Introduction
Career planning in today’s world is increasingly recognised as a complex, multifactorial process. Individuals may be influenced by a multitude of variables, from one’s ‘idiosyncratic characteristics,’ such as ‘age, gender, specific talents, interests, and values,’ to the ‘social and environmental context’ and political climate in which he/she lives1. Aspiring doctors must begin to construct a long term career plan during medical school. Evidence suggests a significant proportion of medical students ‘switch career preferences‘ during preclinical years,2 perhaps as many students ’enter medical school without a clear appreciation of the types of practices or lifestyles associated with specific disciplines‘.3 Students must therefore quickly acquire and analyse this sort of practical information, in tandem with their academic learning, as they transition through medical school.
Multiple international studies have looked at medical student interest in particular specialties, reflecting authors’ area of interest or concerns surrounding health service provision.4,5,6,7,8,9 Recently, some studies have attempted to explore career-planning in a broader, more integrative sense, with analysis of the career-planning process rather than the final specialty destination alone. These have found a multitude of intrinsic and extrinsic factors to influence the career-planning process of an individual student.10,11
There is a paucity of information pertaining to the career planning of medical students in an Irish context, and to the role of the medical school experience in shaping students’ future plans.
The aims of this study were to explore the complexities of the decision making journey related to specialty choice undertaken by future doctors whilst at medical school in Ireland.
Methods
Study Design
The target research population was interns (FY1 equivalents) working in Irish hospitals, chosen to minimise recall bias when reflecting on their medical education. The study setting was nationwide, capturing graduates of a variety of universities. Both a nationwide questionnaire and a regional focus group were designed for data collection. These were both administered during the middle portion of the participants’ first postgraduate year.
An original questionnaire was designed, guided by a literature review and Association for Medical Education in Europe (AMEE) guidelines.12 A Likert scale was chosen for questionnaire responses, for ease of use and ‘adaptability for measuring many different constructs’.12 The questionnaire (appendix 1), was delivered online and included three free text boxes for unstructured reflection or elaboration. To improve content validity,12 four colleagues independently reviewed and critiqued the questionnaire.
A focus group was proposed with the aim of eliciting rich qualitative data,13,14 creating a ‘mixed-methods’ research approach. Such ‘methodological eclecticism’ may ‘cancel out the respective weakness of each method,’15 and allow simultaneous investigation of exploratory and confirmatory research queries.16
This research was approved by the ethics board of University College London, the Intern Network Executive of Ireland and the individual intern networks.
Study Population & Recruitment
A link to the online questionnaire (appendix 1), which was hosted on Google Forms™, with a participant information leaflet was circulated via the intern coordinator in each of six national networks. This was followed with a reminder email approximately 3 weeks after the first. The intern networks incorporate teaching hospitals of Trinity College Dublin, University College Dublin, Royal College of Surgeons of Ireland, National University of Ireland Galway, University College Cork and the University of Limerick. There is no national career-guidance programme for medical students in place in Ireland, and a national population was sought to capture different experiences.
Recruitment for a local focus group was then commenced, by convenience sampling.17 This was at the first author’s institution via an email request and an announcement at a teaching session made by the intern tutor, seeking four to six participants; a suitable size for health science research.18,19
Data Collection
Questionnaire data responses to the Likert scale questions were compiled within Google Forms™. All free text responses to the online questionnaires were typed into a transcript document for analysis.
The focus group was held with five intern volunteers, in a quiet room within the hospital, and took place directly after a teaching session for convenience. This was moderated by the researcher (the first author), using moderation techniques.19 Conversation was guided by the participants, with a discussion guide (appendix 2) to stimulate conversation. The focus group discussion was audio recorded and later transcribed for analysis.
Data Analysis
Quantitative data analysis of questionnaire responses was performed. Qualitative analysis was applied to both interpretation of both free text responses within the questionnaire, and the transcript of the focus group conversation. Thematic analysis20 based on grounded theory21 and concerned with the inductive identification of codes apparent within the data was used,22,23,24 with the aim of ‘generating theory from the range of the participants’ experience’.25
Results
Demographics
One hundred and seventeen questionnaire responses were received, from a population of approximately 580 interns (response rate 20%). Of respondents, 64 (55%) were female, and 82 (70%) had studied medicine as an undergraduate degree. The overwhelming majority, 116 (99%), had studied medicine at an Irish university.
Five interns, representing two universities, participated in a focus group. Four out of five were male and had studied medicine as undergraduates. Pseudonyms were assigned (Richard, James, Ollie, Matt and Sarah).
Timing of Decision Making
Questionnaire respondents’ status regarding career decisions are illustrated in Figure 1. ‘Unsure’ was a choice for respondents who had little or no idea of which area(s) they would be interested in pursuing.
Figure 1 Questionnaire respondents’ status regarding career decisions
Table 1 describes the specialty aspirations of questionnaire respondents. ‘Undecided’ was an option for respondents who were not inclined to one specific area over alternative options.
Table 1 Specialty Aspirations of Interns at Time of Questionnaire
|
Specialty
|
Number (%)
|
|
Anaesthetics / Critical Care
|
5 (4%)
|
|
Emergency Medicine
|
6 (5%)
|
|
General Practice
|
13 (11%)
|
|
Hospital Medicine (subspecialty uncertain)
|
12 (10%)
|
|
Hospital Medicine (subspecialty decided)
|
16 (14%)
|
|
Microbiology
|
2 (12%)
|
|
Obstetrics & Gynaecology
|
5 (4%)
|
|
Occupational Medicine
|
0
|
|
Ophthalmology
|
2 (2%)
|
|
Paediatrics
|
10 (9%)
|
|
Pathology
|
0
|
|
Psychiatry
|
8 (7%)
|
|
Public health
|
0
|
|
Radiology
|
4 (3%)
|
|
Radiation Oncology
|
0
|
|
Sports & Exercise Medicine
|
1 (1%)
|
|
Surgery (subspecialty uncertain)
|
7 (6%)
|
|
Surgery (subspecialty decided)
|
13 (11%)
|
|
Full time academia / research
|
0
|
|
Full time medical education
|
1 (1%)
|
|
A career outside medicine
|
0
|
|
Not yet decided
|
12 (10%)
|
Priorities & Influences
Table 2 outlines the responses of questionnaire respondents related to potential influences on career choice encountered at medical school.
Table 2 Interns’ Views on Potential Medical School Influences
| |
Strongly Agree
|
Agree
|
Neutral
|
Disagree
|
Strongly Disagree
|
N/A
|
|
‘I was encouraged to pursue the specialty I have chosen by a rotation in this specialty during medical school.’
|
2
(19%)
|
41
(35%)
|
19
(16%)
|
13
(11%)
|
9
(8%)
|
13
(11%)
|
|
’I was encouraged to pursue the specialty I have chosen by a role model I identified in this specialty during medical school.’
|
17
(15%)
|
26
(22%)
|
26
(22%)
|
26
(22%)
|
8
(7%)
|
14
(12%)
|
|
’I was encouraged to pursue the specialty I have chosen by a role model I identified in this specialty during intern year.’
|
20
(17%)
|
33
(28%)
|
18
(15%)
|
25
(21%)
|
7
(6%)
|
14
(12%)
|
|
’I was encouraged to pursue the specialty I have chosen by the formal teaching of the specialty during medical school (lectures, organised tutorials etc.).’
|
7
(6%)
|
40
(34%)
|
20
(17%)
|
25
(21%)
|
10
(9%)
|
15 (13%)
|
|
’I felt inspired or encouraged to consider particular specialties due to the portrayal of them by doctors or tutors I encountered during medical school (whether or not these doctors worked in the specialty of discussion).’
|
23
(20%)
|
43
(37%)
|
20
(17%)
|
15
(13%)
|
5
(4%)
|
11 (10%)
|
|
’I felt discouraged from entering particular specialties due to the portrayal of them by doctors or tutors I encountered during medical school (whether or not these doctors worked in the specialty of discussion).’
|
33
(28%)
|
38
(33%)
|
14
(12%)
|
17
(15%)
|
5
(4%)
|
10
(9%)
|
Table 3 illustrates what medical students ranked as the most, and second most, important factors they perceive in specialty selection.
Table 3 Most Important Factors in Selecting a Specialty
|
Most Important Factor
|
|
Second Most Important Factor
|
|
|
Interest in specific aspects of specialty
|
36 (31%)
|
Work-life balance
|
24 (21%)
|
|
Work-life balance
|
25 (21%)
|
Interest in specific aspects of specialty
|
22 (19%)
|
|
Positive perception of the personality type of people working within the specialty (feeling you’d be a ‘good fit’)
|
18 (15%)
|
Positive perception of the personality type of people working within the specialty (feeling you’d be a ‘good fit’)
|
15 (13%)
|
|
Procedural component to the specialty
|
13 (11%)
|
Procedural component to the specialty
|
12 (10%)
|
|
Perception of the specialty’s training programme as high quality or well structured
|
4 (3%)
|
Positive exposure to the specialty as an intern
|
11 (9%)
|
|
The patient demographic encountered in the specialty
|
6 (5%)
|
Positive exposure to the specialty as a medical student
|
8 (7%)
|
|
Positive exposure to the specialty as a medical student
|
3 (3%)
|
The patient demographic encountered in the specialty
|
9 (8%)
|
|
Positive exposure to the specialty as an intern
|
3 (3%)
|
Having a family member or close friend in the specialty
|
4 (3%)
|
|
Ability to train in one (or a limited number of) geographical locations
|
1 (1%)
|
Perception of the specialty’s training programme as high quality or well structured
|
2 (2%)
|
|
Academic/Research opportunities
|
2 (2%)
|
Salary
|
3 (3%)
|
|
Salary
|
0
|
Ability to train in one (or a limited number of) geographical locations
|
2 (2%)
|
|
Status / Prestige
|
0
|
Status / Prestige
|
2 (2%)
|
|
Having a family member or close friend in the specialty
|
0
|
Academic/Research opportunities
|
0
|
|
‘Other’ (free text)
|
|
‘Other’ (free text)
|
1 (1%)
|
|
’Most of the above are important factors…’
’The extent to which you have to look after patients outside of your specialty (general take, social admissions’
’Ability to affect the greatest number of people’s health for the better’
’Personal experience as a patient’
|
’Somewhere I can develop my leadership qualities to the maximum‘
|
Thematic analysis of free-text questionnaire responses and focus group transcripts revealed a number of influences on career choice described by the junior doctors.
Clinical Exposure
Authentic Exposure
The exposure to the ‘real-life’ aspect of a specialty was valued: ’you try something and you like it, but then you have to find out about it, what its really like to live it’ (Ollie).
Expectation versus reality
Several respondents described how experience of a particular specialty altered their aspirations. One respondent found the ’area far more monotonous than ever expected’ whilst another found that exposure revealed ’disadvantages to certain areas.’
Personal Strengths and Preferences
Some respondents used ’increased exposure to the specific area’ to assess personal compatibility. One recalled how ‘I initially wanted to do GP…[however] realised that I don’t like knowing bits of everything and much prefer to know one topic very well.’ One intern ’had previously decided on anaesthetics‘ but decided against it when ’working with intubated patients in theatre’ did not appeal, whilst another ‘enjoyed studying the theory of psychiatry’ however found ‘the placement emotionally taxing.’
Rapport with Clinical Team on Placement
Interns heavily emphasised the importance of team rapport. ’Actually the three main, very different, specialties I’ve been interested in…the common factor was really good experience on rotation and good fun with the team’ (James). Good rapport was associated with increased opportunities, such as being ’brought along to theatre’ (Sarah). The structure of clinical placements affected students’ abilities to foster relationships, ‘if you’re only on a specialty for one week you don’t really get to know the team’ (James).
Role Models
Role models were seen as highly influential in career choice. ‘The single biggest influence overall I’d say, is having a cool, nice consultant [mentor] in that specialty’ (Ollie). Non-consultant hospital doctors who ‘stood out’ in their interest students were also identified as positive role models.
Formal Teaching
One participant felt that ’lectures make a big difference‘ in igniting specialty interest, and theorized that ‘loads of people from [my university] would have “a big interestin neurology” due to an eminent ’inspirational‘ professor lecturing there (Matt). Another felt that a structured curriculum had solidified her interest in obstetrics and gynaecology, describing it as ’intense… but also with very clear expectations‘ which led to a more ’rewarding‘ learning experience (Sarah).
Influence of Practicing Doctors
Practicing doctors emerged as both positively and negatively influential in specialty choice.
Positive: Open Encouragement
Interns recalled being directly encouraged by doctors to enter a particular specialty in some cases, describing how in some cases consultants had ’sought out interested students‘ and attempted ’to involve and interest them‘ (Sarah), or how ’getting a lot of positive feedback‘ on a particular rotation inspired them to pursue a specialty.
Positive: Personal Interactions
One intern recalled being ’influenced positively towards anaesthetics…and towards GP…due to positive attitudes of staff’ and another described changing their specialty of choice based on the ‘experience of interactions with different personalities in each speciality.’
Positive: Observed Skill
Several interns were inspired by the skillset of particular doctors. They recalled wanting to ‘become as excellent as [medical specialist registrars],’ feeling influenced by ‘exemplary surgeons’ or admiring the ‘respect‘ held for ’anaesthetists [who everyone] call[s] when things go wrong.’
Positive: Observed Satisfaction
The perceived satisfaction of working doctors influenced respondents, with them feeling inspired by doctors ’particularly passionate about their specialty’ or seemed to be ‘happier doctors.’
Negative: Discouraging
Doctors were reported to sometimes discourage students from pursuing particular specialties, generally due to ‘lifestyle factors’ or perceived ‘poor training schemes.’ One stated that ‘male hospital doctors, tutors in medical school (all female GPs) and sometimes nurses all told me to do GP because surgery was a hard life for a woman.’
Negative: ‘Bashing’ Particular Specialties
Many respondents had been exposed to negative perceptions held by doctors of other specialties. One had been told her chosen subspecialty was ’not worthwhile or proper surgery,’ whilst others perceived that ’GPs are considered lesser doctors’ and that ’everyone moans about [surgeons].’ Some respondents found this culture influential, others were unconvinced; ‘[doctors] make throw away remarks about other specialities – whomever they’re arguing with that day (!) but nothing sustained or really influential’ (James).
Negative Personal Interactions
Negative personal interactions were profoundly influential. One respondent stated ’the environment and doctors in some specialties are so negative that I would be completely opposed to…the specialty just based on the hostile and negative people that populate it.’ One reported being ‘discouraged‘ by the ‘unwillingness to help and unkind demeanours’ of some doctors whilst another perceived that ‘[surgeons] revel in being blunt and ignorant of students.’ One noted how ‘teams [with] poor group dynamics…reflected in a bad manner on our inclusion, and left me a negative image of the specialty.’
Observed Dissatisfaction
Perceived dissatisfaction of practicing doctors also indirectly negatively influenced respondents. One described how ‘consultants who were unhappy deterred me from their specialty’ and another concluded from observation that ‘surgical schemes make you sad.’
Lifestyle
The observed or reported lifestyle associated with particular specialties was important to participants, with ‘portrayal of the lifestyle, call and expectations of the specialty’ ‘future flexibility’ and perceived [time for life outside work[ seen as crucial. One was attracted to radiology by observing the [apparently balanced lifestyle] whilst others were dissuaded from plans to be a surgeon or [neonatal ICU specialist] based on perceived incompatibility with [a decent work-life balance].
Time to Explore Options Beyond Graduation
Exploring potential career options after graduation was common; ‘I’ve definitely changed my mind a few times…I think that’s pretty universal’ (Richard). ‘Exploring different avenues makes you more confident with your ultimate choice’ (James). The benefit of an intern/foundation year was stressed; ‘I think we’re really lucky…we [can] work in certain areas and see how they are. Because if I’d had to pick straight off like for residency, I’d definitely have chosen wrong!’ (Ollie).
Graduate Entry Medicine
It emerged that graduate entry medical students may feel more pressure to make prompt decisions: ’I think being…graduate entry you’re very conscious of [career planning] from day 1, you just don’t feel like you’ve any time to waste…so every rotation you’re thinking about it’ (Matt). Some wished to build upon their previous academic experience, pursuing the area of a previous PhD or ’science degree…in microbiology.’
Future Employment Predictions
Some respondents considered strategically pursuing a specialty based on ‘a growing area of need.’ Several had seen senior doctors encounter a lack of job opportunity and were disillusioned by this. However, this did not seem to be a strong influence, with interns stating’at the end of the day I’d mostly just [follow my] interest’ (Richard), or that it would be ‘too difficult to forecast [job openings] anyway, really’ (James).
Salary
Earning potential was not important to participants in specialty choice. ‘It’s not really relevant to me…I don’t really know the difference between the salaries of say [two different consultants]’ (James). ‘I think you’re going to have a decent salary in most areas within medicine and if I wanted more than that I’d probably have gone into finance or something instead!’ (Sarah)
Influence of a Family Member in Medicine
The influence of a family member clinician in specialty choice was seen as inevitable: ‘Yeah it’s bound to [influence you]. You’re absorbing that as you grow up’ (James). ‘Yes I think it does steer you a bit…whether you’re inspired to do it or put off’ (Matt). ‘I know [my parent’s specialty] is something I never want to do…they’re always working’ (Richard).
Training Schemes
The number of ‘years in training’ and the perceived quality and structure of the ‘training scheme’ were factors cited. One respondent changed specialty choice due to the duration of ‘training time’ required. The accessibility of training pathways, due to strong competition was acknowledged as another influential factor. One respondent mentioned the potential limitations in choice as a result of ‘being a non-EU citizen (Canadian) trained in an Irish college.’
Discussion
At the time of survey, midway through their intern year, 41% of questionnaire respondents had not decided upon even a broad area of specialisation, similar to the 48% in a New Zealand study.26 This may be a growing trend; the UK Medical Careers Research Group, via a survey sent to 7,095 graduates of 2015 found a ‘rise in the percentage of respondents who did not nominate a career choice’ compared to previous years27, and has been postulated due to contractual uncertainty27, modern day career fluidity28, or a growing culture for junior doctors to work abroad prior to starting a training scheme.29 One focus group participant proposed that graduate entry medical students felt more pressure to make career decisions at an earlier stage. This is supported by one study of a graduate entry medical school (n=139), where 82% of students had a current career choice and 51% had established a career preference prior to entering medical school.30
Interest in the specialty, work-life balance, a positive perception of the personality types within the specialty and a procedural component to the specialty were the most commonly listed priorities of respondents, with no interns citing salary or job prestige as their top priority. One US study identified remarkably similar priorities overall.31 Other US studies, however, have shown potential remuneration to be a more dominant factor in student specialty choice, possibly due to the high loan repayments typically carried by US graduates.32,33 In an Australian study, Harris et al. identified the ‘appraisal of own skills and aptitudes‘ as the single most influential factor in graduates’ career choice. As this study population was postgradaute year three, this potentially reflects greater insight into, and weighting of personal attributes with clinical experience.34 A Japanese study found the five most influential factors to include ‘fulfilling life with job security’ ‘bioscientific orientation‘ and ’advice from others’35, possibly demonstrating cultural differences in determinants. All of these studies, including our own, are perhaps biased in that respondents were presented with a list of variables to choose from, rather than an open question, although we did attempt to mitigate against this by inclusion of a free text box.
A number of extrinsic, modifiable, factors emerged as exerting influence on specialty choice.
Perhaps the most defining feature of the clinical years of an undergraduate programme is the experience of clinical placement, and enjoyment of rotations appears in our research as positively influential in specialty selection. This appears a global phenomenon, with powerful motivators in career choice discovered to be ‘inspiration during…clinical practice’ in an Ethiopian study36[36], and ‘experience on a clinical attachment’ in a New Zealand study.37 This is corroborated by studies assessing recruitment into specific specialties, where a positive experience on clinical rotation has been shown to attract students to a wide range of specialties from anaesthesia to psychiatry amongst others.7,9,38,39,40
A criticism of these studies is that there is largely a failure to uncover specifically why students recorded a particular clinical placement as positive. Superficially one might conclude this was due to an interesting educational experience. However as our data highlight, a positive rapport with the team may also be a powerful determinant of enjoyment. We also discovered that 35% of our questionnaire respondents felt they were not influenced by student rotations. We did not have the opportunity to delve deeper into this, as all focus group participants reported being influenced by placement, but further exploration would be interesting.
Role models were reported as positively influential in career choice by Irish interns, in keeping with the results of other published studies.41,42 Focus group participants outlined perceived role models as senior figures with whom they had recurrent contact over a period of time. However, thematic analysis of further discussion and of free text boxes saw participants frequently refer to the behaviour observed in other doctors as influential; describing how, for example, skilled doctors and those who appeared satisfied in their field positively inspired them. Such clinicians encountered by students in isolated interactions may not fulfil the depiction of a role model if this is interpreted as a person the student interacts with or observes on a continuous basis. However, it seems that they too serve as role models and even fleeting observations of their behaviour may have a sustained influence on the student. Focus group respondents focused primarily on consultants as role models. Some literature would suggest that trainees closer in stage of training, can have a more powerful influence in this regard.43 Medical students in Ireland are typically lectured by consultants and assigned to a consultant on rotation and this may underly this association.
We noted that more respondents reported identifying a role model during intern year than during medical school. Whilst there is the potential for recall bias here, it may be that more sustained exposure to a team, and active involvement in it (as seen at intern level) creates greater opportunity for identifying one of the team members as a role model. More research in this area would assess if this is the case, and whether endeavours such as encouraging longer duration electives in areas of interest or mentorship programmes would facilitate identification of a role model earlier, and of what benefit this would be.44
The majority of questionnaire respondents had previously been discouraged from entering a particular specialty by qualified doctors. The survey questionnaire was not appropriately worded to ascertain whether most such discouragement came from doctors within or outside of the specialty or to what extent it influenced the student/intern’s decision, and this is a limitation. Such discouragement was not a significant issue in the eyes of the focus group participants. It is worth noting than none of the participants had ever been inclined towards specialty choices reported as traditionally falling victim to ‘bashing,’ such as general practice and psychiatry.45,47
Negative experiences and interactions with clinicians were repeatedly cited as indirect deterrents from entering the associated specialty. Both observed behaviours in practicing doctors, such as perceived ‘lack of compassion’ and negative interpersonal interactions, in perceived ’hostile‘ team environments, where members were thought to have ‘negative attitudes‘ towards students emerged as prevailing factors in students’ formation of a negative perception of the specialty. This is a topic that is largely unexplored in the literature, perhaps because it is somewhat unpalatable. The majority of studies focus on the factors attracting students to particular specialties and some also assess broad, constitutional negatives such as so-called ‘long working hours.’ Far fewer address this darker side of clinical exposure, although a minority do report prevalence of student mistreatment in the present time.48,49 This is an understudied, but potentially very relevant, phenomenon on a larger international scale.
Another dimension that emerged was the potential for rotations to dissuade students without necessarily being extremely negative or unpleasant experiences. This was acknowledged by all focus group participants. It is difficult to know if this resulted from true authentic experience or from a poor representation of the specialty during a given period (for example an understaffed service may have been unable to engage students and led them to deduce the specialty was boring). However, it is surely a fact that not every personality is suited to every specialty, and perhaps one of the most valuable experiences a student can have is to achieve clarity that a particular area in the abyss of medicine is not for them. No identified literature looks at this concept in greater depth. Further research, which would ideally capture the perspective of both team members and students, would be interesting to explore this further.
This study provides us with a unique insight into the myriad of factors influencing medical students in their choice of specialty, and the influences that prevail as they enter their early working years. Career choice emerges as a multifactorial process, with innate factors interacting with external influences to shape a medical student’s interest in a particular specialty. This appears an interestingly dynamic process, with changes of inclination frequently reported throughout medical school and in the early postgraduate period. The power of medical educators to exert both positive and negative influence on student’s perceptions of a given specialty, by one’s role in curriculum design, formal teaching or in encounters with students on clinical placement, is profound and should not be underestimated. We must sombrely pay heed to the stark stories of discouragement recollected by participants in this study; yet so too can we be motivated and empowered to encourage students by the uplifting descriptions of inspiration.
Acknowledgements
Acknowledgements to the Intern Network Executive of Ireland (INE) for approving and facilitating this study, and to all interns respondents for their time.
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