Abstract
Background
The distribution of physicians among medical specialties have become increasingly misaligned to population healthcare needs, contributing to global shortages in several surgical fields.
Aims
Our aim was to analyze factors influencing specialty selection among final-year medical students across Türkiye.
Materials-methods
This multicenter cross-sectional study was conducted between May 2018 and July 2022. An anonymous online questionnaire was administered to final-year medical students in Türkiye, collecting data on sociodemographic characteristics, career intentions, and factors motivating or deterring interest in surgical specialties.
Results
A total of 910 final-year medical students (median age: 24, IQR: 23–25) completely filled our survey. Approximately half of the participants reported interest in pursuing a surgical specialty. Male students were more likely to pursue surgery than female students (p < 0.001). Plastic and reconstructive surgery (12.6%) was the most desired surgical field, followed by ear nose and throat (11.4%). More than half of the students who had a surgeon in the family preferred surgical residency. The COVID-19 pandemic was not associated with a change in overall specialty selection but had a significant impact on motivators and deterrents from surgical specialties. The most common factors motivating students to pursue surgical specialties were prestige, high income expectation and dynamic nature of surgical fields, while deterrents were largely structural, including poor work-life balance and gender inequality.
Conclusion
Interest in surgical fields appears to be shaped by a balance between professional rewards and systemic deterrents. Addressing modifiable training- and system-level barriers may be critical to sustaining future interest in surgical careers.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12909-026-09873-6.
Keywords: Surgical career, Türkiye, Medical student, Survey
Introduction
The distribution of physicians across specialties is increasingly misaligned with population needs and shortages in core specialties such as surgery, internal medicine, and pediatrics have increased over the past decade globally [1]. Concurrently, medical students are increasingly drawn to specialties associated with more controllable lifestyles such as dermatology, ophthalmology, and aesthetics surgery. Global projections from the Association of American Medical Colleges estimate a shortage of 13,500 − 86,000 physicians by 2036, including 20,200 − 40,400 in primary care and 10,100 − 19,900 in surgical specialties [2]. While some students pursue their childhood dreams, for many others speciality preference forms during medical school. Specialty choice not only influences one’s career (and life) satisfaction, but can also impact the composition of the healthcare force in the upcoming decades. Declining interest in disciplines such as general surgery have jeopardized healthcare systems [3] as such specialties have largely been associated with rigorous and (often unpredictable) working hours, high risks, and high burnout rates. Many soon-to-be physicians cite factors including predictable hours, work-life balance, high compensation, and professional satisfaction as the main determinants of medical specialty choice, rendering some surgical specialties less desirable. Other factors that influence speciality decision-making include personal or demographic, motivational, and cultural factors. In addition, global trends in education as well as unprecedented challenges of the time can impact career-decision for medical students. Following the COVID-19 pandemic, parameters such as work-life balance and expected income have also become increasingly central to specialty decisions. The pandemic exposed the vulnerability of healthcare systems as many physicians were overworked, leading to widespread burnout [4, 5]. Thus, following the pandemic, a growing number of medical students have shown interest for specialties allowing a greater flexibility of working hours. In contrast, interest in surgical fields has continued to decline owing to extensive hours and poor work-life balance.
Here, we characterize the factors affecting the choice of specialty for final-year medical students between 2018 and 2022 in Türkiye, a country where interest in surgical specialties has decreased significantly over the past decade. Understanding and analyzing the factors deterring students from pursuing careers in surgery can guide the development of better programs in medical school and residency.
Methods
Study design & participants
This study was conducted in accordance with the Declaration of Helsinki, approved by the Institutional Review Board and Ethics Committee of Koc University (2018.119.IRB3.084), and all surveys were completed anonymously and voluntarily (Supplementary Fig. 1). Between 2018 and 2022, final-year medical students in seven medical schools (Koç University School of Medicine, Hacettepe University Faculty of Medicine, Cerrahpaşa Faculty of Medicine, İstanbul University Faculty of Medicine, Ankara University Faculty of Medicine, Gazi University Faculty of Medicine, University of Health Sciences, Gülhane Medical Faculty) across Türkiye were invited to answer a questionnaire about their future careers as residents via an online survey platform (Supplementary Fig. 2). Participants were asked about their preference for a specialty and how they rated the influence of motivational factors on their choice. The online questionnaire was distributed to 1003 final-year students who consented to participate in the study and then received the survey link. Of these 1003 students, 910 students completed the questionnaire in full. The response rate was 91% (N = 910); 52.6% were female students (N = 479), and 47.4% were male students (N = 431).
The questionnaire
The study utilized a structured, self-administered online questionnaire developed following a review of prior studies examining medical students’ specialty preferences and career related decision-making. The questionnaire consisted of 4 domains: (1) sociodemographic and education-related characteristics, (2) career intentions and interest in surgical residency, (3) factors motivating interest in surgical fields, and (4) factors deterring pursuit of surgical fields. Sociodemographic variables and core career intention items (e.g. consideration of surgical residency abroad) were collected using single-choice questions. Academic self-ranking was assessed using pre-defined percentile categories. Motivating and deterrent factors influencing specialty selection were assessed using multiple-response questions, allowing participants to select all applicable options. For students expressing interest in surgical fields, the degree to which specific factors influenced their decision was evaluated using a three-point Likert-type scale (“do not agree”, “agree to some extent”, and “completely agree”). For analytical clarity, deterrent items were grouped into conceptually coherent domains: (1) Workload and work-life balance (e.g., long working hours, number of shifts, lack of post-call rest), (2) Training quality and structure (e.g., insufficient hands-on training, lack of standardization), (3) Legal-financial risk (e.g., malpractice concerns, income-risk imbalance), (4) Workplace culture and hierarchy (e.g., bullying, non-objective hierarchy), (5) Gender inequality, (6) System-level factors (e.g., violence against physicians, surgeon migration abroad), and (7) Educational environment in medical school. Individual item frequencies were retained in the results tables to preserve transparency.
The sociodemographic questions included information such as the age and gender of the students and the presence of a physician or surgeon in their family (Supplementary Fig. 2). The students were asked about the geographical location of their medical schools and the characteristics of their institution (whether it was a foundation or a state university). The students were asked about their motivations for entering medical school, confidence in succeeding on their first Turkish Residency Exam, and aspirations to pursue residency abroad. They were also asked about their interests for surgery and their desired field of further training. Participants who showed no desire to pursue surgical specialties were asked about their reasons to pick non-surgical specialties (one of the 24 reasons for not preferring a surgical field). Those interested in surgery were asked about several factors: at what age they decided to pursue a surgical field, their preferred surgical specialty, whether fellowships or further surgical training was available in their surgical branch, and the requirement for additional mandatory service requirement. They were also asked to compare residency training in Türkiye versus abroad. Finally, those who wanted to choose a surgical specialty were asked why they wanted to choose Surgery, and they were asked to choose the most suitable one from nine different answers.
COVID-19 related survey items and cohort definitions
The core questionnaire remained consistent throughout the study period. Additional items assessing the perceived impact of the COVID-19 pandemic on specialty selection were introduced (Supplementary Fig. 3). Participants were categorized into pre-COVID (academic years prior to March 2020) and post-COVID (March 2020 and onwards) cohorts.
Statistical analysis
Descriptive statistics were utilized to summarize the participating students’ sociodemographic characteristics and school-related variables. Continuous variables were presented as means and standard deviations, while categorical variables were expressed as frequencies and percentages. Chi-square tests were employed to examine associations between categorical variables, including gender differences in career preferences and motivations for entering medical school. A significance level of p < 0.05 was set for all statistical tests. Data analysis was performed using SPSS version 28.0 (IBM Corp., Armonk, NY).
We conducted a multivariable binary logistic regression to evaluate factors independently associated with considering a surgical specialty. Covariates were selected a priori and included age, sex, university type (state vs. foundation/private), perceived academic performance percentile (top 5%, top 10%, top 25%, ≥ 50%), intention to pursue residency abroad, COVID period (pre vs. post), and presence of a surgeon among first- or second-degree relatives. Results are presented as adjusted odds ratios (aORs) with 95% confidence intervals (CIs).
Results
Socio-demographics
Table 1 presents the sociodemographic and school-related characteristics of participating students. The gender distribution shows that 52.6% of the students were female (N = 479) and 47.4% were male (N = 431). Most students (80.2%) were from state universities, while 19.8% were from foundation universities. Additionally, 31.4% of the students reported having a medical doctor in their family, while only 11.2% had a first- or second-degree relative who was a surgeon.
Table 1.
The sociodemographic characteristics and school-related variables of participating students
| Variable | Number (percentage) |
|---|---|
| Gender | |
| Woman | 479 (52.6%) |
| Male | 431 (47.4%) |
| University | |
| Foundation | 180 (19.8%) |
| State | 730 (80.2%) |
| Medical Doctor in the Family | |
| Yes | 286 (31.4%) |
| No | 624 (68.6%) |
| Surgeons in first- or second-degree relatives | |
| Yes | 102 (11.2%) |
| No | 184 (20.2%) |
| Why Did You Enter Medical School? | |
| To help people | 271 (29.8%) |
| High income expectation | 66 (7.3%) |
| Because it is a prestigious profession | 312 (34.3%) |
| Because I thought I could find a job easily | 127 (14%) |
| I entered unintentionally (e.g., environmental pressure) | 62 (6.8%) |
| Other: | 72 (7.9%) |
Results of questionnaire
Table 2 summarizes the results of the questionnaire on career preferences and the impact of COVID-19 on specialty preferences. Notably, 42.9% of students considered specializing abroad, while 52.1% did not. Regarding residency in Surgery, 51% expressed interest, whereas 49% did not.
Table 2.
Results of questionnaire, interest in surgical specialties
| Question | Number (percentage) |
|---|---|
| Are you considering residency abroad? | |
| Yes | 436 (42.9%) |
| No | 474 (52.1%) |
| Are you considering specializing in Surgery? | |
| Yes | 464 (51%) |
| No | 446 (49%) |
| Why not consider specializing in a surgical field? | |
| I don’t want to specialize in any field. | 12 (1.3%) |
| Imbalance of risk ratio according to income and malpractice laws | 252 (27.7%) |
| The idea that the education in Türkiye is insufficient during the residency | 71 (7.8%) |
| Long training period | 27 (3%) |
| Excessive working hours | 284 (31.2%) |
| Excessive number of shifts | 261 (28.7%) |
| Gender inequality | 129 (14.2%) |
| Probability of earning the same or more economic income by expending less effort | 166 (18.2%) |
| Unpredictable working hours | 227 (24.9%) |
| Requires skill | 70 (7.7%) |
| Limited research opportunities | 44 (4.8%) |
| Difficulty advancing in academic medicine | 49 (5.4%) |
| I don’t have a role model | 28 (3.1%) |
| Anxiety about not having time for family and hobbies | 250 (27.5%) |
| Minimal clinical exposure during clerkships/ rotations (e.g. did not get to scrub in for surgeries) | 19 (2.1%) |
| Practical training was insufficient during my surgical internships | 43 (4.7%) |
| Non-objective surgical hierarchy | 235 (25.8%) |
| Negative education conditions and bullying in surgical internships | 275 (30.2%) |
| Fewer open surgeries due to the lack of new technologies such as laparoscopy and robots in the hospital | 12 (1.3%) |
| Lack of standardization of surgical residency | 95 (10.4%) |
| Increasing violence against doctors in Türkiye | 160 (17.6%) |
| Resignation of surgeons in our country, leaving the profession or moving abroad | 118 (13%) |
| The lack of the right not to work after the night shift in surgical branches | 195 (21.4%) |
| If you continue your surgical education in an institution abroad, do you think you will receive education in better conditions compared to institutions in Türkiye? | |
| Yes | 291 (62%) |
| No | 173 (38%) |
Survey participants who expressed hesitation about specializing in a surgical field listed various reasons for their reluctance, as shown in Table 3. A notable 31.2% expressed concern about the demanding nature of the profession, citing excessive working hours. Also, a significant portion (30.2%) pointed out difficulties in educational and workplace environments among specialties, voicing problems related to the lack of educational opportunities and bullying in surgical residency.
Table 3.
Specialty choice of students expressing interest in surgery
| Specialty of choice | Number of students |
|---|---|
| Neurosurgery | 46 (5.1%) |
| Pediatric Surgery | 18 (2%) |
| General Surgery | 90 (9.9%) |
| Thoracic Surgery | 10 (1.1%) |
| Ophthalmology | 75 (8.2%) |
| Obstetrics and Gynecology | 72 (7.9%) |
| Cardiovascular Surgery | 40 (4.4%) |
| Ear, Nose Throat Diseases | 104 (11.4%) |
| Orthopedics and Traumatology | 59 (6.5%) |
| Plastic, Reconstructive and Aesthetic Surgery | 115 (12.6%) |
| Urology | 39 (4.3%) |
Perspectives on continuing their surgical training at a foreign institution also showed variation with 32% of the respondents expressing that they believed receiving surgical training abroad would provide them with better learning conditions compared to institutions in Turkiye. A majority of students showed interest in surgical fields because they believed surgery enabled patients to experience a faster resolution of problems. The second most important factor motivating students to pursue surgery was the dynamic and fast-paced nature of surgical fields. Prestige and the idea that patients respect surgeons more than other physicians as well as high-income expectations were other factors commonly impacting the decision to pursue surgical residency.
Table 4 lists the surgical fields that students plan to specialize in. Plastic, Reconstructive, and Aesthetic Surgery was the most desired residency among participants who intend to specialize in a surgical discipline, with 12.6% of participants indicating their interest for the field. Following that, Ear, Nose, and Throat (ENT) surgery ranked second with a selection rate of 11.4% among the participants, while General Surgery secured the third position with a selection rate of 9.9%.
Table 4.
Factors influencing the surgical career preferences of participant students planning future careers in surgery
| Statements | Do not agree | Agree to some extent | Completely agree |
|---|---|---|---|
| High income expectation | 64 (15%) | 244 (52%) | 156 (33%) |
| Prestigious specialty and patients respect surgeons more than other physicians | 84 (18%) | 194 (42%) | 186 (40%) |
| To address the existing gender inequality | 275 (59%) | 121 (26%) | 68 (15%) |
| Dynamic and fast-paced nature of surgery | 46 (10%) | 161 (34.7%) | 257 (55.4%) |
| Presence of a role model in medical school | 130 (28.2%) | 199 (42.8%) | 135 (29%) |
| Faster response of patients to treatments | 38 (8.3%) | 111 (23.9%) | 315 (67.8%) |
| Surgical illness for me or one of my family members | 356 (76.7%) | 74 (15.9%) | 34 (7.3%) |
| İncreased use of developing technologies in surgical fields | 109 (23.4%) | 205 (44.3%) | 150 (32.3%) |
| Academic expectation | 106 (22.8%) | 237 (51.2%) | 121 (26%) |
Gender and career preferences
The survey results provided insight into gender differences among medical students based on various factors (Table 5). A majority of both male and female students are first-generation doctors: 32.6% of female students and 30.2% of male students have a medical doctor in their family (p = 0.45). 43.1% of male students report having family members in surgical fields, compared to only 29.5% of female students (p = 0.017).
Table 5.
Socio-demographics of participating male and female students
| Variable | Number of Female students | Number of Male students | Total number of students | p-value |
|---|---|---|---|---|
| Medical Doctor in the Family | ||||
| Yes | 156 (32.6%). | 130 (30.2%) | 286 (31.4%). | 0.45 |
| No | 323 (67.4%) | 301 (69.8%) | 624 (68.6%). | |
| Surgeons in first- or second-degree relatives | ||||
| Yes | 46 (29.5%) | 56 (43.1%) | 102 (11.2%) | 0.017 |
| No | 110 (70.5%) | 74 (56.9%) | 184 (20.2%) | |
| Why Did You Enter Medical School? | ||||
| To help people | 180 (37.6%) | 91 (21.1%) | 271 (29.8%) | < 0.001 |
| High income expectation | 19 (4%) | 47 (10.9%) | 66 (7.3%) | |
| Because it is a prestigious profession | 155 (32.4%) | 157 (36.4%) | 312 (34.3%) | |
| Because I thought I could find a job easily | 56 (11.7%) | 71 (16.5%) | 127 (14%) | |
| I entered unintentionally (e.g., environmental pressure) | 27 (5.6%) | 35 (8.1%) | 62 (6.8%) | |
| Other | 42 (8.8%) | 30 (7.0%) | 72 (7.9%) | |
| Are you considering residency abroad? | ||||
| Yes | 234 (48.9%) | 202 (46.9%) | 436 (42.9%) | 0.55 |
| No | 245 (51.1%) | 229 (53.1%) | 474 (52.1%) | |
| Are you considering specializing in Surgery? | ||||
| Yes | 220 (45.9%) | 244 (56.6%) | 464 (51%) | 0.01 |
| No | 259 (54.1%) | 187 (43.4%) | 446 (49%) | |
| If you are continuing your surgical education in an institution abroad, do you think it is a better training center compared to the institutions in Türkiye? | ||||
| Yes | 138 (62.7%) | 153 (62.7%) | 291 (62.7%) | 0.99 |
| No | 82 (37.3%) | 91 (37.3%) | 173 (37.3%) |
Differences across genders are also evident in motivations for entering medical school. More female students (37.6%) than male students (21.1%) pursue medicine to help people, while more male students (36.4%) compared to female students (32.4%) are attracted to medicine due to its prestigious nature (p < 0.001 ). 45.9% of female students and 56.6% of male students are interested in specializing in surgery (p = 0.01).
Table 6 compares career preferences between male and female students. Gender-based data on preferred surgical specialties among medical students reveals different trends in career goals. Among the surgical branches most preferred by female students are Obstetrics and Gynecology (OBGYN) (27.7%), followed by ENT (25%), and Ophthalmology (20.9%). In contrast, for male students, Plastic, Reconstructive, and Aesthetic Surgery emerges as the most popular specialty (29.5%), followed by General Surgery (18.4%), and Orthopedics and Traumaology (18.4%).
Table 6.
Residency preferences of students expressing interest in surgery
| Specialty | Number of Female Students | Number of Male Students | Total number of students |
|---|---|---|---|
| Neurosurgery | 20 (9.1%) | 26 (10.7%) | 46 (5.1%) |
| Pediatric Surgery | 13 (5.9%) | 5 (2%) | 18 (2%) |
| General Surgery | 45 (20.5%) | 45 (18.4%) | 90 (9.9%) |
| Thoracic Surgery | 7 (3.2%) | 3 (1.2%) | 10 (1.1%) |
| Ophthalmology | 46 (20.9%) | 29 (11.9%) | 75 (8.2%) |
| Obstetrics and Gynecology | 61 (27.7%) | 11 (4.5%) | 72 (7.9%) |
| Cardiovascular Surgery | 21 (9.5%) | 19 (7.8%) | 40 (4.4%) |
| Ear, Nose Throat Diseases | 55 (25%) | 49 (20.1%) | 104 (11.4%) |
| Orthopedics and Traumatology | 14 (6.4%) | 45 (18.4%) | 59 (6.5%) |
| Plastic, Reconstructive and Aesthetic Surgery | 43 (19.5%) | 72 (29.5%) | 115 (12.6%) |
| Urology | 5 (2.3%) | 34 (13.9%) | 39 (4.3%) |
Tables 7 and 8 represent factors influencing specialty preferences for male and female students. The most common factors among female students include a strong emphasis on patients’ immediate response to treatments (76.4%), a desire to avoid a monotonous work life (67.8%), and patients’ appreciation of the prestige associated with Surgery (38.7%). Similarly, male students’ motivations are patients’ immediate response to treatments (72.4%) as a driving force for pursuing a surgical career, followed by the dynamic and fast-paced nature of surgery. Additionally, male students show great interest in high-income expectations in surgical fields (49.3%). On the contrary, both male and female students cited excessive working hours, high risks, surgical hierarchy, and undesirable working conditions as factors deterring them from pursuing surgical fields. A high proportion (44%) of female students also cited gender inequality as a factor deterring them from pursuing surgery.
Table 7.
Factors influencing speciality choice for students expressing interest in surgical fields
| Statements | Number of Female Students | Number of Male Students | Total number of students |
|---|---|---|---|
| High income expectation | 45 (22.6%) | 111 (49.3%) | 156 |
| Prestigious specialty and patients respect surgeons more than other physicians | 77 (38.7%) | 109 (48.4%) | 186 |
| To address the existing gender inequality | 66 (33.2%) | 2 (0.9%) | 68 |
| Dynamic and fast-paced nature of surgery | 135 (67.8%) | 122 (54.2%) | 257 |
| Presence of a role model in medical school | 70 (35.2%) | 65 (28.9%) | 135 |
| Faster response of patients to treatments | 152 (76.4%) | 163 (72.4%) | 315 |
| Surgical illness for me or one of my family members | 16 (8%) | 18 (8%) | 34 |
| Increased use of developing technologies in surgical fields | 61 (30.7%) | 89 (39.6%) | 150 |
| Academic expectation | 53 (26.6%) | 68 (30.2%) | 121 |
Table 8.
Factors deterring students from pursuing surgical fields for participating not expressing interest in surgical fields
| Statements | Number of Female Students | Number of Male Students | Total number of students |
|---|---|---|---|
| I don’t want to specialize in any field. | 2 (0.8%) | 10 (5.3%) | 12 (1.3%) |
| Workload and work-life balance | |||
| Long training period | 11 (4.2%) | 16 (8.6%) | 27 (3%) |
| Excessive working hours | 159 (61.4%) | 125 (66.8%) | 284 (31.2%) |
| Excessive number of shifts | 147 (56.8%) | 114 (61.0%) | 261 (28.7%) |
| Uncertain working hours | 133(51.4%) | 94 (50.3%) | 227 (24.9%) |
| The likelihood that I will not be given the right to not work after my 24-hour on-call shift | 107 (41.3%) | 88 (47.1%) | 195 (21.4%) |
| Anxiety about not having time for family and hobbies | 156 (60.2%) | 94(50.3%) | 250 (27.5%) |
| Training quality and structure | |||
| The idea that the education in Türkiye is insufficient during residency | 34 (13.1%) | 37 (19.8%) | 71 (7.8%) |
| Lack of standardization of surgical residency | 57 (22%) | 38 (20.3%) | 95 (10.4%) |
| Requires skill | 45 (17.4%) | 25 (13.4%) | 70 (7.7%) |
| Legal and financial risk | |||
| Imbalance of risk ratio according to income and malpractice laws | 147 (56.8%) | 105 (56.1%) | 252 (27.7%) |
| Probability of earning the same or more economic income by expending less effort | 88 (34%) | 78 (41.7%) | 166 (18.2%) |
| Workplace culture and hierarchy | |||
| Non-objective hierarchical order | 137 (52.9%) | 98 (52.4%) | 235 (25.8%) |
| Limited research opportunities | 20 (4.8%) | 24 (12.8%) | 44 (4.8%) |
| Difficulty advancing in academic medicine | 25 (9.7%) | 24 (12.8%) | 49 (5.4%) |
| Gender inequality | |||
| Gender inequality | 114 (44%) | 15 (8%) | 129 (14.2%) |
| System-level factors | |||
| Increasing violence against doctors in Türkiye | 97 (37.5%) | 63 (33.7%) | 160 (17.6%) |
| Resignation of surgeons in our country, leaving the profession or moving abroad | 71 (27.4%) | 47 (25.1%) | 118 (13%) |
| Educational environment in medical school | |||
| I don’t have a role model | 17 (6.6%) | 11(5.9%) | 28 (3.1%) |
| Minimal clinical exposure during clerkships/ rotations (e.g. did not get to scrub in for surgeries) | 14 (5.4%) | 5 (2.7%) | 19 (2.1%) |
| Practical training was insufficient during my surgical internships | 25 (9.7%) | 18 (9.6%) | 43 (4.7%) |
| Negative education conditions and bullying in surgical internships | 161 (62.6%) | 114 (61.0%) | 275 (30.2%) |
| Fewer open surgeries due to the lack of new technologies such as laparoscopy and robots in the hospital | 7 (2.7%) | 5 (2.7%) | 12 (1.3%) |
Surgical vs. nonsurgical career
The data presented in Table 9 compares the perspectives of individuals considering specializing in surgical fields with those who prefer nonsurgical specialties. The presence of a surgeon in first- and second-degree relatives does not seem to influence specialty selection (p = 0.13). Similarly, having a medical doctor in the family did not significantly impact the student’s choice for surgical versus non-surgical specialty selection (p = 0.41). Main motivations for starting medical school differed significantly between the two groups (p = 0.01). Those considering a surgical residency are more likely to be motivated by the prestige associated with the profession (36.9%) compared to their colleagues without a desire to major in Surgery (31.6%). In multivariable analysis (Table 10), male sex was independently associated with higher odds of considering a surgical specialty (aOR 1.56, 95% CI 1.19–2.04; p = 0.001). Factors such as age, sex, university type (state vs. foundation/private), perceived academic performance percentile (top 5%, top 10%, top 25%, ≥ 50%), intention to pursue residency abroad, COVID period (pre vs. post), and presence of a surgeon among first- or second-degree relatives did not demonstrate an independent association with considering a surgical specialty after adjustment.
Table 9.
Characteristics of students pursuing surgical vs. non-surgical specialties
| Variable | Number of students interested in surgical fields | Number of students interested in non-surgical fields | p-value |
|---|---|---|---|
| Are you considering residency abroad? | |||
| Yes | 226 (48.7%) | 210 (47.1%) | 0.62 |
| No | 210 (47.1%) | 236 (52.9%) | |
| Surgeons in first- or second-degree relatives* | |||
| Yes | 60 (42.9%) | 42 (28.8%) | 0.13 |
| No | 80 (57.1%) | 104 (71.2%) | |
| Medical Doctor in the Family | |||
| Yes | 140 (30.2%) | 146 (32.7%) | 0.41 |
| No | 324 (69.8%) | 300 (67.3%) | |
| Why Did You Enter Medical School? | |||
| To help people | 140 (30.2%) | 131 (29.4%) | 0.01 |
| High income expectation | 34 (7.4%) | 31 (7%) | |
| Because it is a prestigious profession | 171 (36.9%) | 141 (31.6%) | |
| Because I thought I could find a job easily | 45 (9.7%) | 82 (18.4%) | |
| I entered unintentionally (e.g., environmental pressure) | 32 (6.9%) | 30 (6.7%) | |
| Other | 41 (8.8%) | 31 (7%) |
* This item was asked only if the respondent reported a medical doctor in the family; therefore analyses for “surgeons in first- or second-degree relatives” include only those students (restricted denominator; surgical-interest group: n = 140, non-surgical group: n = 146)
Table 10.
Multivariable logistic regression for factors associated with considering a surgical specialty (N = 910)
| Predictor | Reference category | aOR (95% CI) | p-value |
|---|---|---|---|
| Age (years) | - | 0.95 (0.86–1.06) | 0.386 |
| University type (Foundation/private vs. State) | State university | 0.98 (0.69–1.41) | 0.932 |
| Intention to pursue residency abroad (Yes vs. No) | No | 0.92 (0.71–1.20) | 0.534 |
| COVID period (Pre vs. Post) | Post-COVID | 0.85 (0.61–1.17) | 0.317 |
| Surgeon among 1st/2nd degree relatives (No vs. Yes) | Yes | 0.72 (0.47–1.10) | 0.129 |
| Perceived academic rank (overall) | — | — | 0.589 |
| Top 10% vs. Top 5% | Top 5% | 1.00 (0.63–1.58) | 0.988 |
| Top 25% vs. Top 5% | Top 5% | 1.16 (0.78–1.73) | 0.462 |
| ≥50% vs. Top 5% | Top 5% | 1.26 (0.84–1.88) | 0.271 |
| Sex (Male vs. Female) | Female | 1.56 (1.19–2.04) | 0.001 |
Model summary: Omnibus χ²=16.32 (df = 9), p = 0.061; −2LL = 1244.85; Cox–Snell R²=0.018; Nagelkerke R²=0.024
PreCOVID vs. postCOVID
The data presented in the survey also provides the opportunity to observe possible changes in the participating students’ sociodemographic characteristics and school-related variables in the pre- and post-COVID periods (Table 11). Considering residency abroad, there is a marginal increase in the percentage of students interested in pursuing residency abroad in the post-COVID period (49.3%) compared to the pre-COVID period (43.9%); the difference is not statistically significant (p = 0.14). A similar trend is observed in the consideration of surgical residency: 50.4% in the post-COVID period compared to 52.7% in the pre-COVID period (p = 0.53). There is a subtle change in terms of the perception of better education abroad: While 68.8% believed in better conditions in the pre-COVID period, this rate was 60.5% in the post-COVID period (p = 0.1), which is not statistically significant.
Table 11.
The sociodemographic characteristics and school-related variables of participating students prior to and following the COVID-19 pandemic
| Statements | Number of students (pre-COVID) | Number of students (post-COVID) | p-value |
|---|---|---|---|
| Are you considering residency abroad? | |||
| Yes | 104 (43.9%) | 332 (49.3%) | 0.14 |
| No | 133 (56.1%) | 341 (50.7%) | |
| Are you considering residency in Surgery? | |||
| Yes | 125 (52.7%) | 339 (50.4%) | 0.53 |
| No | 112 (47.3%) | 334 (49.6%) | |
| Surgeons in first- or second-degree relatives | |||
| Yes | 60 (42.9%) | 42 (28.8%) | 0.13 |
| No | 80 (57.1%) | 104 (71.2%) | |
| If you continue your surgical education in an institution abroad, do you think you will receive education in better conditions compared to institutions in Türkiye? | |||
| Yes | 86 (68.8%) | 205 (60.5%) | 0.1 |
| No | 39 (31.2%) | 134 (39.5%) |
A comparison of factors affecting students choosing surgical careers between pre- and post-COVID periods reveals notable motivation changes (Table 12). More students were motivated by high-income expectations in the post-COVID (40.8%) period compared to the pre-COVID period (24.3%). Similarly, surgeons’ desire for prestige and recognition increased from 35.9% to 46.4%. On the other hand, the importance attributed to academic expectations experienced a significant decrease, falling from 26.4% before COVID-19 to 7.9% in the post-Covid period. Despite these changes, the dynamic and fast-paced nature of surgery remained the most common factor influencing students’ career choices and remained unchanged between the pre-COVID and COVID periods.
Table 12.
Factors influencing career preferences in students expressing interest in surgical fields prior to and following the COVID-19 pandemic
| Statements | Number of students (pre-COVID) | Number of students (post-COVID) | Total number of students |
|---|---|---|---|
| High income expectation | 25 (24.3%) | 131 (40.8%) | 156 (20.4%) |
| Prestigious specialty and patients respect surgeons more than other physicians | 37 (35.9%) | 149 (46.4%) | 186 (20.4%) |
| To address the existing gender inequality | 17(16.5%) | 51 (15.9%) | 68 (7.5%) |
| Dynamic and fast-paced nature of surgery | 66 (64.1%) | 191 (59.5%) | 257 (55.4%) |
| Presence of a role model in medical school | 36 (35%) | 99 (30.8%) | 135 (14.8%) |
| Faster response of patients to treatments | 73 (70.9%) | 242 (75.4%) | 315 (34.6%) |
| Surgical illness for me or one of my family members | 7 (6.8%) | 27 (8.4%) | 34 (7.3%) |
| More use of developing technologies in surgical fields | 36 (31.1%) | 114 (27.7%) | 150 (16.5%) |
| Academic expectation | 32 (26.4%) | 89 (73.9%) | 121 (13.3%) |
Comparing the most critical factors influencing students’ decisions not to specialize in a surgical field between the pre-and post-COVID periods highlights notable changes (Table 13). The most prominent factor in both periods was “Excessive working hours”; this rate increased from 52.7% before COVID to 67.4% post-COVID. Another important change was observed in the “Risk imbalance rate according to income and malpractice laws” factor. While this factor was 42% in the pre-Covid period, it increased to 61.4% in the post-Covid period.
Table 13.
Factors deterring students from pursuing surgical fields for participating not expressing interest in surgical fields prior to and following the COVID-19 pandemic
| Statements | Number of students (pre-COVID) | Number of students (post-COVID) |
|---|---|---|
| I don’t want to specialize in any field. | 5 (4.5%) | 7 (2.1%) |
| Workload and work-life balance | ||
| Long training period | 6 (5.4%) | 21 (6.3%) |
| Excessive working hours | 59 (52.7%) | 225 (67.4%) |
| Excessive number of shifts | 56 (50%) | 205 (61.4%) |
| Uncertain working hours | 52 (46.4%) | 175 (52.4%) |
| The likelihood that I will not be given the right to not work after my 24-hour on-call shift | 0 | 195 (58.4%) |
| Anxiety about not having time for family and hobbies | 3 (2.7%) | 25 (7.5%) |
| Training quality and structure | ||
| Imbalance of risk ratio according to income and malpractice laws | 47 (42%) | 205 (61.4%) |
| Lack of standardization of surgical residency | 0 | 95 (28.4%) |
| Requires skill | 22 (19.6%) | 48 (14.4%) |
| Legal and financial risk | ||
| The idea that the education in Türkiye is insufficient during residency | 19 (17%) | 52 (15.6%) |
| Probability of earning the same or more economic income by expending less effort | 31 (27.7%) | 135 (40.4%) |
| Workplace culture and hierarchy | ||
| Non-objective hierarchical order | 51 (45.5%) | 184 (55.1%) |
| Limited research opportunities | 15 (12.5%) | 29 (10.5%) |
| Difficulty advancing in academic medicine | 14 (12.5%) | 35 (10.5%) |
| Gender inequality | ||
| Gender inequality | 35 (31.3%) | 94 (28.1%) |
| System-level factors | ||
| Increasing violence against doctors in Türkiye | 0 | 160 (47.9%) |
| Resignation of surgeons in our country, leaving the profession or moving abroad | 0 | 118 (35.3%) |
| Educational environment in medical school | ||
| I don’t have a role model | 17 (6.6%) | 11(5.9%) |
| Minimal clinical exposure during clerkships/ rotations (i.e. did not get to scrub in for surgeries) | 2 (1.8%) | 17 (5.1%) |
| Practical training was insufficient during my surgical internships | 6 (5.4%) | 37 (11.1%) |
| Negative education conditions and bullying in surgical internships | 66 (58.9%) | 209 (62.6%) |
| Fewer open surgeries due to the lack of new technologies such as laparoscopy and robots in the hospital | 0 | 12 (3.6%) |
Discussion
The study addresses gaps in the literature regarding specialty preferences and motivations for pursuing surgical specialties in final-year Turkish medical students. This also presents a rare opportunity to compare career choices and motivations across genders. The impact of sociodemographic factors, including familial backgrounds, on career preferences were also compared. Furthermore, this study examines the effects of the COVID-19 pandemic on students’ career decisions in view of the interface of global events and individual career aspirations.
Motivators and deterrents of surgery
Our survey results provide valuable insights into final-year Turkish medical students’ demographic characteristics, motivations, and career preferences, highlighting many important issues. Motivators were predominantly intrinsic and professional including faster patient response times, the dynamic nature of surgery, perceived prestige, and high income expectations. In contrast, deterrents were largely systemic and structural, centering around workload intensity, lack of work-life balance, malpractice risk, and negative training environments. These findings aligned strongly with findings from literature where academic interests, controllable lifestyles, mentors, career opportunities, income, and prestige have been identified as factors influencing specialty selection [6]. Importantly, this divergence suggests that declining interest in surgery may be driven less by the nature of surgical work itself but rather on modifiable training and health-system factors, highlighting opportunities for targeted educational interventions. Accordingly, interventions aimed at optimized training environments and strengthening mentor-mentee relationships may support medical student interest in surgical fields. In our cohort, Plastic, Reconstructive and Aesthetic surgery was the most frequently selected surgical specialty. This could be explained by students’ perception that plastic surgery can combine high prestige, high earning potential, procedural variety, predictable work-life balance. Several studies in literature have also identified that students are drawn to stimulating and flexible careers, qualities they commonly associate with plastic surgery [7, 8]. Many surgical specialties inherently possess procedural variety and high prestige, however, earning potential as well as training and workplace environments differ significantly among specialties. Student interest in other surgical fields can be supported by implementing structural changes and enabling high earning potential, more flexible career pathways, and stronger work-life balance in various less-desired surgical specialties.
Gender and career choices
The gender distribution among medical students reveals a balanced representation, with 52.6% identified as female and 47.4% as male. This aligns with existing literature on gender distribution in medical education [9]. However, our study found a statistically significant difference between male and female students’ preference for surgery as a career. Female students were less likely to prefer surgery than male students, raising questions about whether certain aspects of surgery appeal to males or if external factors influence this gender distribution [10].
Our results align with other findings in literature. Global studies have also shown that women are significantly underrepresented in surgical specialties. Significant gender disparities seen in fields like orthopedics and general surgery, with women comprising 22% of general surgeons in the US and 18% in the UK [11–13]. Such trends have been explained partly by societal gender norms and expectations as well as implicit and explicit biases from clinicians, educators, and patients [14]. Despite female surgeons having fewer post-operative complications, studies have shown that women earn significantly less than men in surgery [15, 16]. In addition, unequal distribution of home obligations, disproportionate funding, pay gaps, higher rates in mistreatment, less surgical autonomy during residency and fewer opportunities in senior leadership has historically deterred women from pursuing surgical fields [17]. In our study 44% of females compared to 8% of males listed gender inequality as their reason for not pursuing surgical fields. Both females and males listed long working hours, high risk nature, and lower work-life balance as other factors deterring them from pursuing surgery.
Our results also showed that there were some gender differences in the surgical specialties preferred by students. For example, OBGYN is the most preferred specialty among female students, and this is similar to the study done in an Australian medical school [18]. The results that more female students than male students choose OBGYN can be explained by the fact that the number of female doctors in these specialties has consistently been higher than male doctors for years [19]. These trends could be explained by several factors. Women could have more same-sex mentors, motivating their interests to pursue OBGYN. Male medical students in OBGYN rotations more commonly report being excluded from clinical opportunities and may have less clinical exposure, thereby leading to lower interest for the field [20].
Influence of having a relative in medicine and surgery
Our survey shows gender differences in familial background among medical students. Although the likelihood of a family history of being a medical doctor is similar for both male students and female students, a significant disparity emerges when it comes to surgeons in first- or second-degree relatives. A higher percentage of male students (43.1%) reported having surgeon relatives compared to female students (29.5%), and this difference was statistically significant (p = 0.017). This could suggest that potential mentors in surgical fields may direct male students toward surgical career paths. The influence of role models within the family, particularly in surgical fields, could be a critical factor in shaping career goals [10]. Contrary to prior studies suggesting a positive correlation between having a surgeon in the family and pursuing a surgical specialty after medical school, a statistically significant difference was not observed in our cohort. This disparity might reflect a contextual shift in student priorities in choosing a specialty where a greater emphasis is placed on work-life balance, predictable schedules, and workplace environment. Implementing enforceable weekly-hour limits and guaranteed post-call rest may directly address some work-life balance concerns deterring students from pursuing surgical fields.
The data presented also provides the opportunity to compare the perspectives of individuals considering specializing in surgical fields with the perspectives of those who prefer nonsurgical specialties. According to our survey results, there is no significant difference between the two groups, whether one of their family members is a non-surgical physician or surgeon. In contrast, other studies in literature have shown that both having a surgeon in the family and having a family member from medicine have statistically significant effects on choosing surgical specialities [10]. Additionally, the significant difference in motivations for starting medical school (p = 0.01) between those considering surgical and nonsurgical residency is important. This indicates that intrinsic motivations to choose medicine as a profession significantly vary and could be a key factor in the decision-making process for future surgical professions.
Pre-COVID vs. post-COVID
The COVID-19 pandemic marked an important event in medical history, exposing the fragility of healthcare systems and shifting perceptions about specialty selection. Understaffed healthcare systems compelled physicians into working extended hours under immense psychological burden [4, 5]. The increased burnout rate among physicians during and following the pandemic revealed the poor work-life balance in medicine, prompting many medical students to place a greater emphasis on achieving a greater work-life balance in their future career. Although the COVID-19 pandemic has widely been discussed as a driver of shifts in medical specialty selection, our findings suggest that its impact was more pronounced on motivational factors than on overall specialty choice. Despite the lack of statistical significance, our findings suggest a consistently high level of interest in pursuing residency abroad among medical students in Türkiye, alongside a prevailing perception that training opportunities outside Türkiye may offer advantages. These advantages could include perceptions of local training conditions, work-life balance concerns, and economic considerations among other factors. Notably, this perception appears to have modestly declined in the post-COVID-19 period, which may reflect evolving views on global training systems or increased confidence in local training environments.
While the proportion of students interested in surgical specialties did not differ significantly between pre- and post-COVID cohorts, analysis of factors influencing students’ surgical career choices highlighted a significant increase in the importance of high-income expectations and the desire for prestige among surgeons post-COVID period. This aligns with studies from Great Britain and countries from West Africa and Middle East [21–23]. Conversely, the diminishing importance of academic expectations leads to the consideration of shifting priorities, as also reported by previous studies [24, 25]. Similarly, the notable increase in the “risk imbalance rate under malpractice laws” shows evolving concerns, signaling potential shifts in social and economic impacts. As stated in the literature, both results demonstrate that the COVID-19 pandemic significantly impacted career choice, career perspective, and ideal workplace [26–28]. However, regardless of the COVID-19 pandemic, lack of a monotonous work life remained an important factor motivating final-year students to pursue surgical fields. Excessive working hours and poor work-life balance were some of the most important factors deterring students from surgical fields both in the pre- and post-COVID periods, consistent with previous literature [28, 29]. Notably, poor work-life balance and long, unpredictable hours have been cited as the primary deterrents across literature for years. It has been well established that chronically overworked residents face higher burnout rates, discouraging future physicians from pursuing surgical fields.
Türkiye-specific context
Türkiye-specific deterrents, particularly violence against physicians and emigration of surgeons (and physicians), emerged as prominent concerns influencing medical student decisions. Rising incidents of violence against healthcare workers have been documented in Türkiye and globally and an increased number of doctors in Türkiye have emigrated to other countries in the past few years [30, 31]. With 47.9% and 35.3% of students expressing concern regarding the increased violence and emigration of doctors, respectively, in the post-COVID period, our results demonstrate that outward migration and concerns over safety might reinforce negative perceptions regarding professional security, training continuity, and long-term career prospects (Table 13). In our cohort, perceptions of non-objective surgical hierarchy also emerged as a prominent deterrent to pursuing careers in surgery, reflecting concerns about fairness and transparency within training environments. While hierarchical structures are inherent to surgical environments globally, their perceived lack of objectivity may be particularly prominent in the context of Türkiye. Considered alongside other system-level challenges such as workplace violence and physician migration, this finding may suggest that the organizational structure and training conditions play a critical role in shaping medical student decisions. Enhancing transparency, accountability, and mentorship within surgical hierarchies may present a potential point for intervention in surgical training.
Limitations
Our study has certain limitations. The cross-sectional design makes it more difficult to prove a relationship between the factors investigated and career decisions. The lack of standardized quantitative data has limited our analysis. For instance, reliably recorded working-hour data is inadequate and unmeasured overtime further restricts our ability to quantitatively assess the impact of workload on specialty preference. Due to the concise design of the questionnaire, certain factors influencing specialty choice such as perceived personal fit and preference for procedural work were implied but not explicitly assessed. Because the sample is restricted to final-year medical students in Türkiye, self-reported data may be prone to response biases and not generalizable to other populations. Furthermore, regional variations within Türkiye were not considered, which could impact career decisions because of different local circumstances. In order to establish a solid understanding of medical students’ career choices, future research should incorporate longitudinal studies, a wider range of diverse student samples, and more thorough assessments of contributing factors. In addition, data collection was achieved using a self-administered questionnaire. Responses may have been influenced by social desirability bias, with participants potentially overreporting socially valued motivations or underreporting stigmatized concerns related to specialty selection. Although the survey was anonymous, this bias cannot be fully excluded and should be considered when interpreting the findings. Finally, the questionnaire was not validated using psychometric methods. Although it was developed based on a review of prior literature and major domains examined in studies exploring medical specialty selection, the absence of formal validation may limit precision and generizability of results. Finally, the lack of more recent data beyond 2022 limits our ability to assess the longer-term impact of the COVID-19 pandemic on specialty preferences.
Conclusion
In conclusion, this comprehensive study on the surgical specialty preferences and motivations of final-year Turkish medical students fills a critical gap in the existing literature by providing a multifactorial analysis of demographic characteristics, familial influences, and motivational factors that shape their surgical career choices. This study also highlights post-COVID shifts in career considerations. Findings reveal actionable points of structural intervention in medical education and training. Policy measures ensuring safer and more sustainable working conditions, transparent training pathways, and early mentorship opportunities can help improve perceptions of surgical careers.
Supplementary Information
Acknowledgements
The authors would like to thank all participants who took part in the study.
Authors’ contributions
Study conception and design (IHO, EsB, OA). Data acquisition (EsB, ErB, ZED, YOS, YYY, ES, KB, HOU, SC, OM, BS, OO, RG, OYT). Data analysis (SNK, MK, ST, EO, EBo, AR, EB). Interpretation (SNK, AEN, BTD, DY). Manuscript drafting (IHO, DY, SNK). Critical revision (IHO, EO, EBo, AR, EB, OA).
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Data availability
The datasets analyzed during the study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by the Institutional Review Board and Ethics Committee of Koc University (approval code: 2018.119.IRB3.084). Informed consent was obtained from all participants prior to participation in the online survey (Supplementary Fig. 1).
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets analyzed during the study are available from the corresponding author on reasonable request.