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Vol. 53, No. 1, January 2007, pp.94 - 95 Copyright © 2007 by The College of Family Physicians of Canada
Why medical students switch careersChanging course during the preclinical years of medical schoolIan Scott, MD and Margot C. Gowans, M NUT DIETTeacher and researcher in the Department of Family Practice at the University of British Columbia in Vancouver.
Bruce Wright, MD
Fraser Brenneis, MD
Correspondence to: Dr Ian Scott, UBC Department of Family Practice, Suite 300, 5950 University Blvd, Vancouver, BC V6T 1Z3; telephone 604 827-4194; fax 604 822-6950; e-mail ian.scott{at}familymed.ubc.ca In North America, the number of medical students choosing family medicine as a career is steadily declining. The proportion of students choosing residency in family medicine has fallen in Canada from a high in the early 1990s of 44% to only 25% in the Canadian Residency Match in 2003, the lowest percentage ever.1 In the United States, the proportion of students matching to careers in family medicine has fallen from a high of 72.6% in 1996 to 40.7% in 2005, the lowest percentage ever.2 Several factors have been identified as being associated with students’ choosing generalist careers. Premedical factors include stated career preference on entry to medical school and several demographic factors.3–10 Some specific medical school factors also mediate or alter early career preferences; these factors range from the amount of time devoted to family medicine in the curriculum to the effects of role models.9,11–23 Many of these studies on premedical and medical school factors associated with career choice have been criticized for being biased and having design weaknesses and inconsistencies in both dependent and independent variables.14 Many were carried out in the 1990s before the recent decline in interest in family medicine. As well, the groups studied were in the United States where the definition of primary care is different from the definition in many other nations.22 The literature indicates that students enter medical school with a preference for primary care careers, but this preference changes over time.24–26 Much work has been done on the role of clinical experiences in career choice, but little attention has been paid to the influence of the preclinical years on career choice. This study aimed to determine the demographic and student-identified reasons for switching career preferences during the preclinical years of medical school.
Setting The University of British Columbia, University of Alberta, University of Toronto, University of Ottawa, Queen’s University, and the University of Western Ontario have 4-year preclinical programs. The University of Calgary and McMaster University have 3-year preclinical programs.
Subjects
Procedure
Questionnaire
Data analysis All statistical analyses were performed using SPSS 11.5. Ethical approval for the study was obtained from the research ethics boards of the participating universities.
In September 2001, 2002, or 2003, 1188 (89.9%) of 1321 eligible students completed the entry questionnaire and listed their top 3 career choices. About 2 years later, on completion of their preclinical training, 872 of the 1188 students who had responded to the initial survey responded to the follow-up questionnaire for a response rate of 73.4%. Of these 872 respondents, 27 failed to indicate career preferences on one or both surveys, leaving 845 responses for analysis. About 58.6% of these 845 students were female. Ages ranged from 18 years to 49 years, with a mean age of 23.9 years. Most (71.7%) of the students were single. Nearly all (92.9%) of the 830 students listing their undergraduate training held Bachelor of Science or similar degrees. Most students (76.3%) reported that their most educated parent had a university degree. There were no statistically significant differences in sex or relationship status between students staying in family medicine and students switching to or from family medicine. Students staying in family medicine were significantly older than students switching to (P = .001) or from (P = .007) family medicine. About 19.6% (166 students) changed their top career choices to a specialty or to family medicine (Figure 1); 88 switched to family medicine, and 78 switched to a specialty, for a net increase of 10 students to family medicine. Of the remaining 679 students who did not change their career choices, 542 maintained an interest in 1 of several specialty careers, and 137 maintained an interest in family medicine.
At medical school entry, 215 (25.4%) of the 845 students who answered both entry and follow-up questionnaires listed family medicine as their first career choice. This number rose to 225 (26.6%) at the end of the pre-clinical years. Of the 88 students who named specialties as their preferred careers at entry but changed these preferences to family medicine at follow-up, 68 (77.3%) had named family medicine as either a second or third choice on entry. Of the 78 students who named family medicine as their first choice of career on entry but changed preferences to a specialty at follow-up appointments, 40 (51.3%) had named that specialty as either a second or third choice on entry. Factor analysis demonstrated that all but 1 of the 30 questionnaire items influencing change in career preferences could be grouped into 7 factors (Table 1). Students switching to family medicine rated the importance of 6 of these 7 factors differently from those switching to specialties (Table 2). The influence of both medical lifestyle and ease of residency entry were rated higher by students who switched to family medicine than by those who switched to specialties (P < .0005). The influence of economics or politics (P < .0005), competence or skills (P < .0005), positive clinical exposure (P = .001), and encouragement (P = .031) was rated higher by students who switched to specialties than by those who switched to family medicine. The relative importance of a factor to a student choosing to switch careers can be inferred from the mean Likert score reported.
Students come to medical school with careers in mind or have personal characteristics that predict their career choices.3 The stability of these choices, however, is unclear. Some investigators have found that only 20% of students enter the exact specialty they planned at entry to medical school.29 Others have found that career preferences at entry can substantially affect eventual career choice,30 particularly for those whose initial career interests are in primary care specialties (family medicine, pediatrics, and internal medicine).22,30–32 Results of this study were consistent with these findings of broad career stability. Only 19.6% of students changed their top career choices (broadly defined as a specialty career or a family medicine career) at the end of their preclinical years. While many studies show a trend toward waning interest in primary care among medical students,4,25,26,33 our study showed little change in interest in family medicine during the preclinical years (1% increase). This study found that students who switch careers during their preclinical years identify 7 factors that influence them to change their careers: medical lifestyle, encouragement, positive clinical exposure, discouragement or negative clinical exposure, economics or politics, competence or skills, and ease of residency entry. All except encouragement and discouragement or negative clinical exposure showed a difference of >.5 points on a 5-point Likert scale between those switching to family medicine and those switching from it (Table 2). Medical educators should focus on these factors when helping students make career choices during the pre-clinical years. Various factors were identified as being the most important influences on change in career preference. Medical lifestyle was the most important factor for those switching to family medicine and positive clinical exposure was the most important factor for those switching to specialties. It is heartening that "lifestyle" is not associated with negative perceptions of a career in family medicine; items in the factor "lifestyle" ranged from happy residents and more flexibility to a shorter residency and changing family and location needs. It should be encouraging to medical educators that students did not identify discouragement by teachers and negative clinical exposure as important influences on career changes. It appears that even during the preclinical years students are greatly influenced by clinical experiences. This might have implications for how schools structure clinical experiences during the preclinical years. Those interested in promoting family medicine as a career or those concerned with how students make career choices need to recognize that different factors appear to affect students switching to and from family medicine. Although it is a relatively small influence on career switching, students switching to specialties viewed the factor "economics or politics" as significantly more important than those switching to family medicine did. This should concern family medicine educators. This study highlights the perceived negative effects of health care reform, perceived potential future income, and a possible inability to change residencies as important factors in changing career choices from family medicine to a specialty in the preclinical years. The fact that students who participated in this study were from Ontario, British Columbia, and Alberta, where health care reform is currently under way, might indicate that some of the intended positive aspects of primary health care reform are not interpreted as such by students. The effect of economics or politics on career switching to a specialty has not been described elsewhere. Although it also has a relatively low influence on career switching, the factor "ease of residency entry" was viewed as significantly more important by students switching to family medicine and should, therefore, be of concern to family medicine educators. This study suggests that the availability of family medicine residency positions might entice students who think they will have difficulty being accepted into other residencies to pursue careers in family medicine. The influence of ease of residency entry on career switching to family medicine has not been described elsewhere. Given that most medical students who switch their career choices from family medicine to specialties have considered their new careers at medical school entry, we would recommend that governments, the profession, and undergraduate medical educators provide balanced, unbiased information to students in an effort to allow them to make more informed career decisions during both preclinical and clinical training.
Strengths of the study
Limitations
Conclusion
We thank the students who gave their time and insight to this study and our colleagues at the participating medical schools for their hard work distributing and collecting surveys. We also thank Gina Ogilvie and Leah Douglas for their skilled assistance with editing and Marika Dauberman and Jill Carney for their assistance in preparation of this manuscript.
This article has been peer reviewed. Drs Scott, Wright, and Branneis, and Ms Gowans conceived and designed the study, gathered and analyzed the data, and prepared the manuscript for submission. None declared
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