Specialty choice among final-year medical students and house officers in Nigeria: implications for anaesthesia practice – a cross-sectional study

Abstract

Objectives

Nigeria’s doctor shortage is worsening with mass exodus and imbalanced specialty distribution. Anaesthesia faces particularly critical shortages. Medical graduate specialty choices have a vital impact on the workforce and are essential for healthcare planning. This study aimed to identify the current specialty preferences of final-year medical students and house officers in Nigeria, factors that affect such choices, and their implications for anaesthesia practice.

Design

We conducted a cross-sectional study among final-year medical students and house officers in Nigeria using a self-administered, semistructured electronic questionnaire. The survey question was divided into four sections: sociodemographic data, specialty preferences, factors considered in choosing a specialty, perception of anaesthesia posting and anaesthesia as a specialty.

Setting

The survey was delivered via a Google Form that had been active for 4.5 months.

Participants

A total of 760 valid responses were received from final-year medical students and house officers in Nigeria. The majority (63.82%) of the participants were final-year medical students.

Results

Surgery (26.58%), internal medicine (14.47%) and obstetrics and gynaecology (14.34%) were the top-ranking specialty choices. Only 3.55% (eighth in ranking) intended to specialise in anaesthesia. There was a positive correlation between respondents’ specialty choice and the specialty of their doctor role model. Passion/interest, flexibility, potential future income and job prospects were essential in choosing a specialty. Most decisions were made during clinical rotations (63.95%), and only 35.26% had career guidance. Many enjoyed their anaesthesia posting, but over half felt the exposure was inadequate.

Conclusions

Too few medical graduates in Nigeria prefer anaesthesia as a specialty, and there is an urgent need to increase interest. A lack of career counselling, anaesthetist mentors and satisfactory clinical rotations are factors that can be improved for better recruitment into anaesthesia.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This seems to be the largest survey of specialty preferences among medical students and young doctors in Nigeria.

• Although this study recruited a large number of respondents, we employed a convenience sampling technique; hence, some specific groups might have been excluded.

• The response rate could not be determined owing to the method of data collection.

• Career preferences were limited to the primary medical specialties in Nigeria.

Introduction

There is growing global concern regarding the paucity of doctors. According to the Global Health Observatory of the WHO, Nigeria had a doctor-patient ratio of 3.81 per 10 000 in 2018, a far cry from the minimum recommended ratio of 1:1000.¹ With the mass exodus of medical personnel, including doctors and frequent alteration in the academic calendar of the nation’s public universities in the past few years the current statistics is likely to be worse. This issue concerns anaesthesia practice, a poorly sought-after medical discipline.² The anaesthetist is a multiskilled physician who possesses life-saving skills besides their role in perioperative care and pain management.³ Despite the vital role of the specialty in healthcare practice, few medical graduates enrol in specialty training in anaesthesia. In a study by Oku et al³ and Ossai et al,⁴ less than 5% of final-year medical students indicated anaesthesia as their preferred specialty.

The WFSA Global Anaesthesia Workforce Survey recommended a minimum of five physician anaesthetists per 100 000 population to ensure safe anaesthesia and surgery.⁵ According to this survey between 2015 and 2016, Nigeria had 0.58 physician anaesthesia providers per 100 000 population, which is nine times below this recommended minimum. The statistics have not changed over the last few years.⁶ This shortage of anaesthetists has reduced the number of surgical procedures that can be done, increased cancellation of cases and prolonged waiting time.⁷ Furthermore, the growing number of cases has overwhelmed surgical and anaesthetist trainees and resulted in the proliferation of non-physician anaesthesia providers, thus raising patient safety concerns.^{3 7}

Medical school graduates constitute the future of a nation’s health workforce.⁴ According to the Medical and Dental Council of Nigeria, there are 37 fully accredited medical schools in Nigeria, which produce an average of 3000 doctors annually and 123 approved housemanship training institutions as of October 2022.^{8 9} It has been shown that many medical students decide what specialty to train in their final year.⁴ Medical graduates’ specialty choices determine the physician workforce’s future composition.⁴ Determining these preferences is vital for health planning, career counselling and policy formulation.^{4 10} It is also crucial to achieving a balanced distribution of doctors among all specialties.¹¹

Trends in career choice vary from country to country and even within the same country over time. Hence, periodically evaluating the pattern among medical students and young graduates is vital.^{4 7 10} This study aimed to determine the specialty preferences of final-year medical students and house officers in Nigeria and their implications for anaesthesia practice. Our primary objective was to identify the current specialty preference. The secondary objectives were to identify factors that influence the decision of specialty choice and those that hinder medical graduates from pursuing a career in anaesthesia.

Methods

Study design

This cross-sectional research was conducted among final-year medical students and house officers in Nigeria. A self-administered, semistructured electronic questionnaire designed by the authors was used for data collection. The survey tool was pretested on 10 respondents. The link to the form was circulated through several social media platforms, particularly WhatsApp.

Sample size estimation

The minimum sample size was estimated using Slovin’s formula (n=N/(1+Ne²)). N was approximately 3000 (from data on the MDCN website),^{8 9} and 0.05 was chosen as the margin of error (e). A minimum sample size of 390 was obtained, allowing for a 10% attrition rate. This number was then doubled, considering our study population was two sets of medical graduates.

Data collection

The survey question was divided into four sections: sociodemographic data, specialty preferences, factors considered in choosing a specialty, perception of anaesthesia posting and anaesthesia as a specialty. The questions were designed as a mixture of structured and unstructured formats. Each respondent ranked their top three specialty choices from first to third. The form was active for 4.5 months (17 February to 1 July 2023). The survey tool has been included as an online supplemental file.

Data analysis

Data were extracted, visualised and analysed using Python programming language (V.3.10), with its mathematical, statistical and data analysis libraries. The responses to the unstructured questions were coded inductively and descriptively, and these were then represented using frequencies and percentages, whereas quantitative variables were represented using mean±SD. The data are presented in tables or graphs, as appropriate, for simplicity and clarity. The χ² test was used to test associations for categorical variables. The level of statistical significance was set at a p value of <5%. Missing data are noted in the results. We used the Strengthening the Reporting of Observational Studies in Epidemiology cross-sectional checklist when writing our report.¹²

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Results

789 participants assessed the form, of which 4 declined to participate. It was impossible to determine the response rate as the link was widely circulated across several platforms that were out of the authors’ reach. 25 duplicated responses were excluded. These were identified from the email addresses. The total number of valid responses included in the analysis was 760 (figure 1). The mean age of the respondents was 25.84±2.81 years. The age range was between 19 and 43 years. 54.3% (413) were males while 45.7% (347) were females, giving a male-female ratio of 1.2:1. Majority of the respondents were single (90.79%). 485 (63.82%) final-year medical students and 275 (36.18%) house officers completed the form. Table 1 summarises the respondents’ sociodemographic characteristics.

Figure 1. Study flow chart.

Table 1. Sociodemographic characteristics of respondents.

Variable	Frequency (%)
Mean age (years)	25.84±2.81 (19–43)
Sex
Male	413 (54.3)
Female	347 (45.7)
Marital status
Single	690 (90.79)
Married	69 (9.08)
Separated	1 (0.13)
Tribe
Yoruba	276 (36.32)
Igbo	189 (24.87)
Hausa	55 (7.24)
Idoma	22 (2.89)
Igala	19 (2.50)
Ibibio	17 (2.24)
Esan (Ishan)	15 (1.97)
Others	167 (21.97)
Current status
Final-year student	485 (63.82)
House officer	275 (36.18)

The responses were received from 39 medical schools and 52 internship training facilities in Nigeria. 52 (6.84%) respondents trained abroad. China, Ukraine, Sudan and the Philippines were the most common destinations. Of the respondents, 86.8% intended to seek specialist training, 11.2% were undecided and 2% did not intend to specialise. The top five preferred countries of practice were the USA (28.31%), Nigeria (28.31%), the UK (20.20%), Canada (10.81%) and Australia (6.12%) (online supplemental figure 1).

Analysis of the first-choice specialty demonstrated that surgery was the most desired (26.58%), followed by internal medicine (14.47%), obstetrics and gynaecology (14.34%) and paediatrics (6.58%). Academics (basic sciences), radiation oncology and Ear, Nose and Throat (ENT) surgery were the least preferred specialties. Anaesthesia ranked eighth, with only 3.55% of respondents choosing it as their first-choice specialty. When the three choices were summed (cumulative), surgery (16.93%), internal medicine (13.55%), obstetrics and gynaecology (10.83%) and family medicine (8.38%) were the top-ranked specialties while academics (basic sciences), radiation oncology and ENT surgery were still the least preferred. Anaesthesia remained at eighth position with 4.82%. Figure 2 shows the specialty preferences, while figure 3 highlights some factors considered in choosing a specialty.

Figure 2. Specialty preferences of respondents. Each respondent ranked their top three specialty choices in order of preference. The cumulative refers to a summation of all top three career preferences.¹.

Figure 3. Factors considered in choosing a specialty.

Only 35.26% of respondents had career guidance in school, while just 67.03% had researched their chosen specialty. Most respondents (63.95%) chose a career during their clinical rotations (p value<0.01). Only 9.21% had decided on their specialty choice before entry into medical school. Table 2 highlights some of these attributes. More than half of the respondents (57.81%) had a different choice earlier.

Table 2. Contributing factors in choosing a specialty.

Variables	Frequency (%)
Career guidance
Yes	268 (35.26)
No	492 (64.74)
Research on choice
Yes	498 (67.03)
No	245 (32.97)
Timing of decision
Before medical school	70 (9.21)
Preclinical	28 (3.68)
Clinical	486 (63.95)
Housemanship	82 (10.79)
Not certain	86 (11.32)
Undecided	8 (1.05)
Different choice earlier
Yes	422 (57.81)
No	308 (42.19)
Doctor role model
Yes	423 (55.66)
No	337 (44.34)
Doctor parent
Yes	74 (9.74)
No	686 (90.26)

Table 3 summarises the reasons for such changes. Only 55.66% of respondents had doctor role models, while 9.74% had parents who were doctors. There was a significant correlation between the respondents’ first-choice specialty and that of their role models, p<0.01. However, there was no correlation between first-choice and parent’s specialty among those with a physician parent (p=0.996).

Table 3. Reasons for change in specialty preference.

Reasons	Frequency (%)
Interest changed	82.70
Future prospects	55.45
Busy schedule	52.84
Financial prospects	41.47
Availability of training slots	14.21
Family expectations	14.21
Career counselling	13.98
Others	7.11

Perception of anaesthesia posting

Only 37.6% of respondents had heard of anaesthesia before medical school. 4.61% do not/did not do anaesthesia rotation in school. The duration of anaesthesia postings was 2–4 weeks in 87.04% and ≤1 week in 0.28%. Most of those who did not do anaesthesia posting were foreign-trained. A significant proportion (73.59%) enjoyed their anaesthesia posting, while 54.98% felt the exposure was inadequate. Table 4 highlights some of these findings. Onlinesupplemental figures 2 3 highlight what the respondents liked and disliked about their anaesthesia postings, while table 5 summarises what they disliked about anaesthesia as a specialty.

Table 4. Perception of anaesthesia posting.

Variables	Frequency (%)
Prior knowledge of anaesthesia
Yes	286 (37.6)
No	474 (62.4)
Anaesthesia postings
Yes	725 (95.39)
No	35 (4.61)
Duration of postings (weeks)
<1	2 (0.28)
1	10 (1.38)
2	262 (36.14)
3	89 (12.28)
4	280 (38.62)
>4	80 (11.03)
Missing	2 (0.28)
Enjoyed posting?
Yes	550 (80.06)
No	121 (17.61)
Missing	16 (2.33)
Adequate exposure?
Yes	270 (39.30)
No	401 (58.37)
Missing	16 (2.33)

Table 5. Reasons for disliking anaesthesia as a medical specialty.

Reasons	Frequency (%)
Dependence on surgeons	31.32
Lack of recognition by patients	30.92
Minimum contact with patients	27.37
Litigation risk	28.03
Boring	25.26
Risks associated with it	23.68
Inflexible working hours	20.26
Complex and difficult	15.79
Stressful training	9.21
Length of training	6.05
Poor remuneration	5.13
Unpleasant experience with anaesthetist	4.47

Discussion

This study evaluated the specialty preference among final-year medical students and house officers in Nigeria and its implications for anaesthesia practice. The main findings were that surgery, internal medicine and obstetrics and gynaecology were the most preferred specialty. Passion/interest, flexibility, potential future income and job prospects were the major factors considered in selecting a specialty. The most frequent reasons for disliking anaesthesia were dependence on surgeons, lack of recognition by patients, minimum patient contact, litigation risk and the practice being boring.

The mean age of the participants was 25.84±2.81 years, which seems to represent the typical age group of final-year medical students and recent medical graduates.^{3 4 7 13} Aslam et al,¹⁰ however, had slightly younger respondents. We reported a somewhat higher proportion of female respondents compared with previous surveys.^{3 4} This indicates a relatively balanced representation of genders in the sample, highlighting the increasing inclusivity of the medical profession. Unlike most surveys which reported a male preponderance, a Brazilian survey by Guilloux et al¹⁴ reported a slight female preponderance of 52.9%.

Most respondents in this study desire to pursue specialty training, which might be attributable to better job prospects, career fulfilment and creating an academic culture.¹⁵ This is compatible with the findings of Ossai et al⁴ and Oku et al³ in Nigeria and Abdul-Rahman et al⁷ in Ghana which also reported that over 80% of medical graduates desire to pursue specialty training. This high proportion of graduates seeking specialist training calls for urgent action by the government to provide adequate and appropriate training facilities for these graduates.

The top four preferred specialties by final-year medical students and house officers in Nigeria were surgery, internal medicine, obstetrics and gynaecology and paediatrics in decreasing order, while the least preferred specialties were academics (basic sciences), radiation oncology and ENT surgery. This pattern of specialty preferences is similar to that of several other studies,^{3 4 7 10 13} although with slight alterations, implying that career choices are primarily still focused on these four broad medical specialties. Mahfouz et al,¹⁶ in Saudi Arabia, reported a slightly different pattern, with family medicine, ENT surgery and internal medicine as the most preferred specialties. They, however, broke down the different surgical subspecialties as separate options.

Anaesthesia accounted for 3.55% of first-choice specialty in our study, ranking eighth. This finding represents a slight improvement compared with previous surveys in Nigeria, which reported that <3% were interested in anaesthesia.^{3 4} It is also not far-fetched from reports from other climes.^{7 10 16} Kutessa et al,¹³ in a similar survey at Makerere, Uganda, in 2019, reported that none of the final-year medical students considered anaesthesia as their first career.

An analysis of the factors considered in choosing a specialty revealed that passion, that is, interest, experience during clinical rotations, flexible working hours, financial gains, that is, potential future income and future job prospects, were the top five factors considered. About 20% of decisions were influenced by senior colleagues or childhood dreams. These factors are similar to those reported by previous authors.^{3 4 7 16} Of particular importance is that passion/interest remains the major determinant of specialty preference.^{3 4 7 16} This is quite commendable as it is a vital ingredient for excellence. Trends in career choice vary from country to country and even in the same country over time.^{4 7 10} Our study proved this assertion, with over half of the participants changing their preferences within a few years of school or a few months of internship. The reasons for this change include ‘interest changed’, prospects, busy schedules, financial prospects and availability of training slots (online supplemental table 1).

The period of clinical clerkship is a defining moment for many young medical graduates.^{2 4} Unfortunately, a few respondents stated that they do not do anaesthesia rotation in school. Almost three-quarters of our survey respondents made specialty decisions during their undergraduate clinical rotation or internship. The first few years post-graduation is also another critical decision-making period. Manjooran et al,¹⁷ in South Africa, reported that 38.5% of anaesthetists at their facility decided to practice anaesthesia as medical officers. The need for career guidance in medical school has been a subject of great emphasis in many literature.^{4 13 16} However, many Nigerian schools still do not have a formal programme for this, as reflected in our findings.⁴ Kuteesa et al in Uganda and Mahfouz et al in Saudi Arabia reported that about 60% of their respondents had received career counselling, implying that this issue might be a local problem.^{13 16} The influence of role models in selecting what specialty to practice has shown wide variations, from as low as 3.8% to as high as 67.1%.^{3 4 7 16 17} Our study highlights the impact of role models. More than 50% of the respondents had physician role models, and their first-choice specialty was closely matched with the specialty of their role model.

Anaesthesia is still a poorly known medical specialty among Nigerians, as alluded to by Eyelade et al¹⁸ and Ige et al.¹⁹ This fact has been corroborated by the findings of our study in which a significant proportion of respondents had no prior knowledge of anaesthesia before entry into medical school. Anaesthetists need to undertake public awareness campaigns to promote their work. Enjoying a clinical posting does not necessarily translate to selecting it as a specialty choice, as demonstrated by our findings. This fact was also highlighted by Ossai et al,⁴ who reported that though obstetrics and gynaecology was the clinical posting enjoyed most by the students, it ranked third among their preferred specialty of practice. The top five reasons for disliking anaesthesia were dependence on surgeons, lack of recognition by patients, minimum patient contact, litigation risk and ‘boring’. Abdul-Rahman et al also noted that many students complain that anaesthesia was ‘boring and uninteresting’ and was too complex to understand.⁷

The ability to understand and predict a medical student’s choice of specialisation is a complex process.¹⁰ Specialty choice results from a complex inter-relationship of various factors, such as student interests and expectations, the specialty’s future scope, availability of spots in the current workforce and suggestions from the experts, family and social influence.^{16 20} Thus, efforts to improve enrolment in anaesthesia and other poorly desired clinical field must also be multipronged. The literature suggests that specialty choice does not remain stable throughout medical education and medical practice after undergraduate study. The preferences may be refined over the internship period or when they start practising as licensed doctors; hence, there is a need to routinely determine these preferences as it could guide policy formulation.¹³

Limitations

Though this study recruited many respondents from at least 39 medical schools and 56 internship training centres in Nigeria, most responses were from the southern region and north-central geopolitical zone, hence its findings might not be generalisable. We did not evaluate the impact of geopolitical zones on specialty choice. Choice of career preferences was also limited to the primary medical specialties in Nigeria. We also did not examine the role of public/private teaching hospitals on career choices.

Conclusion

Too few medical graduates in Nigeria prefer anaesthesia as a specialty, and there is an urgent need to increase interest. A lack of career counselling, anaesthetist mentors and satisfactory clinical rotations are factors that can be improved for better recruitment into anaesthesia.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.