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| Journal of the New Zealand Medical Association,
07-August-2009, Vol 122 No 1300
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Jason Du, Janarthanan Sathanathan, Gill Naden, Stephen
Child
Today’s medical graduates are moving away from surgery
in favour of ‘family or lifestyle-friendly’
careers.1–7 Evans et al reported up to
75% of graduating medical students in 2002 cited length of training and poor
lifestyle as factors influencing choice against a surgical
career.7 Current junior doctors in the
workforce are part of what is known as ‘Generation Y’ which is
associated with characteristics such as: self-centred, protected, optimistic,
confident, technologically savvy, have job-hopping tendencies in search for the
ideal career and expect constant positive reinforcement from their senior
colleagues.8 As such, the perception that a
surgical career requires long hours, little sleep, arduous exams and contact
with ‘difficult’ personalities may have contributed to the marked
decline in interest in surgery over the past
decade.9,10
According to the Royal Australasian College of Surgeons
report in 2005,11 31% of the New Zealand
surgical workforce is aged 55 and over. With one-third of the current active
surgeons expected to retire in the next 5 years and a declining interest in
surgical training, there is a projected increasing surgical workforce shortage
in New Zealand.
While two studies have looked at the career aspirations of
medical students in New Zealand,12,13 and one
study looked at postgraduate career choices in
2003,14 no study has looked at the factors
affecting the career choice of New Zealand junior doctors with respect to
surgery specifically.
The primary aim of the study was to determine the level of
interest in a surgical career amongst junior doctors and trainee interns (final
year medical students) in Auckland. Secondary aims were to identify the positive
and negative factors that influence career choice as well as the timing of
career choice.
MethodsBased on a literature review, a structured 12-question
questionnaire was developed on basic demographics, level of training, career
preference, factors influencing their choice, and previous experiences in
surgery. All participants were given a list of factors to prioritise when
deciding on a career choice in general. They were then asked to score 1–5
from a more specific list of factors relating to choosing surgery or not as to
how influential these factors were (1 being least, and 5 being the most
influential).
Questionnaires were distributed to all trainee interns
(TI) and junior doctors in their first to fifth postgraduate years (PGY1-5) in
the Auckland region. Questionnaires were sent both in paper form and
electronically via email between April and September 2008. In addition,
questionnaires were also distributed at weekly junior doctor teaching sessions
at Auckland hospitals.
All questionnaires were anonymous, although respondents
were asked their gender and level of training. All questionnaires were received
and analysed by the principal author.
Ethics approval was obtained via our internal research
office. All statistical analyses for the study were done using excel at 95%
confidence intervals with a p value of less than 0.05 considered significant.
ResultsA total of 87 replies (37% male, 63% female) were received
and all were included in the final analysis. The estimated response rate was 25%
as it was difficult to quote actual response rate since both paper and
electronic questionnaires were distributed. Over 75% of responses were from TI,
PGY1, and PGY2 with PGY 3+ making up the rest (see Figure 1).
Overall, 31/87 (36%) junior doctors were interested in
surgery (surgical group) and 56/87 (64%) were interested in non-surgical
specialties (non-surgical group). Lifestyle, career ambitions and family were
the top three factors influencing career choice in general in both groups (see
Table 1). In the surgical group, career ambition seemed to be the most
influential factor whereas lifestyle and family were the most influential in the
non-surgical group. However, p values were >0.05 when the two groups were
compared due to small population numbers.
Figure 1. Training level of
participants.
 Table 1. Factors influencing career
choice.
When asked more specifically about factors that affected
whether or not surgery was chosen. Personal interest, practical hands-on aspect
of surgery and positive previous experiences were the top reasons why 36% of the
junior doctors chose surgery (See Figure 2).
Poor lifestyle, lacking interest, limited part-time work,
and previous negative experiences were the top reasons why 64% of our junior
doctors did not choose surgery (See Figure 3).
Figure 2. Factors affecting choice of
surgery
 Figure 3. Importance of factors for not
choosing surgery
 In the surgical group, everyone (100%) had positive previous
experiences with previous surgical runs versus 71% of the non-surgical group
(p<0.05). Of the surgical group 94% had positive previous experiences with
their surgical consultants versus 61% of the non-surgical group (p<0.05). Of
the surgical group 90% had positive previous experiences with surgical
registrars versus that of 54% of the non-surgical group (p<0.05) (See Figure
4).
Figure 4. Positive personal experiences in
surgery
 * = p<0.05
A significantly larger number of junior doctors in the
non-surgical group had negative previous experiences on their surgical runs and
with their surgical consultants (p<0.05) (See Figure 5).
In the surgical group, 26/31 (84%) junior doctors decided on
their careers either during or before the PGY1 year compared with that of 26/56
(46%) in the non-surgical group (p<0.05) (See Figure 6).
Figure 5. Negative personal experiences in
surgery
 * = p<0.05
Figure 6. Timing of career
choice
 DiscussionHistorically, surgery has been considered a highly
respected, prestigious profession and has involved a competitive selection
scheme.1 However, studies abroad have suggested
a trend among recent medical graduates moving away from surgery as a result of
lifestyle issues, likelihood of litigation, absence of role models, and lack of
undergraduate exposure.2,7 The changing nature
of healthcare delivery, societal values, and medical school selection may also
be contributing factors influencing career choice among medical
professionals.
Although extensive literature exists internationally on
career choices of junior doctors and some literature exist on New Zealand junior
doctors,12–14 our study is the only study
specifically looking at factors influencing a career choice in surgery.
In this study, 36% of respondents were interested in surgery
which was similar to a previously conducted survey in
2003,14 and aligns with international
data.4, 5 Although only the Auckland junior
doctors were sampled, it is likely that the results are representative of New
Zealand as a whole.
When asked about factors influencing career choice in
general, it was interesting to find that regardless of which specialty the
junior doctors are interested in, the top three factors were: Lifestyle, career
ambitions and family. However, career ambitions topped the surgical group list
whereas lifestyle and family topped the non-surgical group list. This shows that
the medical graduates of today have significantly different lifestyle interests
and goals than those from prior
decades.5–7
The desire to keep leisure and work separate and balanced is
increasingly prominent. In effect, the need for a ‘controllable
lifestyle’ has become an essential factor in career selection and
specialties that can address this concern such as dermatology, radiology and
anaesthesiology, are increasing in
popularity.1,3
Of note, gender analysis with respect to factors influencing
a career choice in surgery was not performed in this study. However, other
studies have shown that the desire for greater flexibility of schedule and
lifestyle is no longer limited to female doctors but is an influencing factor
shared equally among men and women.6,7
When surgically inclined junior doctors were asked
specifically about why they chose surgery, the top reasons were: personal
interest, practical hands-on aspect of surgery and previous positive experiences
with their surgical rotation and consultant and / or registrar mentors. Not so
surprisingly, poor lifestyle, lacking interest, limited part-time work and
previous negative experiences with their surgical rotation and consultants were
the main reasons why the majority of the junior doctors did not want to pursue a
surgical career.
Many studies have illustrated the importance of a positive
role model in attracting and maintaining medical graduates’ interest in
surgery, particularly at an early
stage.1,5–7 International studies
coincide with this study suggesting that consultant surgeons have a critical
role in this respect. Consultant surgeons are in the strongest position to
demonstrate the benefits of the field, act as role models or mentors for
students and junior doctors.
Perhaps more importantly, they also demonstrate the
satisfaction and enjoyment of a surgical career. In particular, exposure to
positive role models with balanced, successful personal lives can counteract the
many lifestyle concerns facing current graduates and demonstrate that becoming a
surgeon is an obtainable goal for any hardworking junior
doctor.2
It is known that junior doctors interested in surgery decide
on their careers earlier compared to their non-surgical colleagues. Early
surgical education from exposure to operating experiences, participation in
surgical teamwork, surgical skills practice in training courses and laboratories
for junior doctors, trainee interns and medical students may all contribute to
developing interest in the specialty.
Junior doctors, especially those with enthusiasm for
surgery, are not discouraged by high demands, but these demands must be
structured, visible, goal oriented, and
achievable.15 Junior doctors who are interested
in a surgical career respond positively to a clear and structured educational
curriculum. Coaching and mentorship from senior surgeons along with a positive
team experience are important aspects to developing potential surgeons.
A too-high workload and too much pressure for an optimal and
error-free performance in hospital and society may well discourage young doctors
from choosing surgery as a career with a result that they end up looking for
simpler solutions outside of surgery.2
Motivation is lost when basic career needs are not met. This
means having an adequate salary, job security and satisfaction, which includes
leisure time for friends, sports, relaxation, cultural events, and hobbies.
Motivation is also diminished by poor role models and unstructured surgical
education.15
To encourage more junior doctors to pursue a surgical
career, it is postulated that consideration needs to be given to improving
working conditions (controllable lifestyle), better role-modelling / mentoring
from consultant surgeons, clearly structured education or training curriculum
and encourage a friendlier, team atmosphere.
ConclusionCareer aspirations of New Zealand junior doctors were
similar to those reported overseas and appeared not to have changed since 2003.
To promote surgery amongst junior doctors and medical students, it is necessary
to take into account that current graduates, consistent with known generation Y
attributes, place more emphasis on lifestyle and family. However, the junior
doctors are not discouraged while interest is maintained and the demand is
structured, visible, and achievable.
In short, attention should be given to improving working
conditions and well structured surgical education programs with good academic
and career mentoring. Encourage a friendlier and supportive team environment for
all staff. The creation of opportunities for junior doctors and students in
surgical education through early exposure to a variety of surgical disciplines,
participation in surgical teamwork, practice in surgery and laboratory training
courses would contribute to enhanced recruitment and efficient effective
training of future surgeons.
Competing interests: None known.
Author information: Jason Du, House
Surgeon, Auckland City Hospital, Auckland; Janarthanan Sathanathan, House
Surgeon, Auckland City Hospital, Auckland; Gill Naden, Clinical Education
and Training Unit, Auckland District Health Board, Auckland; Stephen Child,
Consultant Physician and Director of Clinical Education and Training Unit,
Auckland District Health Board, Auckland
Correspondence: Jason Du, PO Box 110145,
Auckland City Hospital, Grafton, Auckland 1148, New Zealand. Email: tojasondu@gmail.com
References:
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