, and his enthusiasm encouraged me to learn more. I found it was a great field for me based on the issues touched on in the survey 5 pediatrics and child I practiced primary pediatrics for some time on my psychiatry own and became depleted. I then did a psychiatry/ child psychiatry residency. I now combine both pediatrics and psychiatry and feel very satisfied. 7 Pediatrician I always wanted to take care of kids who cannot express themselves. 9 Urology choosing a speciality is a very complex decision. The process should be delayed in medical school. Currently you have to decide very early in your 4th year or in reality mid-3rd year so you can prepare a solid application for competitive fields, yet elective rotations in the chose field do not occur until early in the 4th year. 14 Neurology/Neurocritical I didn't know what I was going to do until I was on Care rotation and found that my personality did not mesh with any other specialties. Even though someone may like a topic and like surgery, the people you run into may make it unappealing. 15 Medicine, Pulmonary I graduated from med school in Germany, where and Critical Care medicine is very research and technology-driven. After patient-centered clinical experience in the UK I chose internal medicine. During my residency in the US I chose pulmonary and critical care medicine - interesting physiology, interesting diseases, acuity of care 17 Pathology Great mentor, excellent lifestyle in Pathology 18 neurology important to base this on what is right for the individual. takes practice, mentors and clinical experience can be very helpful 20 pediatrics I found my world view was closest to the doctors practicing in the field I chose. 21 Pathology I switched my specialty from medicine to pathology because I would like to have more time do research 25 radiation oncology No Thank You 26 Internal Medicine Strong role models, love continuity of patient interactions which I find rewarding.
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27 Adiction Psychiatry I started out in the first 2 fields because I loved them. I later found out that they didn't love me back, i.e. were not a good match for my temperament. Don't be afraid to change fields if you learn that a certain field is not a good fit. You can't possibly learn all of this from medical school. Psychiatry allows me to interact with others in a way that I enjoy. I excel in the discipline. I've had personal experience with the specialty. 32 Pediatrics I did what I love. 33 ophthalmology It was largely chance experiences in 3rd year clerkships - I saw some interesting exams and learned about some of the amazing examination tools in ophthalmology. I soon realized that it was a perfect mesh of medicine, surgery, cutting edge technology, and lifestyle 35 Obstetrics and I initially thought I wanted to be a Pediatrician and Gynecology, prepared with research and volunteer experiences in Reproductive that field since high school. However, once I Endocrinology and completed my Peds clerkship during my 3rd year of Infertility medical school, I realized it was not for me. I had a wodnerful mentor during my OB/GYN clerkship and became very interested and intrigued by OB/GYN and particularly Repro Endo. Also, I felt like my personality fit perfectly with the OB.GYN's that I worked with, much better than those in Peds. This is why I chose OB/GYN and REI as a subspecialty. 36 Internal Medicine I had great mentors in Internal Medicine, which made it an easy choice. Also, i felt I was a better fit as I liked thinking through things, and wasn't much of a 'doer'. I went to medical school in India, so my experience was probably a little different. 37 Fetal diagnosis and I chose what I liked and it has worked out fine for therapy me. 38 hematology and medical Bone marrow transplant is a great speciality to go oncology into. The patients physician interaction is closer than anything I have experienced. The see the physician roughly 2-3 times a week. The time in the hospital is months at a time and the bonds between the nursing and medical staff become very strong. 40 Child Psychiatry Initially I wanted to study OBGYN. This dream led me to Medical School. After a two week elective in OBGYN-which was awesome, delivering babies, in the OR, I decided it didn't fit my vision of myself as a Physician. So I considered other specialities for a few months and signed up for an elective in my current field. I loved it from the first 5 minutes and continued to find things to love about it for those two weeks. I have not wavered since.
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42 Internal Medicine I wanted a field that would allow for continuity of care and interactions with patient in mutiple different settings. Also, I love the idea of taking care of the whole patients and all their medical problems rather than just a specific issue. 43 internal medicine All about lifestyle. 46 General Surgery I wanted to be a surgeon, I like the technical aspect of performing procedures, and I don't mind that it will take significantly longer than many of my peers to complete my training. 52 Internal Medicine Endured 2 episodes of anaphylactic shock. Due to circulatory collapse, I wanted to know exactly how to counteract that in any setting (I went into shock out in the country, 30 minutes from the hospital). Second, my experience with oncology patients. I recognized that medicine was not the cure, but just a palliative measure. To be there for people in their times of need, when they are most vulnerable with no one else to turn to; that is why I ended up going into medicine. 54 Dermatology Dermatology treats a wide range of patients-from children to geriatrics and the skin is very interesting to me. 55 Anesthesiology I did a rotation with a family friend who was an anesthesiologist. At that point, I fell in love with the specialty. I decided to pursue anesthesiology because it is a procedure-based specialty that also includes the cardio-pulmonary physiology that I enjoy, has higher earning potential than primary care, and has opportunities to pursue fellowships and further sub-specialize. 58 internal medicine I ""fell in love"" with hematology/oncology during my internal medicine clerkship; so I chose medicine as a means to get to hem/onc 59 Anesthesiology I realized during medical school that I liked acute medicine and was considering Emergency and Anesthesia for this reason. When I asked Emergency attendings who were out of residency 5 or 10 years, I found that many of them wanted out of the ER even though they loved the profession. They were burnt out. When I talked to Anesthesia attendings, I did not get the same sense of burn out and I saw many anesthesiologists in their 70s who continue to practice. I had to think long term. The other thing I realized was that Critical Care is what I really liked and I like performing procedures. Anesthesiology allows me to perform procedures on a very regular basis and allows me to practice critical care every day in the OR. It also allows for an accredited fellowship in anesthesiology critical
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care after residency. 61 Emergency Medicine I wanted to be in a specialty where I could save lives and have a positive impact on society. I originally thought about being a surgeon as I loved the work involved adn what you could do to better your patient's lives, but when weighing the cost, it was too great. Working 80 hour weeks for 5-9 years after medical school on a paltry 50k salary (much less than others with doctoral degrees and comparable levels of education), being expected to give up other pursuits in life to that end. It was just not worth the cost. I wanted a life, a family, and not to be working all the time. Emergency medicine was the only logical choice I could make during medical school to give me the earning potential to pay back 450K in loans (not all med students have rich families to pay their way through), to give me the time I want for hobbies and family (after all, aren't we supposed to be working to live and not living to work), and to have a job where my specialty is literally acute resuscitation and to save lives. 62 Plastic surgery I was shadowing my first year of medical school. thought I'd go into general surgery but I fell in love with plastic surgery. Love the creativity and elegance of the field. 65 Radiology I liked many different things so why not pick a specialty with relatively easier lifestyle and a good amount of pay. I have a lot of debt and want a bunch of kids. After the intellectualism of enjoying my daily work in my area, the lifestyle (not surgeon's hours) and ability to provide for my children were my main drivers. 69 Internal Medicine I chose my medical speciality based on career projection and specifically wanted better lifestyle. However, I am realzing, almost all speciality can be demanding during residency and make it challenging to have a better lifestyle. 73 Pediatrics Father is pediatrician, much time was spent at his office. Also, did not particularly enjoy working with adults (multiple chronic issues, poor prognosis in general). 74 Pediatric Critical Care I chose pediatrics because I was interested in applying my medical knowledge that I have gained thru many years and lots of money, to people who I think deserve it the most. I think that society fails children in children, so this is a small way that I can contribute. I chose critical care for many reasons: love having a high level of acuity, love the coordination of care, love working with all the
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subspecialities to try and fix a complicated problem, see it as a good entrez into administrative medicine and physician leadership, which is ultimately what I want to do 76 Pediatrics I thought I wanted to do pediatrics 1st year of med school, then rotated around and changed my mind a lot, but ended up coming back since my advisors and mentors were very inspiring, and I've loved kids and working with families. I ended up training in neonatology, which was never on my radar and is pretty different from the rest of pediatrics, and I ended up there kind of serendipitously. 77 pediatrics I really enjoy my speciality. I used medical school as an opportunity to figure out the best speciality for myself 78 Urology Based on a good mixture of surgical and outpatient experiences. High level of satisfaction amounst doctors in the specialty, interest in the organ system, choosing a specialty with opportunity to improve quality of life, lifestyle 82 hospice/palliative care I think for the majority of us in medicine, we go and internal medicine into it to help people. It is truly one of the few professions where courage, candor, kindness, selflessness, and intelligence are essential to a fulfilling life/career 91 family medicine Many of my classmates in medical school told me ""I thought about primary care, but I want to be able to make enough money to support a family"". It makes me angry that people hide behind the idea of ""supporting a family"" when what I feel they really mean is ""I want to make a lot of money and I feel entitled to that as a doctor"". After all, I work part- time as a family physician and my salary is more than the income for the average family of 4 in the US, so obviously any primary care physician can ""support a family"". I think many (even most) doctors are too selfish. We are no better than anyone else -- why do we feel like we deserve so much more money? Probably the other reason people don't choose primary care is, it's the hardest job -- all the specialists can just tell any patient at any time, ""sorry but I can't help you with that, ask your family doctor"". The family doctors are where the buck stops. 94 Pediatrics I have worked with and been around children all my life. I find that I am able to connect with children, making them feel comfortable, which is something that proved to be very useful as a babysitter of my cousins when I was young, and then as an aide in a daycare which took a large number of special needs
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kids, and then in medical school, residency, and with my post-residency practice. I knew that I wanted to work with kids before I knew that I wanted to practice medicine, but I had decided both before high school graduation. My love for science led me to medicine, although psychology was a close second that periodically outranked medicine. I'm very happy that I've chosen the field I have, though. I feel like I can make a difference, and that I can get fulfillment out of my daily job, which is what I feel is important. 96 Oral & Maxillofacial I shadowed a OMFS in high school through a Surgery funded program. I shadowed him for 75 hours and had to complete a presentation on my own research of a typical procedure. This was extremely influential. This was further solidified through professional school 99 Family Medicine Spent 6 months interviewing practicing physicians, asking their recommendations- then followed my gut. Worked out pretty well 102 Ophthalmology Having a general surgeon as a father largely influenced my decision to go into ophthalmology because of lifestyle (in addition to still being able to do surgery and interact with patients). 106 infectious disease Enjoy the mental skills needed to solve cases and make a difference. Love ot teach. 107 Radiology Go for what you love! Forget salary and job opportunities. 108 Radiation Oncology Lifestyle and compensation were the most important factors. I wanted to avoid working 'surgeon' hours, but wanted to be compensated well (not through the roof, but didn't want to get paid < 100k like some pediatricians and primary care physicians). Secondarily, i chose based on what my strengths are (math, problem solving, data driven mindset) and found the best fit. In the end, even though my primary motivations may not have been sound, i think my ultimate goal of finding the best available specialty was realized, i wouldn't switch if i could. 109 Radiology I had no radiology rotations as a 3rd year student; it's not part of our curriculum; so in between 3rd and 4th years I was still undecided, and shadowed a radiologist that my father knew (he is not a radiologist). I knew right away that this was the best fit for me, and I never looked back. 111 family practice General surgery was fun, but family practice suits me better in the long run, 112 pediatrics Early in third year of medical school, I spent two weeks in an ICU setting with great mentors. I
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scheduled a few month of ICU for the beginning of fourth year to affirm my decision. 114 Pediatrics It was very easy; I chose to do what I loved. I have always loved working with and for kids, and so it was an obvious and easy choice for me to do pediatrics. However, I am coming to the US as a foreign graduate (from Ireland where med school is free) with no debt, so I did not have that factor weighing in on my decision...whereas I believe it does for many in the US. 117 Pediatrics Had done work in high school and college with kids so had a broad interest in pediatrics going into medical school but wanted to keep an open mind. During my 3rd year clerkship in pediatrics I noticed I loved going to work, days flew by, and even going in on a Saturday flew by- that solidified my interest in pediatrics. 118 Pediatrics I was a teacher. It only made sense to be a pediatrician 120 pediatrics I choose pediatrics after wanting to do Pediatric orthopedic surgery prior to my thrid year of medical school. However, after doing my surgical rotation and realizing how miserable everyone was and the long hours they had to work I decided to choose pediatrics. 130 Pediatrics I knew I was interested in Pediatrics even before medical school. But during my clerkships I kept an open mind and fell in love with the specialty for other reasons, newer more relevant reasons. 145 Internal medicine I loved the idea of primary care, and my main mentor in med school was a family physician who I vibed with from the time I first met him. He showed me what a rewarding and unique field family medicine was, and encouraged me to pursue it. I had another very positive experience during my time on my outpatient internal medicine rotation, and ultimately chose to go in to internal medicine because I didn't want to be confined to just clinic work and I thought internal medicine would allow me to have more options after residency. 146 Urology Had a friend doing residency in Urology, choose to shadow him, liked it, decided to do it, by the time I started my elective, he quit Urology for Anesthesiology in his 3rd yr in residency. I persisted and here I am 147 Family practice My child had medical debt. The only job that could cover it was being an MD. The community needed an FP MD, easy choice. 152 Pediatrics preliminary, I decided I wanted to do Dermatology when I did Dermatology my elective rotation during third year. I briefly
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considered switching to pediatrics when I did my pediatrics required rotation at the end of my third year. I didn't initially know that you could do a pediatric preliminary year, but I found out after talking with one of the deans at my medical school. When I found this out, I decided that I would do a pediatric prelim year, followed by dermatology, possibly to go into pediatric dermatology. 154 Family med I entered med school interested in 'social medicine', very idealistic. But I was very unsure that it fit my talents and natural interests. After 2 years I was very disillusioned. I dropped out OR took a 2 year leave of absence to do community organizing. When I returned I was very clear there would be no role model for me. I wanted to do family med. I just needed to get thru and move on. 155 General Surgery As a child I used to watch the show ""The Operation"" on TV. This sparked my interest in surgery and has continued to this day. 159 Anatomic and Clinical Selecting a specialty was difficult for me because I Pathology truly enjoyed every single one of my medical school rotations. When it came time to make the choice, a friend of mine told me to try pathology since it encompasses all specialties. If it weren't for him, I never would have known pathology existed. Medical schools do not require it as a rotation, and therefore, many students do not even consider it as an option. The hardest part of making the choice to do pathology was letting go of seeing patients frequently. I've since found that my subspecialty of cytopathology allows some patient contact, which allows for a nice balance. 160 anesthesia I felt I got an adequate appreciation of the specialty from my medical school rotation. 161 Family Medicine I was not aware that Family Medicine was a residency-trained specialty until my first day of Medical school. From that day onward, I felt that I should follow this path. I indicated that I didn't decide until my third year because I quite seriously tried to talk myself out of Family Medicine by trying other specialties, but by the end of third year I realized that I loved everything, and the only place I would be happy was Family Medicine, because I could still practice all aspects of medicine. 162 Physical Medicine and Thought I'd go into neurology till I did rotation, Rehabilitation ironically at CCF, and a little too esoteric. I spoke with other PMR doctors, asked them what they did, shadowed them for month; then I did 4th year elective in neurology and PMR at OSU. Fell in love with OSU's PMR residents and attendings....fit in.
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163 pediatrics I had started to apply for residencies in internal medicine because that was more ""fashionable"" than pediatrics at my medical school. Then I realized I loved going to my pediatrics rotation. When the patients got better they were often well for another 80 years and didn't return immediately with the same problems. Plus you could completely prevent diseases. 164 clinical cancer genetics I wanted to be a physician-scientist after fourth grade (and I am an MD-PhD and practice both). In High School, I dreamt putting together cancer and genetics, and have trained myself towards that end. Together with a handful of colleagues, we created the new subspecialty of clinical cancer genetics in 1995+/- 165 Family Medicine The match chose me. Sometimes you don't get to decide, you must learn to accept what you have been given and find satisfaction in this. 167 vascular medicine I had no idea about the specialty as an intern. But then I had to take care of patients with problems that required my current subspecialty. That's how I met one of my mentors, and learned a great deal. It opened up a universe of new information, new areas to learn/explore. Sicentific/academic challenge was the main motivator. I put professional choices first, personal choices second. That was a mistake. 168 Pediatrics I can't imagine practicing any other type of medicine. I have the best job in the world. 169 Neurology Although I enjoy the speciality I have chosen, it is somewhat discouraging to see some physicians enjoying a greater lifestyle due to higher salary. I sometimes regret not going for a speciality with higher pay. 170 Pathology Know yourself well and try to be introspective in regard to what your needs are to keep you satisfied in your career. No matter what specialty you choose, you can tailor it to fit your needs. Many door remain open even after you close the doors on other specialties. In medical practice, most are able to individually carve out a niche for themselves to remain satisfied. 172 Family Medicine A number of my professors in med school tried to discourage me from becoming a family doctor. 173 Pathology I had a lot of outside influences discouraging from pursuing pathology because I was ""so good with patients that it would be a waste and I would end up sad and unfilled."" I listened to others rather than listening to myself and was totally miserable during my first year of internal medicine residency. I watched the attendings still being miserable and
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realized that things were not going to get better and I did not want to live my life as a martyr for medicine or an angry embittered doctor. I was extremely fortunate to be able to switch residencies due to good timing and good USMLE scores. I am generally happy with what I do now, but if I had it to do over again I would not go to medical school. 174 Otolaryngology I had applications for pediatric residencies. I went to Israel for two clerkships. One was with my father and the other with anyone who spoke English. It turned out to be ENT. I had not experienced ENT until then. My mentor loved what he did. I loved what he did. I came home and changed my plans. 176 Vascular Surgery Was going to become a cardiac surgeon, mentor who was a cardiac surgeon told me ""There is no future in cardiac surgery."" Was doing research fellowship in vascular surgery (only available) and decided to proceed with vascular. 177 Family Medicine Board scores were low so did not get residency of choice. 178 Pediatrics I had a PhD in Developmental biology. I was intially interested in Ob/Gyn. However, I found the attendings to be quite disrespectful of their patients and were disagreeable people. I liked the pediatricians and decided to go that route. I had to do a primary care training due to the Public Health service scholarship that I had. 179 Infectious Diseases By accident I took a rotation in ID and loved it. I Pediatrics was going to do general practice and did for about 1 year and then decided to go back and do a fellowship. I love my field. It is the interactions with patients that keeps you idealistic and stops you from burning out. Vacations help also. I am able to teach and do some research which also keeps me fresh and enthusiastic. Not sure as I age how long I can practice, but so far so good. 181 Hospice and Palliative During residency, I saw the need to better end-of- Medicine life care. Nobody talked about goals of care when I was in training and I felt that doctors should discuss this with their patients. The field of palliative medicine was new then but it matched what I was looking for - the science of symptom management to ensure quality of life and the art of communication and care. 184 Diagnostic Radiology I had originally wanted to become an architect. After deciding against architecture I examined what I liked about the field and applied that to choosing my field in medicine. Specifically, I liked the technical aspects, the high skill level needed, the
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ability to work alone, but also to be able to collaborate and work in a consultative manner. Radiology seemed to fit the bill for me. 186 dermatology At the time I graduated, group practice was rare. I wanted a specialty that would give me a better life style than solo family practice, but still give me the opp to see all age groups, have ongoing relationships with patients, and a lot of variety in tasks and interractions. I also liked the idea of being able to feel that I was an expert in my field. 187 Internal Medicine I liked the medical ""detective work"" that defines Internal Medicine. 188 Obstetrics and I realized early on in my clerkships that I couldn't Gynecology stand being in an office all day every day, that I did not want a predominantly elderly patient population, and that I preferred self limited medical problems to chronic problem management. These factos drew me towards obstetrics. 190 Family Medicine I chose the specialty of Family Medicine because I wanted to be able to care for families - from birth to death. This is totally not reality. The system does not allow primary care physicians to truly get to know their patients and families due to having to see so many patients to actually be profitable financially. I spend almost as much time doing paperwork as spending time with patients. I would never choose primary care if I had to do it all over again. 191 Pediatrics I had a great pediatrician growing up, so I kind of always thought I'd be a pediatrician, or at least family med, doctor. I decided officially my third year of medical school after my OBGYN rotation when I realized all I really cared about was the baby on the warmer and nothing about the woman who just gave birth. 192 Anesthesiology Liked the innovations that Anesthesia was going through in the early 80's in the UK while I was training, which attracted me to th specialty. 193 Physical Medicine and I was fortunate to get exposure to PM&R early in Rehabilitation my training at Ohio State College of Medicine. PM&R is still not very common at some major medical centers, but it is becoming very popular among graduates. I meet many orthopaedists and pain management specialists who wish they had learned about PM&R before their decision to pursue their current specialty. 194 neurology I knew before college that I wanted to practice either neurology, psychiatry or some other type of mind/body specialty in a group practice/academic setting. my disatisfaction is from the disatrous state
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of our health care system in the us, not from the specialty. 196 Internal Medicine I choose IM because of the intellectual challenge that I experienced during my med school clerkships and opportunity to form long term relationships with patients; however, I do not think that I really understood what practicing in an out-patient primary care setting on a daily basis meant. If I had to do it overagain, I would not choose medicine as a career. This is primarily because the non-direct patient care burdens of practicing medicine including paperwork and ever shorter time with patients now outweigh the satisfaction of caring for patients. 198 Endocrinology, I had an mentor during a medical clerkship who Diabetes and made thinking about physiology/metabolism and Metabolism translating it into patient care both provocative and fun. In fact his approaches to such things as treating diabetic ketoacidosis were novel when I was working with him and became the standard of care about 10 years later. Taking on challenging patients who had puzzled other physicians is common for Endocrinologists/Diabetologists and he made it real. 199 pediatrics I truly enjoy working with children, in part because I don't have to figure out how to behave with them. Kids are, for the most part, open, direct, nondeceiving, and fun to be with. If it weren't for the kids, I don't think I would have lasted in medicine.
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APPENDIX L
ADVICE TO OTHERS MAKING A SPECIALTY DECISION
RESPONDENT SPECIALTY ADVICE TO MEDICAL STUDENTS 2 family medicine the money and payment system will change through the years. know your skill set, how you think, work with your hands and your pace and lifestyle. be true to yourself and no one else and you will make the right decision. even the right decision will have some rough patches and areas that you won't like but your will realize you made the right decision. 3 Reproductive In today's world they need to consider the market Endocrinology and place in choosing a specialty Infertility 4 Urology, oncology I am very enthusiastic about our field but recognize that it is not best for everyone and always best for each person to decide what they want to do most 5 pediatrics and child I think it is important for students to stay present psychiatry to what they are experiencing through the clinical years and talk with an experienced and wise mentor. 7 Pediatrician You have to enjoy day to day work, please don't choose anything thinking about money. 8 Anesthesiology I would tell the the same thing when my sister was considering medicine: It is an amazing field, but requires an unbelievable level of dedication, sacrifice, and delayed gratification in all other aspects of your life. If it is the ONLY thing you can see yourself loving to do, it's great. If you can imagine loving anything else as a career, do that instead. 14 Neurology/Neurocritical First decide if you like children. Then decide Care how much you like the OR. There are specialties that have some of both and you have to figure out what you want most. Never look at the money. 15 Medicine, Pulmonary and 1) Do what you like bests, you will spend you Critical Care whole career doing it 2) Beware of challenges on your time - acute medicine / surgery can be very demanding (but rewarding) on your time 17 Pathology Choose what you love because you will be spending a lot of time training and practicing throughout your career. 18 neurology Know thyself. 19 Ob/Gyn go with your interests don't under-estimate the
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impact of lifestyle on your future happiness 20 pediatrics Consider how you feel about cases that go well and cases that don't go well in a field and how you would handle both. 21 Pathology Do rotations, Find your interest, and Go with your heart 24 Internal Medicine Choose something you'll be interested in for 30 years. 25 radiation oncology Don't Go To Medical School 26 Internal Medicine Think about not what you do during your clerkship, but look at what the attendings do day to day, because that is what you will actually be doing for most of your career, and think about if that would make you happy. 27 Adiction Psychiatry Do what you like...you'll be doing it for a long time! Consider what's important to you (family time, personal values, location of practice) Don't let money be the deciding factor...would you want to go see an doctor who is treating you solely because of financial gain? 32 Pediatrics choose the lifestyle that fits. 33 ophthalmology Talk to as many physicians in diverse fields as possible. If you have an interest, do some shadowing early on. Be honest with yourself about what you like and are good at. Try to find what you enjoy most about medicine (not just organ system but also the mix of procedures, surgery, clinic time, type of patient interactions, personalities in the field) and find the field that allows you to spend your time, both at work and at home, doing what you love most. 34 Pediatrics You never really know the small details of a specialty until you are immersed in it, and by then its usually too late to decide if it is right for you or not, so trust your instincts, and make sure you like the field enough to live with that decision regardless 35 Obstetrics and Find a specialty that your personality fits with. Gynecology, Reproductive It is very important to feel comfortable with your Endocrinology and peers. Also, make sure it is something you Infertility enjoy, because medicine is a changing field and you will only succeed if you enjoy what you do. 37 Fetal diagnosis and therapy I think life is too short. One should always go with what they love. Also, if you have to force yourself to read the literature in a particular area, do not go into that specialty. You will be doind a lot of reading in that area in the future. It tells you that you really do not like the subject. 38 hematology and medical Choose a speciality that makes you feel good oncology about helping people, not about money or
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prestige. 40 Child Psychiatry Consider something intellectually stimulating you can do day in and day out. Every speciality has their bread and butter. Which bread and butter can you do multiple times a day? Also please please please consider your life goals. Do you want to hustle everyday monday thru Friday 7am to 7p without lunch and you're children begging you to be on time to the school play? But you're late to the school play to do paperwork? This should be a questions applied to how you envision your life at 30, 40, 50, 60 and 70. If you don't want to be working midnight to 8am when you're 60, then don't pick certain specialities. If you think you can be on call for decades of your life, consider how this will impact your family. Even if you don't have a family, imagine the ideal. If it doesn't fit with your ideal at the start of your career-it'll never work. Also, life is short-don't spend it rounding or in front of a computer. Lastly, pick a speciality that has room to change-Family Medicine, Peds, Surgery, IM aren't changing any time soon so you'll pretty much be doing the sam thing every day for decades and that should be ok with you 42 Internal Medicine Follow your heart but do your research so you can make an informed decision. 43 internal medicine radiology 46 General Surgery If there is any other specialty that you enjoy, or would be happy with, then do not do surgery because it will challenge you in ways that you never foresaw. There is almost never any down time, and what down time we do have, it is limited in comparison to the other specialties. 48 PM&R Go ith your heart. 51 Emergency Medicine Keep an open mind, don't let other people's opinions of certain specialties sway your judgement, and always remember to respect every specialty/specialist you encounter. 52 Internal Medicine Seriously consider what kind of life you picture for yourself in the future. If you want a family, family life, involved in other activities/organizations then pick a specialty that fits what you would like to do outside of the hospital. The importance of distancing yourself from the hospital and patients is difficult yet mandatory if individuals would like a life outside of medicine. 54 Dermatology Rotate for a few weeks in that specialty.
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55 Anesthesiology Lifestyle is extremely important factor, student loan debt is massive, do you want to do medical specialty (use your brain only) or surgical specialty (lots of hands-on skills involved). 56 Pediatrics do something you will want to do everyday for years 58 internal medicine Do something that makes you want to get out of bed in the morning! (because you will have to!) 59 Anesthesiology Choosing a specialty is a difficult decision as there are many factors to consider and medical students may have limited experience in many specialties. The best way to choose in my opinion is to try to get as much experience in the specialties that seem interest to you. Pick 3 or 4 and do as much time in those as you can. Also, think about what subjects or organ systems you enjoyed in your first 2 years of medical school and seek out those specialties that directly involve them. Do not choose based on money and lifestyle alone (although compensation is definitely something to consider.) Another thing to consider is weather you like procedures or not. This will help you choose between more surgical fields vs medical fields. Think about what patient population you enjoy interacting with. Try to ask attendings directly about why they chose their specialty and ask if they would make the same decision again. This can provide a lot of information. 61 Emergency Medicine Set your priorities before you even think about making a decision about your specialty. Do you want a life? Do you want free time? Talk to people in the real world outside of medical school to see what it's really like. 62 Plastic surgery See as much as you can, shadow as many people possible. 65 Radiology Go with your gut. There will be a lot of second guessing and ""the grass is always greener mentality"", but you'll probably be fine and can always change if you don't like your field in residency. And don't be a neurosurgeon unless you love working without sleep more than anything else in your life. 69 Internal Medicine Chosing a medical speciality can be very challening--as there are many factors that play into the decisions we make, but most importantly one should pick a speciality based on interest and understanding about what the profession and career entails, this can be challening to understand. Also make sure to go have at least
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two experiences at an outside hospital and an out-patient exprience. 72 Emergency Medicine Choose an autotelic career, but do not forget lifestyle considerations. 73 Pediatrics Do what you enjoy--sometimes that means crossing off things you don't. Focus less on salary--physicians don't go starving. 74 Pediatric Critical Care Choose the patient population that you love first. Don't place too much of an emphasis on ""lifestyle"" - you can pick the kind of lifestyle you want later (ie -there are lots of different ways that you can practice critical care medicine, with lots of different call schedules) 76 Pediatrics Keep an open mind even if you know what you want to do, you may end up doing it anyway, but you'll have more fun along the way if you stay interested. Usually your gut is right, but think about the most boring parts of the specialty and ask yourself if you could take care of that day in and day out (like ear infections in Peds) and be satisfied. I was discouraged from thinking about ""lifestyle"" when picking a specialty and instead think about the ""intellectual stimulation"" but at the end of the day, your life is important, and lifestyle has to play into that. You have to figure out what life/work balance is important to you. Do what you want and not what someone else says you should do, but do keep mentors in mind & role models for who you want to be in the future. 77 pediatrics I would recommend pursuing a feel that you love. 78 Urology above all pick something you enjoy. You will spend most of your early adult life engulfed in the specialty, make sure its something that is intellectually stimulating to you. 82 hospice/palliative care and do what you love, love what you do internal medicine 83 anesthesiology Talk to as many people in the specialty you have an interest in as possible. Try to determine what is truly important to you, and choose a specialty that allows you to enjoy these things. 86 Family Medicine Pick a specialty that will allow you to enjoy life outside of medicine - your job isn't everything! 89 Child and Adolescent To follow what they find most fascinating or Psychiatry stimulating and stay in a field where they can feel empathy for the patients they are treating. 90 pediatrics Do what makes you happy and work will not seem like work. Money and lifestyle do not equate happiness.
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92 General Pediatrics Enjoyment 94 Pediatrics Do what feels right to you. I wouldn't (and don't) want a doctor who is just doing it for the money or prestige, because they are not fully invested in it. If they are between specialties, I strongly recommend they do rotations in those during their 3rd and 4th years of medical school, and that they investigate the things that are important to them, and that they make well- informed decisions. 96 Oral & Maxillofacial check everything out that you can while you Surgery have the opportunities to. 97 Pediatrics Speak to people in that specialty at different levels of training (residents, fellows, new attendings and well established attendings). The perspectives on the specialty are often quite different depending on the level of training. Also, talk to attendings in different settings (inpatient versus outpatient, academic versus community, etc). 99 Family Medicine Have advised several hundred students, basically be honest with yourself regarding what is important to you- then follow your heart. In reality, there are few if any bad choices. 100 derm choose what they're interested in and what makes them happy 102 Ophthalmology Don't underestimate the impact of lifestyle on happiness. 106 infectious disease spend time in the that speciality 107 Radiology Study hard, make patient contact more and approach to problems systematically with less use or abuse of paraclinic. 108 Radiation Oncology Know what you're getting yourself into. Research specialties in depth when choosing (including the trajectory of your specialty, as in how it will be practiced during the bulk of your practicing years), and listen to yourself (meaning be truthful with yourself and base your decision in reality and not the ideal perfect practice, because most physicians do not achieve that). 109 Radiology You have to weigh the pros and cons of everything, and every specialty will have aspects of it that you're not crazy about, but in the end you should go with what makes you the happiest. 110 pediatrics you have to do what you love. 111 family practice do what they enjoy and think will have a lifestyle they would like. 112 pediatrics Get as much exposure as possible and in as many settings as possible (inpatient, outpatient, subspecialty).
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113 Pediatrics pick a specialty that will make you happy to come to work each day 114 Pediatrics Do what will make you happy and that you're passionate about...cause you're going to be doing it for the rest of your life. And think carefully before you commit yourself to a life-time of a specialty with harsh working hours/ lifestyle. 116 Pediatrics Choose a specialty where they enjoy the mundane, day to day tasks. Every specialty has interesting aspects but you must enjoy the everyday work. 117 Pediatrics Keep an open mind about every speciality during clerkships, ask questions and choose what you love and are passionate about. 118 Pediatrics Go with your gut. Respect can only get you so far, you need to enjoy what you do. 120 pediatrics Choose something that you would like to do for the rest of your life considering family and life outside of medicine. Medical students need to realize that you need to work to live, not live to work! 122 Pediatrics Although medical school is expensive, try not to pick your career based on money; make a caeer choice on what makes up happiest. 127 Pediatrics Choose pediatrics. 130 Pediatrics Even if you think you know what you want to do, keep an open mind and get the most out of every specialty. 131 Child Neurology Find people who are like you, who you share attitudes and personality with, and talk to them about why they are happy or unhappy in their specialty. If they are happy, consider that specialty because likely it attracts people like you. 134 Pediatrics Listen to your instincts about picking a specialty and find something that makes you love waking up for everyday. 135 General Surgery be exposed to a variety of specialties before making a decision 136 Pediatrics Choose a field that you love and trust your gut instinct! If you choose to do something just for its salary or for its benefits, you will quickly realize that it's very difficult to care for your patientsl 137 Pediatrics Play to your strengths in choosing a specialty, you will be happier that way 141 internal medicine dont do medicine. The good intentions that you have are not the realities of how healthcare plays out in reality 145 Internal medicine Follow what you like, and what you see yourself
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being the happiest doing. It's not about what others want or expect of you, it's you're life. I tell them that primary care is a very rewarding experience that I've loved, but I don't try to convince anyone to go in to it because it's such a personal decision ---I let them observe me enjoying what I do and tell them why I like it, not why I think they should like it. 146 Urology Find a role model, and pick their brain 147 Family practice It's not about you! It takes the US a good amount of resources to develop an MD..so grow up and do primary care, the US needs more primary care. 148 Internal Medicine The world of medicine is changing. This includes rules, regulations, and reimbursement. If you plan to continuing to pursuing a career as a physician, explore all possibilities early in med school. Choose what you enjoy doing the most, because this will always be the most important factor. No amount of perceived compensation will make you happy, and with the changes that come, you never know how incomes will be affected in the coming future. If you are uncertain or indifferent between 2 or 3 options that you have narrowed down, certainlly it would be advisable to take current and future compensation into regard. But you should assure you truly feel you like all of these specialties equally. Pursue the specialty you love. If you do not think you have the scores or ranking you need, if you want it bad enough, keep putting in the work. If you're not willing to put in the work, that should be a sign you probably don't care for that specialty as much as you thought. If you do like a certain specialty that is thought to be 'out of your league,' at least give it a chance. regret is tough to deal with. 152 Pediatrics preliminary, Don't make up your mind before you have tried Dermatology everything else, or at least go in with an open mind. Think very hard about the things you like and don't like about each rotation. It can help point you in the right direction in terms of what specialty will ultimately make you the happiest. Every specialty has its pros and cons. The trick is finding the specialty whose cons you can tolerate. 154 Family med The situation in tne US is impossible. Its totally driven by money, huge loans amassed in expectation of huge income. Its also driven by expectations of 6 figure income. Residents
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finishing training think they are being exploited if they make less than $180k starting out. In only a few countries in the world do average physician salaries fall in thaqt range. ee US professionals iun general believe we are entitledy tyto what is extraordinary pri ilege seen from a global perspective. oprQwpPhysician income seems to be closely aligned with the expense ( ) 155 General Surgery I advise students to find out what they enjoy doing, forget pressures by clinicians/parents/family/etc and do what feels right and is fun to do, regarldess of pay or hours worked. Working harder & longer at something you enjoy is much much better than working shorter and easier at something you may dislike. 156 Family Medicine Think beyond just medical school and residency and try to learn what opportunities exist after residency and how you can make them a reality. Consider also whether a particular residency program is truly a good match to help you achieve that goal, investigate what graduates are doing and what interests the attending physicians have. 158 Pediatric Critical Care Choose a specialty that you are passionate about, that supports your decision to enter medicine and that gives you the most satisfaction. Most of the time, you will find a job that will offer you the lifestyle and work times that suit you. If you're happy working, the hours and money do not matter as much. Happiness, and not money or stature should define your success. 159 Anatomic and Clinical Don't make a decision lightly or based on Pathology perceived lifestyle. Truly look into what the specialty entails, not just for residency, but down the road when thinking about fellowships/transitioning to life as an attending. Look into attending lifestyle, call schedule, salary (hugely differs depending on specialty), job market in the location you'd like to be, whether those specialists are limited to hospital employee status or can be part of a private practice, independence, etc. Lots of these are things that med students consider for residency, but don't look at the big picture of what it's like to be an attending (e.g. every student says path residency is perceived as less demanding time wise, but when acting as a path attending, call and time spent at the hospital is dependent on what surgeons want you there/what surgeries are
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happening and when, etc...Things a student or even a resident may not have been aware of) 160 anesthesia important to evaluate practicing physicians lifestyle and practice patters- not just residency 161 Family Medicine Go with your gut. Spend the time you need to make sure it's the right fit. Don't worry about money or prestige. They will follow. It's gotta be fun, because it's too damn hard if it's not. 162 Physical Medicine and Talk to many physicians in the areas that they Rehabilitation are considering...ask why they chose it; times are changing now...still should do what they love and feel passionate about. 163 pediatrics Make sure you have ""happy feet"" when you are going to work in your chosen specialty. 164 clinical cancer genetics Follow your passion. What makes you tick and utilise your strengths. 165 Family Medicine Pray. Accept what is in store for you. Don't stress out too much about what is the ""right"" choice. 167 vascular medicine First and foremost, practice in an area of his/her liking. But also make sure that the setting in which he/she will practice matches individual personal choices/lifestyle choices. 168 Pediatrics Do something they are passionate about and forget about compensation, prestige, etc. 169 Neurology I never discourage a student to not go into the speciality they have chose based upon finances despite my personal opinions- primarily because we need good physicians in primary care specialties. 170 Pathology Make sure that you love the daily work of currently practicing physicians in that specialty. 173 Pathology Do what you think will make you happy. Listen to other people, but do not simply bow to their knowledge and expectations. If you want to do a speciality that is a ""lifestyle specialty"" don't let other make you feel guilty about choosing to have a life. 174 Otolaryngology First of all choose something you love doing. Don't choose on prestige or compensation because you never know how that will turn out. Choose a specialty the mundane of which you dislike the least because very few physicians see only the most exciting and complicated cases. 176 Vascular Surgery Choose field that they would work in for free if they came into a billion bucks 177 Family Medicine Choose specialty based on personality. Also consider debt to income ratio. 178 Pediatrics Do what you enjoy and be with people you enjoy 179 Infectious Diseases To do what you love to do.
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Pediatrics 181 Hospice and Palliative Choose a specialty that will give you satisfaction Medicine and fulfillment and a good work-life balance 184 Diagnostic Radiology Do what you love. Through thick and thin, through popular and unpopular times you'll still be happy. 186 dermatology Talk to physicians in fields they are contemplating. See if they are still happy after years of practice and specifically find out why or why not. Really think about the life style as well. 187 Internal Medicine I would stress to them to think about life-work balance and to consider possibly a procedure driven speciality as re-imbursement and proof of value for primary care is very difficult and at times defeating. 188 Obstetrics and Gynecology Know yourself, your strenghths and your limitations. Be realistic about what you expect in all aspects of your future life, and how your career choice fits into those expectations. 190 Family Medicine Do not choose primary care. 191 Pediatrics I always tell them that you go into medicine, any field of medicine, because you love it, not because you're going to make a lot of money. You never see a homeless doctor. We don't make what we used to make, but it's still a livable wage which is better than many other people. I always encourage them to pick what they love doing, and if anything else should afect the decision it should be family reasons. If you love neurosurgery, but you want to have 10 children and you never want to miss a baseball game with your kids, probably not a great idea to be a neurosurgeon. It's all about values and if you stick to your gut and your values, you'll end up just fine. 193 Physical Medicine and I tell them that they must enjoy what they do. Rehabilitation Without job satisfaction, the work is too challenging and patient care suffers 194 neurology Look at where medicine is going, and where the aging population is going. Be realistic about what you like and dislike about patient populations and diseases. 195 Family medicine Do what you enjoy the most. Money is not worth not enjoying your work. 196 Internal Medicine don't choose to be a generalist 197 cardiothoracic surgery Think about life twenty years from now, not five years from now. Will you be happy doing this then? 198 Endocrinology, Diabetes Now retired from clinical practice and work full
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and Metabolism time for a pharmaceutical company. However, do mentor students who do rotations with us (working with 2 at present). 199 pediatrics Do what makes you come alive, not what others expect of you. Personalities make a big difference, so pay attention to the kind of personalities drawn to a specialty you're interested in.
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