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Research Article

Factors Motivating Medical Students in Selecting a Career Specialty: Relevance for a Robust Orthopaedic Pipeline

Rao, Raj D. MD; Khatib, Omar N. MD; Agarwal, Arnav MD

Author Information
Journal of the American Academy of Orthopaedic Surgeons: July 2017 - Volume 25 - Issue 7 - p 527-535
doi: 10.5435/JAAOS-D-16-00533

Abstract

The factors that play a role in any medical student’s selection of a career specialty are complex and poorly understood. The role of the demographic characteristics of a medical student, and how demographic characteristics interact with the medical school experience in affecting career specialty selections, are also unclear. However, it is clear that some population groups remain underrepresented in orthopaedic surgery. Whereas women accounted for 7% of all medical graduates in 1965,1 they now make up 50% of matriculants into medical schools.2 Although the representation of female trainees in several surgical specialties has kept pace with women’s rate of entrance into medical schools,3 a substantial gender gap remains among orthopaedic trainees.4 Women accounted for 7.5% of orthopaedic trainees in 1998, with a modest increase to 14.5% in 2011.5 The gaps in African American and Hispanic representation among medical students and orthopaedic trainees are even more pronounced. Whereas African Americans and Hispanics make up 13.3% and 17.6% of the US population, respectively,6 they each account for 7.1% and 6.3% of matriculants into medical schools, respectively, and 4.1% and 2.7% of orthopaedic trainees, respectively, with no appreciable growth over the past decade.2,5,7 Other studies report similar data demonstrating that orthopaedics is among the least diverse surgical fields with regard to representation of women and minorities.8-11

The proposed benefits of increased diversity among surgical trainees include having a physician workforce representative of the population at large, improving access to specialty care for minority populations, advancing cultural competency within the workforce, strengthening the medical research agenda, and ensuring optimal management of the healthcare system by involving diverse mentors and policy makers.12 Published literature shows greater patient satisfaction when patients are treated by physicians from similar cultural backgrounds.13-15 In addition, minority physicians are more likely than nonminority physicians to practice in underserved communities and to see minority and low-income patients.16,17 Reports have described the lack of diversity in orthopaedics,9-11,18-20 and anecdotal recommendations have addressed the need to increase diversity within the field.21-24 However, few scientific reports examine the underlying reasons for this predicament. Hill et al25 reported that female medical students’ perception of their acceptance by senior faculty was a barrier to their selection of orthopaedics instead of general surgery. Quintero et al26 found that orthopaedic admission committee faculty were more likely to select students with similar Myers-Briggs Type Indicator personality types. The authors of that study postulated that having a more diverse faculty would increase diversity among orthopaedic trainees.

The aim of the present study was to identify factors that motivate medical students in the selection of their career specialty. Data were stratified by sex, race/ethnicity, and interest in orthopaedic surgery. The timing of students’ selection of a career specialty was reviewed, and the role of faculty mentorship and the effects of orthopaedic or musculoskeletal education in the curriculum on students’ career selection were studied. The study was performed through a web-based survey of 657 medical students from 10 US medical schools. To our knowledge, this study is the broadest sampling of medical students in the orthopaedic literature.

Methods

We conducted a web-based survey of medical students currently enrolled in 10 US medical schools. The survey was based on previously published questionnaires on career selection in medical specialties.27-30 Demographic data including age, sex, race/ethnicity, medical school year rank, and marital status were elicited. Factors that might motivate a student to select a specialty were listed, and respondents were asked to rank each factor on a Likert scale ranging from 1 (no influence) to 10 (highly influential) (Appendix 1, see Appendix 1, Supplemental Digital Content 1, http://links.lww.com/JAAOS/A33). Factors rated 1 to 4 were categorized as unimportant; 4 to 7, moderately important; and 7 to 10, important.

The students’ current levels of interest in orthopaedics, surgical fields, and nonsurgical fields were rated on a scale of 1 (no interest) to 10 (maximal interest). Students were asked whether orthopaedics was their top choice, one of their top three choices, one of their top five choices, or a specialty in which they were not interested. Data were stratified by sex, race, and interest in orthopaedics. The students who ranked orthopaedics in their top three choices were considered to be interested in orthopaedics. Students who stated that they were not considering orthopaedic surgery as a specialty were deemed not to be interested in orthopaedics.

Medical students were asked whether they had a mentor and were asked to rate the influence of this mentor on specialty selection. Students were also asked whether the race/ethnicity and sex of the mentor were concordant with their own race/ethnicity and sex. The extent of orthopaedic education within their medical school curriculum was rated as none, very little, somewhat, or extensive. Follow-up questions asked whether this level of education positively or negatively influenced their decision to select orthopaedics as a career. Finally, we asked students to identify when they chose the specialty they would pursue after medical school (answer choices were high school, college, graduate school, medical school basic science years, medical school clinical years, or undecided).

A pilot group of 10 medical students at our institution received an initial version of the survey and were interviewed to discuss the clarity and validity of the questions. The questionnaire was revised on the basis of feedback received from this group. A web-based survey tool (SurveyMonkey) was used to embed the survey and collect responses in blinded fashion. The survey link was e-mailed to medical students at 10 US medical schools in widespread geographic locations by the deans’ offices at three institutions and through available class e-mail lists or via classmates at the other institutions. Reminder e-mails were sent 2 weeks and 4 weeks after the index e-mail was sent. Data analysis was performed using SAS statistical software (SAS Institute). After the normality of the data was confirmed, appropriate parametric statistical tests were undertaken, with the threshold for statistical significance determined a priori at 0.05. The Institutional Review Board of the Medical College of Wisconsin approved the study design and survey.

Results

A total of 657 medical students responded to our survey (Table 1). A minimum possible response rate of 13.9% was calculated on the basis of the maximum number of students who could have received the survey (4,721 students). If the questionnaire had been received by all students in the seven medical schools where it was not distributed by the dean’s office, the response rate would have been higher. The mean age of the respondents was 25.8 years (range, 19 to 48 years), and 343 respondents (52%) were women. First-year (M1) students accounted for 160 respondents (24.5%), with M2, M3, and M4 students constituting 153 respondents (23.5%), 125 respondents (19.2%), and 215 respondents (32.9%), respectively. Most students were Caucasian (494 respondents [76.4%]), followed by Asian (56 respondents [8.7%]), African American (51 respondents [7.9%]), multiple races (21 respondents [3.2%]), Hispanic (13 respondents [2.0%]), and other races (12 respondents [1.9%]).

Table 1
Table 1:
Demographic Data of Survey Respondents

Medical students ranked the subject matter of the specialty as the most important factor in the selection of their specialty, followed by their perception of the quality of life/lifestyle/stress level within the specialty. Factors deemed unimportant were one’s experience as a patient in a particular field, gender diversity and racial diversity within the specialty, and media exposure for a specialty (Table 2). Stratification of the data by sex showed that women ranked anticipated income (5.2 versus 6.1; P < 0.01) and prestige of the specialty (4.1 versus 4.6; P < 0.01) significantly lower than their male counterparts did. Although of low importance for both women and men, gender diversity (3.6 versus 2.0; P < 0.01) and racial diversity (3.0 versus 2.1; P < 0.01) within a specialty were significantly more important for women than for men. African American and Asian students valued racial diversity significantly higher than Caucasian students did (4.3 and 3.2, respectively, versus 2.2; P < 0.01).

Table 2
Table 2:
Rating of Factors Influencing Medical Students’ Selection of Career Specialty

Students who were likely to select orthopaedics as a career ranked experience as a patient, anticipated income, and prestige of a specialty as significantly more influential and ranked quality of life/lifestyle/stress level, length of training, and gender diversity significantly less influential (P < 0.05) compared with the responses of students who were not interested in orthopaedics (Table 3). Subanalysis of the students interested in orthopaedics demonstrated that, compared with men, women were less motivated by income (5.9 versus 7.1; P < 0.01) and prestige of a specialty (5.0 versus 5.8; P < 0.01). Women interested in orthopaedics were more concerned with gender diversity (3.7 versus 1.7; P < 0.01) and racial diversity (3.2 versus 2.0; P < 0.01) than men interested in orthopaedics were.

Table 3
Table 3:
Career Selection Factor Ratings With Statistically Significant Differences (P < 0.05) Between Medical Students Interested and Not Interested in Orthopaedic Surgery

Among medical students in their preclinical years (M1 and M2), 193 students (63.7%) were undecided regarding their career specialty. Of the remaining preclinical students, 44 students (14.5%) decided during the preclinical years, 40 students (13.2%) decided during college, 19 students (6.3%) decided in high school, and 7 students (2.3%) decided in graduate school. Among M3 respondents (121 students), 20 students (16.5%) had yet to decide, 59 students (48.8%) made their career decision during their M3 year, 19 students (15.7%) decided during their preclinical years, 10 students (8.3%) during college, and 13 students (10.7%) decided during high school. Most M4 students (207 students [98.1%]) had decided on their specialty at the time of the survey; 138 M4 students (65.4%) made their decision during the clinical (M3 and M4) years, 31 students (14.7%) decided during their preclinical years, 22 students (10.4%) decided during college, 14 students (6.6%) decided during high school, and 2 students (0.9%) decided during graduate school. No difference was found in the timing of the decision with regard to sex, race, or interest in orthopaedics.

Overall, 471 of 652 medical students (72.2%) identified themselves as having a faculty mentor, with 67.5% and 62.9% of those with mentors identifying the mentor as being of the same race/ethnicity and sex, respectively, as the respondent. Women had a mentor of the same sex 51.2% of the time, compared with 67.9% of the time for men (P < 0.01). The mentor’s race/ethnicity was concordant with the respondent’s race/ethnicity for 76.3% of Caucasian respondents, compared with 45.7% of minority respondents (P < 0.01). On a scale of 1 (no influence) to 10 (highly influential), students rated their mentor’s influence on their career choice as 6.0. Mentors of the same sex played a significantly stronger role in influencing specialty selection than mentors of the opposite sex did (6.4 versus 5.6; P < 0.01). The greater influence of a mentor of the same sex was similar for men and women (P = 0.96). The influence of the mentor was similar for mentors of the same race/ethnicity and mentors of a different race/ethnicity (6.0 versus 6.1; P = 0.57) (Figure 1). Students interested in orthopaedics and students not interested in orthopaedics rated mentor influence similarly (6.3 versus 6.0; P = 0.41).

Figure 1
Figure 1:
Bar graph showing medical students’ ratings (scale, 1 [ no influence] to 10 [highly influential]) of mentor influence on career selection, when the mentor and student were of the same sex or same race/ethnicity and when they were not. (For sex, P < 0.01. For race/ethnicity, P = 0.57.)

The mean interest level in orthopaedics was 3.6 on a 10-point scale. Interest in orthopaedics decreased similarly with medical school year rank for both men and women, with M1 students rating their level of interest at 4.1; M2 students, at 3.9; M3 students, at 3.5; and M4 students, at 2.8 (Figure 2). Women ranked their interest in orthopaedics significantly lower than men did (2.9 versus 4.3; P < 0.01) (Figure 3). Caucasian, African American, Asian, and Hispanic students ranked their level of interest in orthopaedics at 3.6, 4.0, 2.7, and 4.7, respectively; analysis of variance significance, P = 0.06 (Figure 3). Orthopaedics ranked in the top three choices for 26.6% of male students and 10.9% of female students (P < 0.01) (Figure 4).

Figure 2
Figure 2:
Line graph showing decreasing ratings of interest (scale, 1 [no interest] to 10 [maximal interest]) in orthopaedic surgery with increasing medical school year rank among male and female medical students.
Figure 3
Figure 3:
Bar graphs showing medical students’ ratings of their interest level (scale, 1 [no interest] to 10 [maximal interest]) in orthopaedic surgery, stratified by sex (P < 0.01) and race/ethnicity (P = 0.06).
Figure 4
Figure 4:
Bar graph showing the percentage of respondents indicating interest or lack of interest in orthopaedic surgery, stratified by sex.

Among all medical students (656 students), 33 students (5.0%) and 144 students (22.0%) reported extensive or moderate exposure to orthopaedics, respectively, whereas 340 students (51.8%) and 139 students (21.2%) reported very little or no orthopaedics education, respectively. Among students with moderate or extensive orthopaedics exposure, 133 of 176 respondents (75.6%) stated that this experience influenced their decision for or against applications to orthopaedics, with 69 of 133 students (51.9%) being more likely to apply to orthopaedics and 64 of 133 students (48.1%) being less likely to pursue orthopaedics as a result of this orthopaedic exposure; however, this difference was not statistically significant (P = 0.66) (Table 4). Among students with very little exposure to orthopaedics, 232 of 337 students (68.8%) stated that having very little exposure did not influence their decision for or against applying to orthopaedic surgery. Of the 105 students who were influenced, 70 students (66.7%) were less likely to apply and 35 students (33.3%) were more likely to apply (P < 0.01) (Table 4).

Table 4
Table 4:
Students’ Reported Orthopaedic Curriculum Exposure in Medical School, Rating of Interest in Orthopaedic Surgery, Percentage of Students Influenced by Curriculum Exposure in Selection of Specialty, and Influence of Curriculum Exposure on Likelihood of Applying for Orthopaedic Surgery Residency

Discussion

The data in this study, gathered from students in all medical school years and at multiple schools, show that quality of life and stress associated with a specialty are important to both men and women and are equally important among all the race/ethnicity groups in the survey. Residency in orthopaedics is considered rigorous; a survey of medical students interested in orthopaedics found that 87% of students (46 of 53 students) anticipated working >80 hours per week.31 This factor and others, such as the evolving lifestyle and career expectations of today’s medical students, lack of exposure to a musculoskeletal curriculum in some medical schools, uninspiring clerkships, and diminished enthusiasm and time for teaching of medical students because of the pressures of current health care, may all be contributing to a lower level of interest in orthopaedics among medical students. Although we did not query comparative levels of interest in other specialties, the average level of interest in orthopaedics among all medical students surveyed, rated as 3.6 on a 10-point scale, represents lower interest in the field than we had expected to find. This study, which is the first broad delineation of interest levels in orthopaedic surgery among a large group of medical students, provides useful baseline data for further studies.

The factors that contribute to the statistically significant lower level of interest in orthopaedics among women than among men are unclear. The low interest level among women appears unlikely to be the result of a lack of affinity for the content of the specialty. A previous study of 87 M2 students found that both women and minorities rated the favorability of an orthopaedic career highly; however, women and minority students considered the professional lifestyle, competitiveness, and physical demands as statistically significant negative factors.32 The present study found, to the contrary, that the lifestyle associated with a specialty was equally important among women and minorities, compared with men and nonminority students, respectively. However, we did find that, compared with men, women are more highly influenced by racial and gender diversity in a specialty field.

Our findings on African American and Hispanic medical students are different from those in women. These students’ interest in orthopaedics was higher than that of their Caucasian counterparts, although this finding did not reach statistical significance. However, unlike the scenario for female applicants, in which the percentage of women in the applicant pool and the percentage accepted into orthopaedic residency are approximately the same, the percentage of African American and Hispanic medical students accepted into orthopaedic residency programs is only half their representation in the applicant pool.4,7 Changes currently in process—the mandatory duty-hour limits and on-call restrictions, a focus on improved work-life balance during residency, and greater promotion of diversity within the resident pool and faculty—may increase the numbers of both women and men in the orthopaedic applicant pool.33,34 Although the number of underrepresented minorities in orthopaedics may increase as a result of these changes, we need to reexamine the efforts of orthopaedic residency programs in relation to this segment in order to transform the relatively high levels of interest and equally high application rates into higher residency matriculation rates.

The influence of mentors in selecting a specialty was independent of student sex and race/ethnicity. We found that both men and women with same-sex mentors rated their mentor’s influence higher than those with opposite-sex mentors did. However, the role of the mentor was rated as the same by students with a mentor of the same race and students with a mentor of a different race. The present study also found that the influence of mentors was similar for students interested in orthopaedics and those not interested in orthopaedics. In an era of independent and self-aware medical students with access to multiple information resources through the Internet, the present study finds mentor influence valuable for students. The overall lower emphasis on medical student mentorship among orthopaedic surgeons preoccupied by practice-related concerns in a period of healthcare reform may have a negative influence in attracting applicants to the field. To increase interest levels among women in orthopaedic surgery, orthopaedic department leadership should focus their efforts on recruiting female orthopaedic faculty to mentor female medical students. Several authors have recommended orthopaedic mentorship programs targeted at college students in an effort to expand the pool of women and minority candidates who may be interested in a career in orthopaedics.21,22,35 The yield from such programs may be low. Our data show that <10% of students make the decision to pursue an orthopaedic career while in college, with no difference between men and women.

Our results corroborate previous reports on the dearth of orthopaedic education in medical school curricula.28,36-39 Exposure to orthopaedic education was classified as very little to none among nearly three-fourths of medical students in our sample. Nearly 7 in 10 students stated that their very little exposure did not influence their decision for or against applying to orthopaedics. Among the students who reported that very little exposure was sufficient to influence their decision, significantly more students stated that this exposure made them less likely to apply for orthopaedic surgery residency, compared with the number who reported that this exposure made them more likely to apply. Unexpectedly, among students with moderate or extensive exposure to orthopaedics, equal numbers of students were more likely and less likely to pursue orthopaedics after this exposure. Although our study design did not permit us to compare the influence of clerkships on interest levels in other specialties, these findings may have implications for the orthopaedic workforce pipeline. We suggest a careful review of orthopaedic surgery clerkships and medical student curriculum design at academic centers nationally to more effectively influence students to select careers in orthopaedic surgery.

The strengths of the present study include the large number and broad geographic distribution of respondents, providing a robust data set on the mindset and intellectual considerations of today’s medical students in the selection of a specialty career. The comparable numbers of respondents from each medical school class provide data on students in all 4 years of medical school. The primary limitation of the present study is the inability to determine an accurate response rate, as indicated in the discussion of the methodology of our study. Although the demographic data of the sample were similar to the overall national matriculant demographic data, further studies are needed to assess whether the data can be generalized to all medical students. We did not have control groups of students interested in other specific surgical specialties to compare with students interested in orthopaedics. The low level of interest in orthopaedics among women may be similar for other surgical subspecialties. Finally, similar to the results of other cross-sectional surveys, our data represent medical students’ opinions at one point in time. Medical students’ opinions may evolve and likely do, sometimes rapidly in response to national trends that are specific to a specialty.

Conclusion

The data in this study provide useful information to medical schools and to those involved in overseeing the orthopaedic workforce. Our wide-ranging questions provide data on how multiple factors play a role in the complex and highly individual decision of medical specialty selection. The low level of interest in orthopaedics and the relative lack of influence of the orthopaedic curriculum in medical school raise our concern for the vigor of the orthopaedic pipeline. We recommend that the broader scope of musculoskeletal issues, prevention, treatment, and outcomes be more widely disseminated through public-service and education campaigns. Efforts should be made to expand the general perception of orthopaedics as a discipline in which physicians care not just for patients with sports injuries, but also for children with orthopaedic conditions and for men and women with arthritic joints, musculoskeletal tumors, spinal disorders, and similar conditions. These efforts will likely attract a wider pool of applicants, change perceptions of the specific personality types typically involved in the profession, and result in a deeper reservoir of candidates interested in orthopaedics. Although current efforts at improving the number of women and underrepresented minorities in the profession will likely be successful with time, more efficient use of resources may be achieved by enhancing the quality of medical school orthopaedic curricula and clinical rotations to inspire more applicants and attract them to orthopaedic surgery. Finally, despite current practice pressures, academic orthopaedic surgeons and medical school leadership should carefully revisit their approach to mentorship and relationship building with medical students at their institutions.

References

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      Keywords:

      career selection; diversity; education; medical student; orthopaedic surgery; residency training; specialty

      Supplemental Digital Content

      Copyright 2017 by the American Academy of Orthopaedic Surgeons.