There is a decline in medical student interest in surgical careers in Canada.1–3 Recent data from the Canadian Resident Matching Service (CaRMS) shows a decline in applicants ranking surgical programs as first choice from 28% in 2008 (589/2110) to 21% in 2019 (621/2934).4 This reduction in new trainees may result in an inability to meet the surgical demands of an aging population.5,6
Numerous factors are known to influence students’ career decision-making including gender, perception of lifestyle, prestige, mentorship, and role models, among others. Specifically, gender discrimination and limited early surgical exposure are core factors that negatively influence a student’s interest in a surgical career.7 Student “fit” into the culture of surgery is an additional deterrent to surgical career interest. The culture of surgery has traditionally been described as prolonged work hours, negative impacts on work-life balance and unique patient-interactions in surgery.7 In contrast, early surgical interest, having family or friends practicing in surgery, previous experiences volunteering in sports, and interest in medical over social problems, have been identified as predictors of choosing a career in surgery.8,9
The primary objective of this study was to identify factors associated with pre-clerkship student interest in surgery versus non-surgical specialties. In addition to demographic variables and career-influencing factors as identified by Scott et al., research interest, and residency factors were included to provide a more holistic assessment of medical students interested in surgical disciplines, medical disciplines, or undecided.
Questionnaire Development & Variables
Career factors for the survey were derived from a thorough literature review, with reference to the factor analysis performed by Scott et al. (2011). The survey was revised to ensure clarity and feasibility by three medical students (T.D, S.H, and M.S) prior to survey dissemination. The survey was composed of four sections. The first section of the survey assessed demographics such as gender, age, education level prior to medical school, current marital status, highest level of parental education, parental status, whether the participant had immediate family in medicine, and varsity sport participation. The second section of the survey assessed current career interests (medicine, surgery or undecided) and top-three career choices. The third section allowed participants to rate the importance of career factors using a Likert scale (1-Not Very important, 5-Extremely Important). Thirty-two previously identified career factors were grouped under the following themes: lifestyle, community orientation, prestige, hospital orientation, scope of practice, role model and other (Table 2). A mean score was obtained for each group. New factors to be explored and factors with low internal consistency were kept separate in further analyses.
Using a cross-sectional approach, electronic surveys were distributed to medical students in their first and second year of training at Dalhousie University. At our institute the first two years of teaching are mainly classroom based and are prior to students receiving significant clinical first-hand experience. Opinio (Object Plant, Oslo, Norway) was used to collect anonymous responses over a four-week period. Students were only able to complete the survey once. Informed consent was submitted with survey completion.
All results of the questionnaire were blinded during data analysis using participant specific identifiers. Comparisons between study groups were made using the chi-square test and Fishers exact test when cells were ≤5. Factors associated with current career interests (surgery, medicine or undecided) were evaluated using logistic regression. Multivariate logistic regression was conducted using the enter method, incorporating variables and factors which were significant or near-significant (p≤0.20) on univariate analysis. Based on previous research demonstrating their association with career interests, age and gender were also included in the models.9 Results were considered statistically significant at p-value <0.05. Analyses were conducted using SAS version 9.4.
This study conformed to the guidelines outlined by Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Study approval was obtained through the Nova Scotia Health Authority Research Ethics Board (No. 1023325 & 1023087 for the first-year and second-year class, respectively).
Participant demographics are listed in Table 1. Overall, 107/219 (48.9%) students responded and 66/107 (61,7%) were female, 62/107 (57.9%) were between 20 and 24 years of age and 59/107 (55.1%) were first year medical students. There were 57/107 (52.3%) students that were undecided in their career path. Eighteen students (16.8%) had participated in varsity sports.
When assessing the seven career-influencing factor themes, several trends were identified. Factors allocated to the “Lifestyle” theme were important (mean=3.7 ± SD=0.7) influences on student decisions, which included flexibility, acceptable hours of practice and on-call schedules (Appendix 1). Students also rated “Community Orientation” (3.3 ± 0.7) as an important theme, which included health promotion, long-term relationship with patients, focus on patients in the community, social commitment, and interesting patient population (Appendix 1). “Hospital Orientation” (3.0 ± 0.7) was further rated as an important theme, including a focus on urgent care, a focus on in-hospital care, results of interventions being immediately available, and a preference of medical to social problems. “Prestige” (3.4 ± 0.7) included students’ preferences for careers in which they would have adequate income to eliminate debt and have a stable future. “Role model” (2.7 ± 0.9) appeared to be a factor of a lower significance for most students. Of the other survey items, students were interested in finding a good match career choice for themselves (4.1 ± 0.8) and being well supported in their residency program (3.9 ± 0.9; Figure 1).
On multivariate analysis (Table 2), lower prioritization of an acceptable lifestyle was independently associated with an interest in pursuing a surgical career (OR 0.32 95%CI (0.11-0.91)). Male gender (0.086) was noted to be approaching significance. Older age (OR 10.14 95%CI (2.27-45.28)) and a decreased interest in research (OR 0.27 95%CI (0.27 (0.13-0.60)) were associated with an interest in medical specialties, while controlling for other factors. A community orientation (interest in health promotion, outpatient medicine and longer-term relationships with patients) demonstrated a trend towards significance (p=0.071) of association with the career choice of medical disciplines. Older students (OR 0.20 95%CI (0.06-0.65)) and students in their second year (OR 0.18 95%CI ((0.06-0.54)) were less likely to be undecided in their career choices. Higher scores for lifestyle (valuing acceptable hours of practice, job flexibility and acceptable on-call schedules) closely correlated with reporting an undecided career choice (p=0.055). The factors and demographic variables included in the multivariate models account for the variance in the undecided (34%), surgery (45%) and medicine (50%) models.
In our cohort of medical students who have not yet received clinical hands-on teaching, students valued career factors such as lifestyle, prestige, and being well supported in residency. Recruitment strategies for residency programs to attract medical students may be improved using this data. Specifically, residency programs can utilize this data in career discussions with medical students and elaborate on the career factors deemed most valuable by students interested in the specialty.
Medical Specialty Interest
Both age and decreased interest in research were associated with medical specialty interest, which is reflected in other studies.10,11 Interestingly, student interest in academic medicine has historically been associated with older age.12 It is possible that the students are still attracted to other aspects of an academic career such as teaching, which was not captured here. Additionally, previous research has demonstrated that interest in a career in a medical specialty has been linked with high prioritization of specialty lifestyle,10,13 but this was not evident among our students. The traditional belief that medical specialties carry a good lifestyle may be changing. For instance, one study found that the prevalence of burnout among second-year internal medicine residents is 42.6%.14 This may be due to an increasing prevalence of major chronic disease in Canada,15 but this was not assessed in this study.
Surgical Specialty Interest
Lifestyle is a significant factor in medical student career navigation,16,17 which is reported by our students. However, surgical interest was associated with low prioritization of a lifestyle-related career factors. Other studies have found similar results.7,8,18 Peel and colleagues found that students interested in surgery tend to consider lifestyle as less important when making career decisions, while students not interested in surgery highly valued lifestyle.7 Our study may demonstrate that these beliefs are still prevalent, even in medical students in their pre-clinical years. Furthermore, it may indicate that students who value life-style related career factors are ruling out a career in surgery early on in their teachings, prior to clinical exposure to surgical specialties. This may contribute to a perpetual culture where surgical disciplines are perceived as having a poor lifestyle. While lifestyle can vary across disciplines, pre-clinical medical student perceptions may not accurately represent the demands of a certain specialty or the variety of ways to practice within it. The narrow focus on lifestyle within surgery does not account for other factors of surgical practice and may lead medical students to rule out surgical careers prematurely. To overturn this culture, surgical residency programs should take this into consideration and ensure that accurate, honest work-life balance discussions are held with medical students. Such information sessions are often held in later years of schooling, aimed at attracting medical students with surgical interest to a specific field of surgery. Our findings suggest that information sessions should be held at an earlier stage to better assist pre-clinical medical students plan their careers. Additionally, medical students must ensure that they carefully self-examine each of their career options and determine how their own unique values fit into the work culture prior to ruling them out prematurely.
Undecided Specialty Interest
Half of our students were undecided in their career plans and were closely correlated with a preference for a good lifestyle. To our knowledge, this has yet to be reported and may indicate that students who specifically value a strong work-life balance are delaying choosing a career path in order to closely examine each specialty for the one which best meets their value in this area. This also suggests that a significant portion of medical students value a good “work-life balance”, which is “'the ability to balance work commitments with personal time in which you are able to relax, socialise and pursue extra-curricular interest.”19 This demographic is understudied compared to their counterparts with defined career interests, and more research must be conducted on this population. Residency programs should use this information and not “shy away” from honest work-life balance discussions with medical students.
There are several limitations inherent to this study. Firstly, the data stems from a single institution and conclusions drawn may be affected by inter-institutional variabilities in medical education curricula, research milieu, and level of exposure to various specialties. However, Canadian medical schools are routinely assessed by the Association of Faculties of Medicine of Canada (AFMC) and must meet accreditation expectations set out by the Committee on Accreditation of Canadian Medical Schools (CACMS), therefore a degree of standardisation exists, and these findings can likely be extrapolated to other institutions to some degree. Additionally, career interest was grouped into “medicine,” “surgery,” and “undecided.” The nuances of choosing specialties and sub-specialties that do not fall directly into these categories may not be well reflected. Nonetheless, our findings do provide meaningful data that can be considered when optimizing career exposure and interest in medical students.
This study provides an in-depth analysis of career-related factors of medical students in their pre-clinical years. Our analysis demonstrates that lifestyle-related career factors were less valued in students interested in surgery. Furthermore, students with undecided career interests were highly correlated with a high value of lifestyle-related career factors. This indicates that students may delay career decisions to identify a specialty that matches their ideal work-life balance. Furthermore, it may indicate that students who highly value lifestyle-related career factors are ruling out a career in surgery in their pre-clinical years.
Conflicts of Interest
None to report.
No funding to report.