Journal of the New Zealand Medical Association, 07-August-2009, Vol 122 No 1300
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.
Based 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.
A 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
Historically, 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.
Career 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: email@example.comReferences:
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