With our final research question, we looked at the importance of lifestyle compared to income by examining a mixed model ANOVA, which included value (lifestyle versus income) as the within-subjects factor and career specialty as the between-subjects factor. Results revealed a nonsignificant within-subjects effect (p = .949), indicating that the average value placed on lifestyle (2.70 ± .85) did not reliably differ from the average value placed on income (2.72 ± .76). A significant interaction term (p < .001) suggested that this balanced concern with lifestyle and income did not characterize all career specialties. After using a Bonferroni correction to adjust the .05 level of significance to control for family-wise error, we conducted a series of paired samples t tests to compare the value placed on lifestyle versus income within each specialty. As Figure 2 shows, medical students who chose seven specialties were significantly more likely to value lifestyle over income: radiology, physical medicine/rehabilitation, emergency medicine, ophthalmology, psychiatry, family practice, and general pediatrics. Meanwhile, students who chose four specialties were significantly more likely to value income over lifestyle: internal medicine subspecialties, orthopedics, general surgery, and obstetrics–gynecology.
Our data representing lifestyle and income's influences on medical students' career specialty choices show that between 1998 and 2004, both lifestyle and income became increasingly important to the graduating medical students in our study. However, the correlations between year of graduation and lifestyle/income were small, suggesting that recent rises in the importance of lifestyle and income may not be as dramatic as indicated by past work looking at career choice trends in the absence of data assessing students' perceptions of the factors they considered important when selecting a specialty.4
While lifestyle and income became only slightly more important over time to the students in our study, the absolute importance of these two factors (irrespective of time) should not be overlooked. When students were asked to indicate the influence of lifestyle and income, the average rating assigned to both of these factors was higher than 2 on the four-point scale (1 = no influence, 4 = major influence). It is interesting to note that the influence of lifestyle, as compared to income, did not differ significantly for the study group as a whole. However, when we examined specialty careers individually, we found a significant difference in the influence of income versus lifestyle for 11 of the 20 specialties studied.
Our respondents viewed eight specialties as lifestyle friendly: radiology, physical medicine/rehabilitation, emergency medicine, ophthalmology, anesthesiology, urology, dermatology, and otolaryngology. Students who chose each of these eight specialties indicated that lifestyle was significantly more influential in their career choices than did students who chose a number of other specialties. In addition, no other specialty received significantly higher lifestyle ratings than did these eight specialties. To the contrary, students with relatively minor lifestyle concerns tended to choose general surgery and obstetrics–gynecology, specialties considered more lifestyle unfriendly than any of the other 18 specialty choices.
Ten specialties (psychiatry, family practice, neurology, general pediatrics, general internal medicine, plastic surgery, the pediatric and internal medicine subspecialties, combined internal medicine–pediatrics, and orthopedics) were between the extremes, or lifestyle intermediate, as the students viewed them as more lifestyle friendly than some specialties and less so than others. It is of note that we found significant variation within the lifestyle-intermediate group. Both neurology and psychiatry were highly rated and only considered to be less lifestyle friendly than one specialty, radiology. In contrast, students rated three specialties at the lower end of the lifestyle-intermediate group: internal medicine subspecialties, combined internal medicine–pediatrics, and orthopedics. Although students gave these three specialties a low lifestyle rating, they rated them significantly higher than general surgery and obstetrics–gynecology.
While prior studies about the influence of lifestyle have defined controllable lifestyle careers on the basis of the investigators' a priori perceptions,3–5,7 we looked at the perceptions of fourth-year medical students in our study. The data revealed some important differences between the views of these students and the views of investigators published in the literature. First, in our study urology emerged as a lifestyle-friendly career specialty even though past studies have placed it in the uncontrollable-lifestyle category.4 Second, it was of great interest to note that in our study students rated physical medicine/rehabilitation, a specialty not included in prior studies, as the second most lifestyle-friendly specialty. Additionally, our data suggest that in the past investigators' tendency to dichotomize careers into lifestyle-controllable versus lifestyle-uncontrollable categories may have masked important complexities. The data in Table 2 reveal finer gradations and lead to the conclusion that in the eyes of fourth-year medical students, some of the careers typically lumped into the uncontrollable-lifestyle category (e.g., family practice, general pediatrics, general internal medicine) may actually reside between the lifestyle-friendly and lifestyle-unfriendly extremes.
In our study, we defined a lifestyle-friendly career as one that allows leisure time, opportunities to enjoy life outside of work, predictable work hours, time to pursue activities outside of work, and family time. Our definition of “lifestyle friendly” is therefore somewhat different than the definition of “controllable lifestyle” used in past research.7 Recent researchers who have based their work on defining controllable lifestyle as simply control of work hours acknowledged that controllable lifestyle may “capture other less tangible and even less easily quantified influences that ultimately affect lifestyle.”4,p.1,177 Thus, our expansion of the lifestyle construct may provide a useful addition to the literature.
From a practical standpoint, our study can be used to examine a number of the career trends in the medical community. For example, there has been an overall decrease in applications to primary care residencies, but an increase in the applications to medicine and pediatrics subspecialties.11 Because general internal medicine, general pediatrics, combined internal medicine–pediatrics, family practice, and medicine and pediatrics subspecialties were included in our list of potential career choices, our data provide insights into perceptions about ultimate career paths for students entering the primary care residencies. In general, students' perceptions of the primary care fields as a whole were consistent, all clustering in the lifestyle intermediate range. However, careers in internal medicine subspecialties or in combined internal medicine-pediatrics were rated as more lifestyle unfriendly than any of the other generalist specialties. We are unclear why a career in combined internal medicine–pediatrics was viewed less favorably than was a career in either of the two separate specialties, general internal medicine and general pediatrics. Although students rated a career in a subspecialty of medicine or pediatrics as lifestyle intermediate, we realize that this rating may have masked differences in students' perceptions of each of the various subspecialties. It is possible that students viewed one subspecialty, such as endocrinology, as more lifestyle friendly than another one, such as cardiology, thus leading to a mean score within the lifestyle-intermediate range.
Finally, while the analysis of recent changes in career trends has been largely attributed to lifestyle issues,4–6,12 we found that income concerns were also on the rise. As Figure 2 shows, lifestyle and income played distinct roles that varied by chosen specialty. Students entering fields such as orthopedics, general surgery, obstetrics–gynecology, and internal medicine subspecialties were more influenced by income issues than by lifestyle.
Our study had several limitations. First, the sample sizes characterizing certain career specialties were rather small, thereby limiting our power to detect statistically significant mean differences when examining those particular specialties. We took some measures to diminish this concern (i.e., careers chosen by fewer than ten students were dropped from the data set). Nevertheless, we looked at several careers with relatively modest sample sizes (e.g., plastic surgery, otolaryngology). Despite potential power limitations, we chose to include these careers to afford readers the opportunity to examine the ratings associated with these important specialties. Second, we conducted our study at two schools that both emphasize primary care education. Although the emphasis on primary care education may have influenced the absolute numbers of students who chose primary care careers, we do not believe this emphasis affected the relationship between student-rated influences and career choice. Also, the characteristics of the two schools are quite different, and the combined study population had demographic characteristics very similar to national data.8 Third, our results are students' reports of anticipated long-term specialty choice, rather than their actual entry to a preferred residency or fellowship. It is possible that a student stating plans to enter a career, such as a pediatrics subspecialty, would change his or her mind over the three years of a pediatrics residency. Fourth, we used a four-point scale that allowed students to express equal weights for lifestyle and income, if they were so inclined. We are unable to determine which factor would have emerged as the primary factor if respondents were forced to choose between the two. Fifth, we did not determine the accuracy of students' insights into the factors shaping their career preferences. However, choosing among specialties tends to be a very deliberative process; accordingly, we believe students' ratings provide meaningful information about the factors driving their career decisions. Finally, by design in this study we focused on only two factors (lifestyle and income) that influence career choice. We did not investigate the influence of other factors (e.g., altruism, debt, demographic characteristics).
Although recent literature has focused on the influence of lifestyle on medical students' career choices, we found that both lifestyle and income play a notable role. In order to reverse the current downward trend in applications to fields considered lifestyle unfriendly or economically unrewarding, the current models of practice and reimbursement may need to be restructured. Certain specialties have the potential to become more lifestyle friendly, with a reorganization of expected work hours within shared practices or with the increased use of physician extenders. It is possible that the wider use of technology, such as the electronic medical record, may allow some physicians the flexibility to do part of their work at home. Finally, the disparity in reimbursement by specialty for physician services continues to have a major influence on specialty choice. Policymakers need to take these considerations into account as they plan for future workforce needs.
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© 2005 Association of American Medical Colleges
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