The unfortunate combination of increasing medical school class size and stagnant numbers of residency slots has created a competitive, stressful environment in which students are often forced to make premature, uninformed decisions about medical specialties and career choice. Yet those decisions are critically important, not only to the student and medical school but also to society at large. In their study on career decisions, Gillie and Isenhour1 made a strong case for “informed and considered” decisions based on the cost to society: “The cost of preparing to become a physician is enormous for both the individual and the public. To protect such an investment (and similar investments in many other occupations), it would be prudent to ascertain career fit before investing substantial time, energy, and resources.”
The value of counseling and advising students on specialty choice has been recognized by the Liaison Committee on Medical Education (LCME), which recently strengthened its career development standard to say,
MS-19. A medical education program must have an effective system in place to assist medical students in choosing elective courses, evaluating career options, and applying to residency programs.
Despite the imperative, MS-19 is one of the most common areas of noncompliance.2 Career counseling often happens outside the formal curriculum, and “until recently most medical schools lacked comprehensive career development programs.”3 There has been some improvement, as noted by Borges4: “Medical schools have been slow to recognize this need, but are beginning to offer structured programming to help students with career decision making.” Improved resources at the national level make it easier to conceptualize and implement career programs locally. With support from the AAMC Careers in Medicine program, medical schools have either begun or expanded their career development programs.3,5 Still, much room remains for medical schools to better address their students' career development and specialty selection.
The Careers in Medicine program admits that “[t]here is no formula for a successful career-planning program. Implementation depends a great deal on the resources and time available to staff and faculty involved in career planning.”6 Many schools continue to feel their way through designing and implementing career development programs. Despite sessions on career development programs offered at annual and regional meetings, there is a paucity of literature on actual programs and activities that medical schools provide their students. Our search of AAMC (CurrMIT and MedEdPORTAL) and library (PubMed/Medline) databases yielded few results. Only two schools have published career development courses in MedEdPORTAL.7,8 The articles we did find often focused on efforts to recruit future physicians into specific specialties.9–13
An educational process that disseminates career information can powerfully improve the decisions students make about specialty choices.1 Ideally, formal career advising would begin the very first week of medical school and take a longitudinal, developmental approach. Making this part of the formal curriculum seems an effective approach, and so in this article, we outline three curricular models that address career development, demonstrating a range of possible programs. Two curricula involve minimal budgets, a critical consideration in the current financial climate. We discuss challenges and lessons learned from implementing each of these programs. Although we have evaluated the curricula and adjusted their content and delivery based on student feedback, we lack IRB-approved data, and so we shall limit ourselves to general thoughts.
Three Career Development Models
Despite the differences in the three models, they share goals designed to help medical students
* possess a clear and stable picture of their goals, talents, values, and interests related to career choices and decision making as influenced by and developed in multiple contexts, and maintain a unique sense of self as a physician;
* identify the realities of serving as a physician in the community, including the impact on one's lifestyle and the integration of a busy career with family life and social endeavors; and
* take advantage of the opportunities and resources available to explore, decide, and implement careers.
These goals draw extensively on the AAMC Careers in Medicine four-stage model of self-assessment, exploration, decision making, and implementation14 and espouse Holland's person–environment theory of career development in an attempt to assist medical students find congruence with the attributes of a specialty (personal communication, Jeanette Calli, Program Manager, Careers in Medicine, AAMC, June 7, 2010).15
Model 1. Simple and less resource-intensive: Career advising in a specialties elective course
One easily sustainable method of medical student career advising is an elective course. First presented in 2005–2006 for first- and second-year students at the Oregon Health & Science University, Specialty Talks offers students the ability to meet the following objectives.
* To assess her/his goals, talents, values, and interests in the context of specific specialties.
* To identify the realities of the various specialties, both professionally and personally.
* To complete the exercises from the AAMC Careers in Medicine program's first two modules: Understanding Yourself and Exploring Options.
Students attend 12 to 14 noontime panel discussions held September through January on a variety of specialties that can be entered directly after medical school (subspecialties are not included).
Organization of the elective.
A second-year student who is a member of the AAMC's Organization of Student Representatives chairs the elective and works with the director of career advising to plan the year's program. Each May, they hold a planning meeting, to which they invite student representatives from all specialty interest groups. Interest groups associated with specialties chosen for the panel discussions invite a faculty member, a resident, a community physician, and a fourth-year student who is applying to that specialty. Every specialty panel answers the same set of predetermined questions to ensure comparability of information.
Requirements for elective credit and evaluation.
Although the presentations are open to all students, those who register for credit must complete questionnaires for 75% of the sessions, submit their results from the AAMC Web site's Medical Specialties Preference Inventory and the Indecision Scale self-assessments, and turn in questionnaire results from two informational interviews with physicians.
The session questionnaire asks,
1. “What surprised you about the specialty?” This question yields helpful information on what students know and do not know about specialties, revealing aspects of the specialties that faculty mistakenly assume students know.
2. “Does this specialty fit your values, interests, skills, and personality? If so, why? If not, why not?” A student's perception about his or her compatibility with a specialty is an important facet of career advising, especially if it is based on misperceptions or lack of assessment. On the other hand, declaring one's attributes and talents in writing can strengthen the student's decision-making process.
A final written evaluation of the elective also is required to gain one elective credit (four elective credits from the first two years may be used for graduation). One of the evaluation questions asks students to rate the value of the elective. In addition to consistently rating it highly, students comment on two perceived benefits: learning details of specialties they never before considered and finding physician advisors in the specialties that interest them. This program's evaluations so far indicate to the elective planning team that the elective should be continued.
This format's major advantage is that it takes only a small time commitment to offer information on a variety of specialties to a large number of students. Several challenges exist. This being an elective course, not all students participate. The student interest group leaders who plan the following year's lineup are limited by time and resources and so are bound to disappoint some students whose areas of interest are not placed on the program. Also, although protected time for Specialty Talks was set aside in the first three years, this has not been the case in subsequent years, and conflicts with other medical school activities have arisen. Attendance for Specialty Talks had been stable, but scheduling is a continuing challenge. Finally, student planners are advised to invite more panel members than are needed because panel members occasionally are delayed or cancel at the last minute.
Model 2. Moderate complexity and resource-intensive: Integrated career development courses
Careers in Medicine course.
For three years beginning in spring 2004, the Virginia Commonwealth University (VCU) School of Medicine offered a second-year Careers in Medicine elective, originally conceived to integrate career planning and advising into the curriculum. Based on an informal needs assessment, the course was developed by curriculum office faculty for second-year students. The course philosophy was to offer personalized career assessment, exploration, and information. The goal was not to leave the course having chosen a specialty but, instead, to acquire effective tools for making an informed choice. The Careers in Medicine elective sessions covered personal assessment, career exploration, the Match, making effective decisions, writing a CV, and topics chosen by the students. To earn credit, students were required to attend all sessions, write and submit a CV, and conduct and report on an informational interview with a physician in a specialty of interest. The 19 students in the program's pilot year represented a range of decisions, from cementing a specialty choice to questioning medicine as a career. On the basis of the pilot's success, the elective was offered for the next three years, and enrollment grew until one-third of the class was taking the course.
Since fall 2006, the Careers in Medicine course has been required for all second-year students and covers the basics taught in the elective: overview of the Match, writing a CV, qualities and qualifications for residency programs, writing a personal statement, and financial considerations for careers. These topics were chosen intentionally as the basic information and skills all students need. Students earn credit based on attending sessions and submitting a CV. The CVs are read by a cadre of faculty who use a standardized checklist to offer each student feedback. Although the sessions occur in a large-group setting, presenters are encouraged to use an interactive format as much as possible. Workshops and panel discussions are used extensively. The spring elective course has been retooled with an increased focus on personal assessment, career choices, and decisions. The AAMC Careers in Medicine program has served as a cornerstone of both the elective and required courses since the beginning, and both courses use a variety of presenters from the School of Medicine, university, and larger community.
Evolving to a fully integrated, longitudinal model.
Because of successful collaboration between student and academic affairs units, the VCU School of Medicine has expanded to offer a comprehensive career development program. After the Careers in Medicine elective began, the student affairs office developed Project HEART (Healing with Empathy, Acceptance, Respect, and inTegrity) to maintain the qualities of compassion and altruism in students. In Project HEART, individual faculty mentor small groups of first- and second-year medical students during the course of each academic year. Meeting several times each semester, the purpose of the Project HEART groups is to foster humanism as students develop their physician identities. Career development activities are woven into the Project HEART sessions, beginning with first-year orientation, when the groups first meet, and continuing with sessions that debrief Careers in Medicine class activities.
During the clinical years, Project HEART groups are much less structured, and formal career development sessions are offered around clinical commitments. Topics include effective career decision making, a detailed follow-up of the Match and residency application processes that previously were covered in the first and second years, information about the Electronic Residency Application Service, the National Resident Matching Program, a review of writing personal statements, and employment interviewing skills. Individual career development activities are tailored to fourth-year students and include personal statement and CV reviews, interviewing practice, and support during the Match and Scramble processes. One activity that spans the first through third years is an annual career fair, held in the spring. This event gives students the opportunity to explore their specialty interests with program directors and community physicians.
Integrating the timing and content of career development with the rest of the curriculum and the humanism program is key to implementing the program to its fullest potential. Careers in Medicine at VCU offers comprehensive career development couched in a humanistic perspective for first- through fourth-year students. Students evaluate the Careers in Medicine courses and the Project HEART program through written or online program evaluations. Because the second-year fall Careers in Medicine is a required course, it is debriefed with student curriculum representatives as part of the school's regular review process. These evaluations are used to improve the content and processes of the integrated programs. This model demonstrates starting with one small course and building from the initial effort.
In a curriculum where getting through each test day drives one's existence, students tend to take a short-term view. Helping students to see beyond the next week, the next month, or even the next year and to view longitudinal career development activities as beneficial has been a challenge. Also, integration of this curriculum has been accomplished with very little financial support, which can be a positive aspect in that collaboration has necessarily been a cornerstone of our efforts. But, in the current economic climate, with the accompanying pressure to increase revenues, it is becoming more difficult to secure faculty volunteers.
Model 3: Complex and resource-intensive: Faculty as frontline career advisors in a doctoring course
In 2005–2006, Northeastern Ohio Universities College of Medicine (NEOUCOM) integrated its career development and advising program into its formal curriculum as a central component of the four-year longitudinal doctoring course. As one of five course themes, professional identity development focuses on career development, lifelong learning skills, and personal wellness. The course goals are met through didactic, self-assessment, experiential, clinical, and reflective activities. Because students are in different stages, the Career Development and Advising Office designs and implements a curriculum that is an independent learning module with a wide variety of curricular and cocurricular experiences that relate to the overarching goals and objectives of professional identity development and specialty choice. NEOUCOM conducts a 360-degree evaluation of the program at the end of each academic year. Feedback from all advisors and students is used to make general improvements to the program and is also shared with faculty advisors to help them improve their interactions with advisees.
Professional development advising teams.
The lynchpin of this curriculum is the professional development advising team (PDAT). These teams offer students the benefit of advice from four perspectives: clinical advice from a practicing physician, academic advice from an administrative staff and/or faculty member, peer advice from an upper-level mentor, and collegial advice from fellow team members. Students interact with their advisors as a team and individually beginning in the first year of medical school.
PDAT meetings and career development tasks.
Clinical PDAT advisors are practicing physicians who lead advising groups and provide direction to individual students, especially related to career choice and orientation to medicine. Students are required to attend two PDAT meetings led by their clinical advisor in their first and second years. The goals of the first-year fall meeting are to orient students to the PDAT concept and review the goals and objectives for the professional identity development curriculum. Students are required to read the “Careers in Medicine Student Guide: Unlocking Your Specialty Choice” and to create their AAMC Careers in Medicine user profiles. The first-year spring meeting goals are to help students plan summer professional development activities, such as research fellowships, service or mission work, and shadowing. This meeting also introduces students to self-assessment and includes a discussion of their Myers–Briggs Type Indicator. In the second year, students continue to work on self-assessment and specialty exploration with their clinical advisors in biannual meetings. Homework assignments include completion of the Medical Specialty Preference Inventory and presentation of a report related to one of the specialties identified on the inventory.
During the third and fourth years, students work with their clinical advisors individually to plan their fourth-year elective schedule, create a residency application plan, and write the summary paragraph of their Medical Student Performance Evaluation. In addition to the required career advising component, students participate in didactic sessions and workshops during the longitudinal doctoring course. Students may participate in extracurricular activities that facilitate their professional identity development.
Self-assessment and goal-setting.
As part of the professional identity development process, students are required to write a self-assessment at the end of each academic year. Students attend a session to learn about the requirements for their annual self-assessment and goal-setting. When writing their first-year self-assessment, students are encouraged to think about how they learn, to review their strengths and weaknesses, and to reflect on what they have yet to learn about their different professional roles. They are also encouraged to develop goals for continuing their professional identity development with specific objectives related to these goals. At the end of their second year, students rewrite their self-assessment and create new goals for their third year; these are reviewed by their clinical advisors.
This program is extremely resource-intensive, requiring a firm commitment from the administration and faculty. The director of career development and advising directs the professional identity development module of the doctoring course and is a member of the course committee. To help defray the cost of their group meetings, clinical faculty receive a small stipend, which comes out of the annual operating budget for the Career Development and Advising Office. Recruiting and training clinical faculty advisors is challenging because of the extensive time commitment. Clinical faculty receive training and commit to meeting with their PDAT teams for approximately 90 minutes twice a year for four years. To counter the burden, clinical advisors are given a great deal of flexibility in the logistics of their meetings and the training sessions are made available in person, online, and through streaming video.
Collective Lessons Learned
The different designs of these three models for instituting career development programming were based on the cultures of the particular medical schools in which they were conceptualized; their successful implementation required differing levels of resources. Resources are a primary consideration when institutions decide what type of career development programming is most feasible. Some programs, such as NEOUCOM's PDAT program, require both a funding stream and human resources, specifically clinical faculty to teach and advise. Other programs, such as Project HEART at VCU School of Medicine and the Specialty Talks elective at Oregon Health & Science University School of Medicine, require little funding but do require dedicated time in the curriculum and committed faculty. Institutions must also consider staffing needs and skills. For example, facilitators of Myers–Briggs Type Inventory assessments must be formally trained and certified by the Association for Psychological Type. In addition, student affairs staff may be qualified to offer medical career advising services, but general career counseling might be best left to the university counseling center.
Schools wishing to institute or expand their career advising programming should conduct a thorough needs assessment, which should include surveying students and an analysis of services offered and gaps to address. The AAMC Graduation Questionnaire is also a useful resource for feedback from students about career advising services, and the AAMC Careers in Medicine program offers support and resources to institutions considering the design and implementation of a career development curriculum. In addition, the LCME has mandated changes, and other opportunities for change may arise during curriculum redesign through student initiatives. Flexibility is key.
Finally, it is important to realize that none of the models presented here sprang up overnight. Each was the result of incremental change, trial and error, and the utilization of opportunities. We suggest neither that these programs are suitable for every institution nor that they should be implemented in their entirety. We hope, however, that they provide a variety of ideas for institutions to consider when implementing a curricular-based career development program.
The authors wish to thank George Richard and Jeanette Calli at the AAMC Careers in Medicine program for their support as the courses and programs were being developed and for their assistance with this article. The authors also wish to thank their schools for the support of these programs as well, especially Paul Hartung and Mark Savickas at NEOUCOM and Chris Woleben at VCU.
Some of this article's content was presented at the June 2007 AAMC Professional Development Conference in Salt Lake City, Utah, and the June 2009 AAMC Professional Development Conference in Savannah, Georgia.