Primary care (PC) is an essential part of an effective health care system in the United States,1,2 yet experts predict a deficit of 45,000 PC physicians by 2020.3,4 Although some of the basis for this shortfall is well characterized, the fact that PC physicians have the highest rates of burnout and career dissatisfaction among all physicians5,6 may contribute to fewer medical graduates choosing to enter PC in favor of other specialties.7 Furthermore, an aging population and enhanced access to health care following the implementation of the Affordable Care Act will increase the demand for PC.3,4 Understanding the factors that lead students away from careers in PC is necessary for developing solutions that will promote the expansion of the PC physician workforce which will, in turn, begin to address the emerging mismatch between the nation’s increasing health care demands and the physician supply.
Specialty selection is multifactorial and influenced by a medical student’s values, his or her experiences, and characteristics of the specialty.8,9 A model by Bland et al 8 describes determinants of PC specialty choice and serves as a conceptual framework to help understand the complexity of specialty selection that takes place during medical school. According to this model, student characteristics, medical school characteristics, and students’ perceptions of specialties all influence graduating medical students’ decisions to select or reject careers in PC.8
In two prior studies, investigators tracked the specialty choices of medical students from, respectively, the classes of 198310 and 200311 throughout medical school. Both studies found that students were more likely to consider PC careers early in training and then progress toward more specialization by the end of medical school. In the 10 years since the most recent study,11 cultural, political, and demographic shifts have continued to change the health care landscape; as such, the factors affecting first-year medical student career choice merits reexamination.
Since the time of the study of students in the class of 1983,10 graduating students’ perceptions of specialties—and, more specifically, of their perceptions of lifestyle—have become the focus of much research, as students are increasingly interested in pursuing controllable-lifestyle specialties instead of PC.12–16 These studies focused primarily on fourth-year students12,17–19; therefore, the academic medicine community does not know when aspects of specialty choice become important during a student’s training.
The threefold purpose of this study is (1) to evaluate how first-year students value different domains of lifestyle, (2) to describe the importance of different specialty characteristics that first-year students anticipate considering when choosing their specialty (hereafter, “specialty characteristics”), and (3) to determine whether the relative importance of these domains and characteristics varies by interest in PC.
We hypothesize (1) that first-year students considering PC will rate the importance of lifestyle domains and specialty characteristics differently than students not considering PC and (2) that students will rate the importance of these domains and characteristics differently on the basis of their individual demographics.
Participant selection and sampling frame
This is a cross-sectional study of first-year medical students from the following 11 MD-granting medical schools during the first four months of the 2012–2013 academic year: Warren Alpert Medical School of Brown University; Jefferson Medical College of Thomas Jefferson University; Medical University of South Carolina; Northeast Ohio Medical University; Uniformed Services University of the Health Sciences; University of California, San Francisco, School of Medicine; University of Chicago Pritzker School of Medicine; University of Colorado School of Medicine; University of Miami Miller School of Medicine; University of Washington School of Medicine; and Yale School of Medicine. We selected medical schools to represent a broad national sample with diversity in geography, ownership (public versus private), National Institutes of Health funding ranking,20 research ranking,21 and social mission ranking.22
We obtained either approval or exemption from each school’s institutional review board. We invited all first-year medical students (N = 1,704) from participating schools to complete a questionnaire hosted electronically on www.surveymonkey.com.23 We sent two reminders to nonresponders prior to the closing of the survey (six weeks after it was initially available). We used a raffle as an incentive to participate at all institutions except Uniformed Services University, which was ineligible because of school regulations.
Questionnaire development and content
We initially developed the 31-item questionnaire based on a literature review12–14,17,19 and on our own experiences as medical students and educators. Through interviews with premedical students, medical students, and medical student career advisors, we refined items for clarity, ease of response processing, reduction of respondent burden, and inclusion of all necessary items. Figure 1 demonstrates the conceptual framework for the survey. We developed answer choices so as to avoid collecting identifying information. We piloted the final electronic version with premedical undergraduate students to ensure question clarity, survey readability, and appropriate visual appearance (Supplemental Digital Appendix 1, http://links.lww.com/ACADMED/A148).
The first section of the questionnaire asked students to indicate what they would most likely select as their specialty choice if they “had to choose today.” This section also asked students to select as many as three additional specialties they might be considering, and to identify any specialties (as many as three) that they are least likely to choose. Final questions in this section ask students about their exposure to their current most likely specialty choice prior to entering medical school.
The next section related to lifestyle. First, the questionnaire prompted students to provide a free-text definition of a “good lifestyle.” Then, the questionnaire asked respondents to rate the importance of five domains of a good lifestyle (“financial compensation,” “having control of work schedule,” “having enough time off work,” “enjoying the work environment,” and “enjoying the type of work I am doing”) using a five-point Likert-type scale (1 = not important at all, 2 = slightly important, 3 = moderately important, 4 = quite important, and 5 = extremely important). We based these domains on four student-described themes (schedule control, off-time, financial considerations, and work life) identified in a qualitative analysis of what characterizes “a good physician lifestyle.”19 To better define “work life,” we divided this theme into domains of “enjoying the type of work” and “work environment.”14,15,19,24
Then, the questionnaire asks students to rate, using the same five-point Likert-type scale, characteristics frequently considered when selecting a specialty. We identified 21 such specialty characteristics through a review of prior studies.12–14,19,25 All 21 had previously been used to evaluate how fourth-year students select their specialty.12–14,19,25
The final section of the questionnaire queried students about their demographic, educational, and financial history. Questions asked students to indicate their level of debt and their exposure to volunteer work, research, and the health care field through employment and/or personal experience.
Using previously established definitions,1,6 we classified family medicine, general internal medicine, and pediatrics as PC. We grouped all participants into one of five PC interest categories based on their specialty considerations: PC-first students selected PC as the most likely specialty; PC-second students selected PC as an additional specialty but not as the most likely specialty; PC-mixed students selected a PC specialty as a first or second choice as well as a least likely choice; PC-least students selected PC as a least likely specialty; and no opinion students did not select PC in any category (see Table 1).
We made comparisons among the five PC interest categories using, as appropriate, either chi-square or one-way analysis of variance (ANOVA). We conducted post hoc testing using the Bonferroni multiple comparison test. We determined significance as P ≤ .05, and we classified our calculated effect sizes as small (0.2–0.5), medium (0.5–0.8), or large (>0.8) per convention.26 For lifestyle domains and specialty characteristics with moderate or large effect sizes by PC interest, we used linear regression to control for educational and demographic characteristics. We used STATA version 11.2 (STATA Corporation, College Station, Texas) to conduct our analyses.
Of the 1,704 eligible students, 1,020 completed (60%) the questionnaires. Not all students answered all questions, resulting in numbers less than 1,020 for the denominators for some questions. Table 2 shows the demographics of our survey population in comparison with national demographic data of the 2012 matriculating medical student class.27
Importance of lifestyle domains
Of the five lifestyle domains, students rated “enjoying the type of work I am doing” highest in importance to having a good lifestyle as a physician (mean importance 4.8, standard deviation [SD] 0.6), while they rated “financial compensation” lowest (mean 3.2, SD 0.9). Similarly, most students (61%, 586/969) chose the “type of work I am doing” as the most important of the five domains, and only a few (1%, 13/969) chose “financial compensation” (see Table 3).
Of these five domains, only “financial compensation” differed significantly by PC preference (see Table 4). As interest in PC decreased, the importance of “financial compensation” increased; the mean for importance of “financial compensation” for PC-first students was 2.8 (SD = 0.8), whereas the mean for PC-least students was 3.7 (SD = 0.8) (F 36.04, P < .001 [ANOVA], effect size 1.0). We detected no significant differences in the other four lifestyle domains by PC categories (P > .05, ANOVA).
Importance of specialty characteristics
The ratings for the 21 characteristics that respondents anticipated considering when selecting a specialty ranged from extremely important to slightly important (see Table 5). The highest-rated characteristic was “being satisfied with the job” (mean importance 4.7, SD 0.5), followed by “having time to spend with family” (mean 4.5, SD 0.7), “having a balance between work life and personal life” (mean 4.5, SD 0.7), and “having an enjoyable work day” (mean 4.5, SD 0.6). The lowest-rated characteristics were “research opportunities” (mean 2.6, SD 1.3), “perceived prestige of the field” (mean 2.4, SD 1.1), and “availability of practice locations in rural locations” (mean 2.0, SD 1.1). Of these 21 characteristics, 9 were rated differently by PC interest (ANOVA P < .05 and Bonferroni multiple comparison test P < .05).
Most (i.e., 17) of the differences between PC-first and PC-least had a small effect size (0.2–0.5), but 2 had a medium (0.5–0.8) and 2 had a large effect size (>0.8). “Opportunities to work with underserved populations” had the largest effect (0.98); mean PC-first rating was 3.8 (SD 1.2) compared with 2.6 (SD 1.2) for PC-least students. Similarly, “average salary earned by attending physicians in the specialty” had a large effect (0.94) between PC-first (mean 2.7, SD 0.9) and PC-least students (mean 3.6, SD 0.8). PC-first students rated “perceived prestige of the field” lower than PC-least students (mean 2.1, SD 0.9 versus 2.9, SD 1.2, respectively; effect size 0.73). PC-first students rated “availability of practice locations in rural areas” (effect size 0.64) higher than PC-least students (mean 2.4, SD 1.3 versus 1.7 SD 1.1, respectively).
Effect of demographics and education
To We performed a linear regression analysis to determine whether educational history or demographic characteristics attenuated the medium and large effect sizes for the one domain (“financial compensation”) and the four characteristics (“underserved populations,” “attending salary,” “perceived prestige,” and “rural practice”) and PC interest. For all five of these, we detected slight attenuation (e.g., for the financial compensation domain the effect size of between PC-first and PC-least fell from 0.98 to 0.82), but the interpretation of the effect size (medium or large) was unchanged. Of the educational and demographic characteristics (age, gender, race/ethnicity, time elapsed from undergraduate to medical school, physician parent/s, premedical school debt, and anticipated medical school debt), only “underserved populations” had a moderate or large effect size (data not shown). When we controlled for PC interest, only African American students (effect size 0.77) and Hispanic students (effect size 0.57) gave more importance to this characteristic than Caucasian students. In addition, those with any anticipated medical school debt (effect size 0.31) and women (effect size 0.31) were also more likely to support “underserved populations.”
Previous work12,13,17,19 has described how graduating medical students’ attitudes affect their ultimate specialty choice, but when these attitudes develop remains unclear. This multi-institutional study is the first to describe (1) what first-year medical students consider important for a good lifestyle, (2) which lifestyle domains and specialty characteristics are important in choosing a PC or non-PC career at the beginning of training, and (3) how these domains and characteristics correspond to the demographics of first-year students who consider PC as a specialty. When asked to rank the five domains of a good lifestyle, an overwhelming majority of first-year students in our study, regardless of interest in pursuing PC, selected “enjoying the type of work I do” as the single most important domain. Conversely, the smallest percentage of students selected “financial compensation.” These findings support prior studies showing that fourth-year students consider factors other than finances and control of work hours as determinants of a good lifestyle.13,14,17
The importance of the five domains that defined a good lifestyle differed very little by interest in practicing PC, with the exception of “financial compensation.” Although financial compensation was only moderately important to all first-year students, it was significantly less important to students selecting PC as first choice compared with students with no opinion or those identifying PC as a specialty they are least likely to pursue. This inverse relationship between the importance of financial compensation and interest in practicing PC aligns with findings previously described in studies of fourth-year students.8,17,28
Of the 21 characteristics first-year medical students might consider when selecting a specialty, the most notable differences between the PC-first group and all other groups were in their ratings of opportunities to work with the underserved and their interest in practicing in rural areas; the largest difference was between, specifically, the PC-first and PC-least groups. This finding echoes prior research showing that fourth-year students who have matched into PC specialties have a desire to work with underserved populations and to practice in rural areas.29 Salary, research, and prestige were less important to the PC-first than the PC-least group, findings also supported by the literature.8,17 These findings suggest both that PC-first students may have different long-term career goals than PC-least students and that they are, perhaps, motivated more by service to others than by prestige and financial compensation. These findings support prior work showing that students matching into PC were influenced more by social compassion values than were students entering other specialties.29 Although time for family and balance between work and personal life were important to all first-year students, these specialty characteristics were significantly more important to PC-first students. This finding is similar to those reported in studies of fourth-year students which show that work–life balance is important to those pursuing a PC career at all stages of training.13
Overall, students with higher debt and female students were more likely to value working with the underserved. These demographic subgroups may be driven by a commitment to provide health care for the underserved, and some students may be more willing to assume greater debt to do so. Prior studies have shown that underrepresented minorities30 and students from rural backgrounds31 often enter school with more debt and are more likely to practice in underserved areas.
All students, regardless of PC interest, valued job satisfaction, enjoyable work, and intellectual stimulation along with time to spend with family, work–personal life balance, and time for self. First-year medical students thus strive to achieve career fulfillment through engaging in meaningful work while still attending to their projected needs outside work.32 Fourth-year medical students similarly considered life both at work and outside of work when choosing a specialty,17–19 suggesting that the quest for professional fulfillment is sustained through medical school.
Control of work characteristics (e.g., predictability of work hours, schedule flexibility, frequency of call) were of moderate importance to all students and did not differ by PC interest. In contrast, prior studies of fourth-year students showed that these students considered control of work to be important in their decision to pursue PC.14,19 One possible explanation is that as students become increasingly exposed to the non-patient-care aspects of PC, such as paperwork and insurance, control of work becomes a more important factor leading students away from PC.
This study had limitations. First, the sampling frame did not include international or osteopathic medical schools; however, given the diversity of schools and the large sample size, these results are likely generalizable to all U.S. MD-seeking students. Second, standard survey biases, such as nonresponse bias and social desirability bias, may have influenced respondents.33 Still, the response rate of 60% was reasonable, and missing data were few, as more than 92% of respondents provided data for each item. Overall, the population closely matched most aspects of a national reference group (see Table 2); the only exception was that our sample had less debt. Further, the survey was anonymous, encouraging honest responses. Third, although we developed the survey using the literature and our previous work in this area, some of our possible responses were based on data from a previous survey of graduating students,12–14,17,19 and a portion of our questionnaire was based on a survey of students with military obligations19; thus, some items may have been misunderstood. For example, first-year students without prior exposure to medicine may not comprehend what is involved in “call” or other aspects of physician work. Finally, differences in the relative importance of lifestyle domains between first-year students in this study and those of graduating students in previous studies may be the result of a cohort effect rather than from changes in the conceptualization of lifestyle that occur during medical school training. Following this cohort of students longitudinally may help to clarify if and when preference values change during medical school.
There are several implications to our findings. For first-year students, financial compensation and work hours were less important considerations than enjoying work. This finding demonstrates that students’ perception of a good lifestyle as a physician is not necessarily about more money for less work. “Enjoying work” was the most important lifestyle domain, suggesting that the primary initial motivation for medical students in choosing a specialty is to ultimately engage in meaningful work. Approximately half of the queried students (57%) considered PC as their first or second choice, an encouraging number until one realizes that only about half of the students who initially consider PC ultimately choose it and that even fewer who do not initially consider PC ever switch into it.11 It is quite likely that strong informal curricular factors—such as role modeling of and messaging from residents and attendings; chatter among peers; and strong subspecialty emphasis from preclerkship faculty—influence students’ decisions. If medical school experiences dissuade students from entering PC, rethinking models of health care delivery and the practice of PC may be important for ensuring that it is enjoyable and sustainable for physicians.
Understanding the role of lifestyle in students’ specialty considerations at the beginning of medical school provides an opportunity for comparing the role of lifestyle later, such as when they select their specialty at the end of medical school. Future work comparing these two points in time could elucidate the extent to which perceptions of specialty and lifestyle change during training. Qualitative analysis of the questionnaire’s open-ended responses will add richness and depth to this analysis. In addition, further examination of the survey data can help us to understand the impact of factors such as school mission and funding on student lifestyle values. Future studies examining what determines a “positive work environment” and “enjoyable work” will help the community to better understand how students can attain professional fulfillment through careers in PC.
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