Abstract
Background
The choice of specialty by medical students and early career doctors affects health workforce distribution in any country. In addressing healthcare needs of the populace, appropriate distribution of manpower across board is essential. Several factors come into play in making these choices. This study assessed factors affecting the career choices of final year medical students and how curricular changes may have influenced these.
Methods
This was a cross-sectional study conducted among 236 final year medical students of the University of Ibadan by convenience sampling using self-administered semi-structured questionnaires. Questions were on sociodemographic characteristics, career counselling, preferred future career, and factors affecting these choices. Data were analyzed using SPSS version 21 software.
Results
A total of 236 medical students participated in the study. The mean age of participants was 23.6(±1.9) years. Only 112(47.5%) respondents had received any form of career counseling/guidance in the course of their medical training. The commonest first choice specialties were obstetrics and gynecology 54(22.9%), surgery 44(18.6%), and psychiatry 18(7.6%). Personal interest most often (185, 78.4%) influenced career choice overall, showing significance in obstetrics and gynecology (p=0.02), family medicine (p=0.02), and public health (p<0.001).
Conclusion
The predominant choices of future specialty among final year medical students were obstetrics and gynecology, surgery and psychiatry. The change in curriculum for medical students may have affected the pattern of their choices with more interest shown in previously neglected areas.
Keywords: Future specialty, Medical student, Specialty choice, Final year
INTRODUCTION
Medical students have been shown to make critical decisions such as the specialty to pursue further training in, during their medical school years.1 Although these initial choices may change, the significance of these early stage decisions cannot be undermined, because it is known that medical students tend to eventually specialize in disciplines closely related to these initial choices.2,3 These choices affect the distribution of the health workforce, and the health sector in general, of any country.
The most important factor affecting career choice among medical students and early interns, in several studies in the literature4-8 was personal interest. Other factors considered important included career stability, reputation, lifestyle/prestige, career progression, independence and income5, potential for high income, perceived benefit to the society7 and job satisfaction6. Concerning choice of future specialty, studies carried out in different regions of the country have reported similar trends: surgical specialties6-8 were the most preferred, when results were analyzed generally without specific attention to gender differences. This was closely followed by obstetrics and gynecology, and pediatrics6-9. However, some other studies10,11 reported obstetrics and gynecology as the most preferred specialty followed by surgery and pediatrics. Whatever the case may be, it is clear that these three specialties are the most desired in our environment. Family medicine4,5,12,13 and the basic medical sciences5,7 were the least preferred among various medical students studied. This probably highlights the little attention given to these specialties especially family medicine in various medical curricula. Elsewhere in the United Kingdom, specialties like general practice were reported as the most preferred14. This may be due to a more functional healthcare system with well-defined roles and career path for general practitioners at the primary level in high-income countries.
In Africa, the average physician to population ratio is 0.22/1,000 in urban areas and less than 0.03/100015,16,17 in rural areas, where more doctors are actually needed. This is not surprising in a continent where medical students have shown significantly lower interest in primary care specialties e.g. community medicine/public health or family medicine4,5,12,13, whereas these specialties drive the health indices of any country.
The College of Medicine, University of Ibadan has since 2010 implemented a revised curriculum based on present and projected societal needs, for her medical students with key components being horizontal and vertical integration across specialties and organ systems, clinically oriented and competency-based medical education with increased emphasis on clinical acumen and skills acquisition18. This has increased the amount of time devoted to clinical work, including allocating a two-month clinical rotation in primary care specialty of family medicine, as well as extension of clinical clerkships in psychiatry, radiology, and radiodiagnosis. It is unknown if this curriculum change will have any impact on the career choices of medical students trained with it. Findings from his study may guide future curricula revisions. This study assessed the preferences of final year medical students of the University of Ibadan as regards choice of future specialty, what factors affect this as well as gender differences. This is the first study to evaluate the effects of the new curriculum on students' career choices since its introduction in 2010.
MATERIALS AND METHODS
Study population, design and Ethical considerations
The study was conducted among final year medical students of the College of Medicine, University of Ibadan. The University of Ibadan is federal government funded and located in Ibadan, the largest city in West Africa. It is Nigeria’s premier university with a rich heritage in undergraduate medical training since 1948.
Following ethical approval from the institution's ethics review board (UI/EC/17/0276), a cross-sectional survey of 236 consenting medical students from two consecutive final year classes selected through convenience sampling using a self-administered, semi-structured questionnaire was done. Data was collected between January 2017 and February 2018. It was necessary to use two classes in order to achieve the calculated sample size. The students sampled were the first two sets to be trained with the revised medical curriculum. Only final year students were sampled because they are deemed to have clearer views on the scope of medicine, having gone through all rotations. The principles of ethical conduct of research employed was consistent with the declarations of Helsinki. Sample size was calculated, using the Leslie Kish formula for cross-sectional studies, and adjustment was made for non-response. Prevalence for the most preferred specialty for the calculation was obtained from a similar study by Odusanya et al.6 The 15-item questionnaire was divided into four sections, comprising the sociodemographic characteristics of respondents, desire to study medicine/previous career counselling, preferred future specialty and factors affecting choice of future specialty. Informed consent was obtained and the respondents were required to rank these specialties in order of their preference and indicate how much each of the factors examined affected their choices. The questionnaire was modified from a study by Nighat et al.4 They were crosschecked for completeness on each data collection day before accepting them from the respondents to avoid missing data. The study had a 95% response rate. This study was part of a comprehensive research evaluating career choices and considerations for training in the future among medical students at the University. The study received no external funding.
Data management and analysis
The questionnaires were manually sorted out and checked for errors and omissions at the end of data collection each day. The information obtained was kept confidential. Data collected was divided into categorical and continuous variables. This was entered into a computer and analyzed using the SPSS version 21 software. Continuous variables were summarized using means and standard deviations while categorical variables were summarized using frequencies and proportions. Chi-square statistic was used to test for association between categorical variables such as socio-demographic characteristics, choice of specialty, and factors affecting the choice of specialty. The p value for statistical significance was set at <0.05.
RESULTS
A total of 236 final year medical students with a mean age of 23.6( 1.9) years participated in the study, of which 135(57.2%) were males. Only 64(27.1%) received career counseling prior to choosing medicine as a course of study. Among the remaining 171(72.5%) who did not receive any counseling, 85(50.6%) indicated that if they had been counseled on what studying medicine entails, they would have made the same decision to study medicine. However, 79(46.7%) indicated that with the benefit of hindsight, they would have chosen a different career pathway. The most preferred specialty for 75(31.8%) of the respondents was Surgery, while 62(26.3%) preferred Obstetrics and Gynecology. Psychiatry was the specialty of choice for 47(19.9%), and 52(22.0%) preferred Pediatrics.
The factors influencing the choice of specialty among the respondents are presented in Table 1. Personal interest was found to be the most important factor influencing specialty choice (94.1%), followed by content of the specialty (93.2%), desired practice setting (91.9%), and clinical rotations (91.1%). Other factors such as potential income, parental influence, working with new technology, prestige of the specialty, and faith were less influential.
Table 1:
Sociodemographic characteristics of the study participants
| Variable | n (%) |
|---|---|
|
| |
| Age | |
| ≥ 25 | 49 (20.8) |
| < 25 | 187 (79.2) |
| Gender | |
| Male | 135 (57.2) |
| Female | 101 (42.8) |
| Had a doctor in the family before studying medicine | |
| Yes | 93 (39.4) |
| No | 143 (60.6) |
| Type of relationship to the doctor | |
| Nuclear | 43 (46.2) |
| Extended | 50 (53.8) |
| Father’s level of education | |
| Tertiary | 205 (86.9) |
| Secondary | 22 (9.3) |
| Primary | 6 (2.5) |
| No formal education | 3 (1.3) |
| Mother’s level of education | |
| Tertiary | 199 (84.3) |
| Secondary | 27 (11.4) |
| Primary | 8 (3.4) |
| No formal education | 2 (0.9) |
Gender differences were observed in specialty preference. Surgery was chosen more by males (47.4%) compared to females (15.6%). Obstetrics and Gynecology were preferred by 34.1% of females and 16.8% of males. Pediatrics were chosen by 28.1% of females and 16.0% of males. Psychiatry showed increased interest among medical students with 32.6% females and 7.6% males indicating it as their preferred specialty.
DISCUSSION
The study allowed the students to select the specialties of their choice and rank them in order of preference, rather than assessing interest in just one specialty or selecting one most preferred specialty out of a list, which were the methods used in most of the previous studies conducted in Nigeria on specialty choice7,9,19-22. This provides more information about likely final career choices. Ranking specialties in order of interest also allows an observation of trends/patterns in choices of students, and per adventure the most preferred option is changed, it can be predicted what the likely alternatives would be. This has implications for policy.
The current study revealed obstetrics and gynecology, surgery, and psychiatry in that order as the first choice most preferred specialties. The findings were similar to those from a multicenter survey of three medical schools across South-South and North-Central Nigeria, in terms of the first and second most preferred specialties23. Most of the other studies 7,9,19-22,24 conducted in Nigeria, found surgery to be most preferred, including a study by Asuzu et al9 over two decades ago among final year medical students at the University of Ibadan. Obstetrics and gynecology, internal medicine, and pediatrics followed as the second, third, and fourth in various combinations in these studies. One of the studies11 found public health to tie with pediatrics as the second choice specialty. Only a small proportion (4.2%) and a smaller proportion (2.1%) were interested in family medicine and community medicine respectively as the first choice in our study. The results represent marginal improvement in the interest of medical students in these fields compared to the previous study9 conducted at the University of Ibadan.
The strongest factor influencing these choices was found to be personal interest. Our results, therefore, show that the interest and hence choices of medical students appear to be changing. While the most chosen specialties in many other studies7,9,19-22,24 have been domiciled among the four core clinical specialties; surgery, obstetrics and gynecology, internal medicine, and pediatrics, this study found psychiatry to be one of the leading choices. Apart from being third among the most preferred specialties, it was fourth among the second most preferred, and second among the third most preferred. This differs from what was obtainable previously at the University of Ibadan9 and in other schools across Nigeria6-11,19-23, where the former curriculum is still in use. Psychiatry usually records very low interest among students, and in fact, in one study no student indicated interest in it23. A report from the World Health Organization stated that Nigeria has nine psychiatrists per million citizens, a grossly inadequate figure considering the importance of mental health25. The finding from this study reflects the impact of a training system that is tailored to the needs of the population especially now that mental health is becoming increasingly important. This increased interest most likely reflects a direct effect of the increased clinical exposure to this specialty that the new curriculum affords. Duration of exposure and clinical rotation through various departments was found by our study and others19 to play key roles in the choice of future specialty. We may, therefore, conclude from this that one of the ways to increase/stimulate interest in certain specialties lacking in our health system is to increase the amount of exposure medical students get to them in the course of their training. This has been alluded to earlier by Goldacre et al.26
Gender differences in the choice of specialty were found in our study. Among the males, the most preferred was surgery, followed by obstetrics and gynecology, then internal medicine. For the females, obstetrics and gynecology was the most preferred specialty followed by psychiatry and pediatrics. These results are similar to findings from studies conducted in Sweden and Saudi-Arabia where more female medical students indicated interest in future careers in obstetrics & gynecology compared to their male counterparts27. Considerably fewer females selected surgery and compared to the males they chose pediatrics and psychiatry more frequently in our study. Other studies have also found that more males opted for surgery and its subspecialties8,19,24,28,29 while the females indicated more interest in pediatrics.8,19,28,29 The influence of gender on the selection of career choice is likely to be multifactorial with many considerations involved.
Personal interest was found in our study to have the strongest influence on the choice of specialty, followed by the content of specialty, desired practice setting, and clinical rotation in the department. Participants adduced parental influence as least likely to affect the choice of future specialty. Personal interest as the most important factor influencing the choice has been found in several other studies as well.5,7,19,23,30 The strong influence that personal interest has on the choice of specialty should be leveraged on, to develop methods of instruction that stimulate interest among students as they rotate through the various specialties. Most of the other factors identified to influence choices are not modifiable. In the current study, more males indicated the potential for higher income, parental influence, working with new technology, prestige of specialty, and faith as having a strong influence on their choice, compared to females. Other studies have found similar results with males indicating interest based on pay package8,29, prestige29 and variety of caseload29, while the females' choices were influenced more by having shorter working days29, a large amount of patient contact29, flexibility with training8,29, and compatibility with having a family8,29.
A major limitation of the study was that it recruited students from a single medical school, the oldest and one of the most well-equipped in the country. It may be difficult to generalize the findings to other medical schools with different characteristics in terms of socioeconomic indices, facilities that the students are exposed to and the quality and depth of teaching and mentoring that could have influenced the career choices of students.
CONCLUSION
The predominant choices of future specialty among final year medical students were obstetrics and gynecology, surgery, and psychiatry. The change in curriculum for medical students may have affected the pattern of their choices with more interest shown in previously neglected areas.
Table 2:
Preferred choice of future specialty of the participants (n=236)
| Specialty Choices | Rank 1 | Rank 2 | Rank 3 | |||
|---|---|---|---|---|---|---|
| Freq. (n) | Percent (%) | Freq. (n) | Percent (%) | Freq. (n) | Percent (%) | |
|
| ||||||
| Obstetrics and Gynecology | 54 | 22.9 | 25 | 10.6 | 13 | 5.5 |
| Surgery | 44 | 18.6 | 40 | 16.9 | 10 | 4.2 |
| Psychiatry | 18 | 7.6 | 20 | 8.5 | 17 | 7.2 |
| Pediatrics | 14 | 5.9 | 18 | 7.6 | 13 | 5.5 |
| Internal Medicine | 13 | 5.5 | 21 | 8.9 | 24 | 10.2 |
| Family Medicine | 10 | 4.2 | 13 | 5.5 | 12 | 5.1 |
| Neurosurgery | 8 | 3.4 | 4 | 1.7 | 8 | 3.4 |
| Anesthesia | 7 | 3.0 | 5 | 2.1 | 11 | 4.7 |
| Ophthalmology | 5 | 2.1 | 9 | 3.8 | 16 | 6.8 |
| Radiology | 5 | 2.1 | 7 | 3.0 | 7 | 3.0 |
| Public Health/Community Medicine | 5 | 2.1 | 6 | 2.5 | 11 | 4.7 |
| Ear, Nose and Throat | 2 | 0.8 | 4 | 1.7 | 6 | 2.5 |
| Pathology | 2 | 0.8 | 2 | 0.8 | 5 | 2.1 |
| Clinical Pharmacology | 1 | 0.4 | 2 | 0.8 | 2 | 0.8 |
| Basic Medical Sciences | - | - | - | - | 3 | 1.3 |
| Nuclear Medicine | - | - | - | - | 2 | 0.8 |
| Radiotherapy | - | - | - | - | 3 | 1.3 |
| Sports Medicine | - | - | 6 | 2.5 | 7 | 3.0 |
| Yet to decide | 10 | 4.2 | 1 | 0.4 | 7 | 3.0 |
| I don’t think I will specialize | 2 | 0.8 | 1 | 0.4 | 2 | 0.8 |
| Others | 6 | 2.5 | 6 | 2.5 | 6 | 2.5 |
Freq. – Frequency
Table 3:
Association between factors affecting choice of future specialty and gender
| S/N | Factors | Strong | Moderate | Nil | p-value | |||
|---|---|---|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | ||||||
| Male | Female | Male | Female | Male | Female | |||
|
| ||||||||
| 1 | Personal interest | 103 | 43.6 | 82 | 34.8 | 12 | 5.1 | 0.32 |
| 2 | A well revered role model | 24 | 10.2 | 20 | 8.4 | 88 | 37.3 | 0.78 |
| 3 | Clinical rotation in the department | 51 | 21.6 | 42 | 17.8 | 43 | 18.2 | 0.54 |
| 4 | Intellectually demanding | 32 | 13.6 | 29 | 12.2 | 59 | 25.0 | 0.69 |
| 5 | Potentially lucrative | 53 | 22.5 | 29 | 12.2 | 25 | 10.6 | 0.026* |
| 6 | Content of specialty | 76 | 32.2 | 66 | 28.0 | 30 | 12.7 | 0.34 |
| 7 | Desired practice setting | 60 | 25.4 | 50 | 21.2 | 38 | 16.1 | 0.71 |
| 8 | Minimal/predictable work hours | 29 | 12.2 | 28 | 12.0 | 66 | 28.0 | 0.41 |
| 9 | Parental Influence | 9 | 3.8 | 3 | 1.3 | 97 | 41.1 | 0.025* |
| 10 | Burden of disease in Nigeria | 21 | 8.9 | 20 | 8.5 | 70 | 29.7 | 0.31 |
| 11 | Few specialists in the country | 26 | 11.0 | 14 | 5.9 | 65 | 27.5 | 0.078 |
| 12 | Working with new technology | 37 | 15.7 | 18 | 7.6 | 50 | 21.2 | 0.022* |
| 13 | Opportunity for research | 40 | 16.9 | 28 | 11.9 | 60 | 25.5 | 0.065 |
| 14 | Shorter training periods | 17 | 7.2 | 12 | 5.1 | 82 | 34.7 | 0.093 |
| 15 | Perceived ease of study/practice | 28 | 12.0 | 20 | 8.3 | 62 | 26.3 | 0.064 |
| 16 | Prestige of specialty | 37 | 15.7 | 17 | 7.2 | 27 | 11.4 | 0.002* |
| 17 | Inspiration and guidance from God | 34 | 14.4 | 41 | 17.4 | 69 | 29.2 | 0.024* |
Freq. – Frequency
statistically significant
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