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Increasing surgical diversity among trainees is a priority of the Royal Australasian College of Surgeons (RACS).[[1]] This fits in with the Building Respect, Improving Patient Safety Action Plan on discrimination, bullying and sexual harassment in surgery, launched in 2015, which supported actively working with medical schools to encourage surgery as a career.[[2]]

However, it is clear that career direction in medicine is a multi-factorial process that involves internal and external factors. Personal or internal factors include academic interest in a field, competencies and lifestyle factors.[[3,4]] External factors include the influence of previous experience on rotations.[[5]] For surgical specialties, systematic review suggests experience in the operating theatre as a student is the single most important factor to promote interest in surgery.[[6]] Despite this, less than 10% of students in a recent New Zealand survey felt their medical school exposure was sufficient for making an informed career choice, raising concern regarding exposure to surgery for junior doctors (JD) and medical students (MS).[[7]]

A positive role model has been shown to guide career choice in general surgery.[[5]] The development of mentorship relationships is important for MS and JD to provide support and guide career decision making.[[5,8,9]] Unfortunately, few students in New Zealand feel they have adequate mentorship, with only 10% in a recent survey of UA students reporting having a mentor.[[7]]

Possible deterrents for a career in General Surgery include poor work–life balance and negative experience on rotations at medical school.[[5]] There are also wider societal and cultural factors influencing a career in general surgery. There is a longstanding over-representation of males and the NZ European ethnicity in medicine in general.[[1,10,11]]

The aim of this study was to identify motivators and conversely the barriers to a career in general Surgery among JD and MS in New Zealand. Understanding these factors may improve recruitment and training opportunities in general surgery and importantly facilitate diversity in general surgical trainees.

Methods

An online survey (Appendix 1) was sent to 2,170 participants (1,327 JD and 843 MS). JD included all doctors employed in a house officer role nationwide. These are predominantly postgraduate years one and two. MS were clinical students at The University of Auckland School of Medicine in years four to six.

The researchers sent an email of invitation (Appendix 2) to the student convener at the University of Auckland (UA) and to the resident medical officer (RMO) coordinators at each of the twenty district health boards (DHBs) in New Zealand. This initial email asked to forward a separate email of invitation (Appendix 3) to MS and JD respectively, as well as reminder emails (Appendix 4). The invitation email sent to participants explained the aim of the study and outlined the consent process. This method facilitated anonymity as the researchers did not have access to the participants emails. The survey remained open for three weeks, with reminder emails to participate sent after one and two weeks.  

In the initial email, the student convener and RMO coordinator were asked to reply to the researchers to confirm receival and participation. Confirmation from the medical school student convenor was immediate. Only three DHBs responded immediately. When the RMO coordinator had not responded to the researchers within the first week, they were telephoned to clarify whether they had received the initial email, and then forwarded it on to participants. The researchers phoned each RMO coordinator a maximum of three times until a response was achieved. This ensured that all twenty DHBs had forwarded the email to participants.

The survey consisted of closed “yes” and “no” questions, multi-choice or Likert response questions on demographic data (age, gender, ethnicity, level of training and about family make-up) and motivators or barriers to general surgery. They were also asked about whether they perceived an ethnicity or gender bias which could include their own self-selection bias, or a perceived bias from selection committees. Respondents were able skip questions and still complete the survey.

Results remained anonymous and were analysed using Excel. Weighted averages were used for questions with Likert scales (1—not at all important; 2—not so important; 3—somewhat important; 4—very important; 5—extremely important). For the key motivators (question 8) and barriers (question 9) analysis was by subgroups of gender and ethnicity (Appendix 1). If participants identified with more than one ethnicity, their response was included in all of the ethnicities they identified with.

Ethical approval was obtained via The University of Auckland Human Participants Ethics Committee (UAHPEC21921).

Results

Demographics

The response rate was 21 % with a total of 452/2170 responses. The demographics of participants are summarised in Table 1. In terms of family, the majority (95.6%, n=431/451) had no children and over half (51.4%, n=232/451) were in a long-term relationship. Twenty-one point five percent (n =97/451) of respondents were very likely or likely to pursue a career in general surgery (Figure 1).

View Table 1 & Figure 1.

Motivators influencing a career in general surgery

Over half of the respondents (66.2%, n=298/450) see their medical student experience as very or extremely important in determining their career choice. In terms of experience to date, almost all respondents (94.3%, n=399/423) have had the opportunity to assist in theatre, and 13.0% (n=55/423) have performed an operation as the primary surgeon. Over half of respondents have had the opportunity to see and assess patients independently, with 59.1% (n=253/423) having experience admitting acute patients and 51.5% (n=218/423) seeing patients in clinic. Twenty-six percent (n=108/423) have had experience with research.

The most important factors guiding career choice were interest in clinical aspects (weighted average 4.43), interest in practical aspects (weighted average 4.34) and work life balance (weighted average 4.11) (Table 2). The least important aspect for career choice was research opportunities (weighted average 2.64). Factors guiding career choice are analysed by gender and ethnicity in Table 2. Of note, females place more importance on family commitments guiding their career choice compared to males (3.86 vs 3.66) whilst males place more importance on income (3.25 vs 2.91).

View Table 2.

Regarding ethnicity when compared to all respondents, Māori place greater importance on a mentor or role model (4.05 vs. 3.87) and experience on prior rotations (4.17 vs 3.96). Importantly, Pasifika peoples place the greatest importance on family commitments when compared to all respondents (4.30 vs 3.78) (Table 2). Almost all respondents (92.2%, n=416/451) consider having a mentor important; 34.6% somewhat important, 39.3% very important and 18.4% extremely important. Despite this, only 15.3% (n=69/451) reported currently have a mentor.

Barriers influencing a career in general surgery

There were perceived gender and ethnicity biases in general surgery among respondents. Seventy-nine point seven percent (n=357/448) reported a gender bias, with 99.7% (n=356/357) of these reporting that males are over-represented. Similarly, 68.4% (n=307/449) reported an ethnicity bias. Ninety-seven percent of these (298/307) reported NZ Europeans as being over-represented.

The most significant barrier for choosing general surgery as a career amongst all respondents was perceived hours of work (4.05) and when broken down by gender, hours was a more significant barrier for females (4.11 vs 3.91) (Table 3).

View Table 3.

Discussion

This study demonstrated key factors, both motivators and barriers influencing career decision for MS and JD with a particular focus on general surgery. Key motivators guiding career choice were interest in clinical aspects, practical aspects, and work–life balance. In terms of barriers, the most important was perceived hours of work. Of note, all six barriers were more significant for females.

This study also demonstrated there is an unmet need for mentorship, with 92% considering mentorship important but only 15% currently having a mentor. A perceived over-representation of males—79.7% (n=357/448); and Pākehā/NZ Europeans—68.4% (n=307/449) were also found.

These results are in alignment with a previous meta-analysis indicating academic interests and lifestyle factors were the most important factors guiding career choice.[[3]]  It is also known that experience as a medical student is important to guide career choice.[[3–6]] This is supported by our findings, with over two thirds of participants seeing their medical school experience as guiding their career choice. Thirteen percent of our participants had performed an operation under supervision as the primary surgeon. As such tailoring medical school and house officer training requirements to ensure adequate surgical exposure may help to attract candidates to general surgery.[[6]]

In terms of barriers to surgical training, our data supports previous studies with perceived hours of work being a big determinant of choice.[[3]] Surgical careers will need to find innovative ways of managing hours at work. Other important barriers were feeling overwhelmed and not feeling good enough. The unmet need for mentorship in this study is similar to prior research also among New Zealand MS.[[7]] This was especially important to Māori respondents. Improving mentorship may help address some of the aforementioned barriers, as effective mentorship is known to support junior staff both psychologically and in career decision-making.[[4,10]]

In this study, all six barriers were more significant for females than males. This is similar to a recent qualitative study evaluating view of minorities in surgical training, where women report being discouraged from a surgical career, in particular due to family commitments.[[11]] Likewise, in this study females also placed more importance on family commitments than males. There was a reported under-representation of females in surgical specialties in this study with which is not a new finding.[[12,13]] Female surgeons make up 25% of the general surgical workforce in New Zealand, and only 13% of senior surgical positions across Australasia.[[13,15]]

Similarly, this study has identified a perceived ethnicity bias in general surgery, with 97% of those who reported a bias, reporting over-representation of NZ Europeans/Pākehā. It is well known that NZ Europeans/Pākehā are over-represented in medicine, particularly in surgery.[[12]] There is no publicly available ethnicity data of general surgeons in New Zealand. Similar to recent interviews with minorities in surgical training, these findings in our study suggest the need to improve diversity in surgical training in New Zealand, aligning with the RACS Diversity Inclusion Plan which one of its goals being “to embrace diversity and foster gender equity’”[[1,14]]

This study is the first of its kind in New Zealand, and has a large sample size involving JD nationwide and MS at the UA. As such it provides unique information to help guide training opportunities in general surgery. The results of this study should be interpreted with respect to its limitations. The response rate was 21%, and it’s possible that MS and JD who had already decided on a surgical career were less likely to participate. To facilitate anonymity, the specific hospital that respondents were working in was not known by the investigators and as such it cannot be established whether exposure and experience in general surgery is different in tertiary hospitals compared to smaller rural hospitals. Knowledge of this difference may enable specific tailoring of mentorship and training opportunities in different regions. Given the role of a JD is reasonably standardised across New Zealand, application of these results outside of New Zealand is unclear. This study did not evaluate the views of training or pre-vocational training registrars. Knowledge of barriers and challenges trainees face is also essential to guide future training programmes. Perhaps and more importantly, a study would benefit from capturing the view of registrars who have initially expressed interest in a surgical career, but then opted for an alternative career. Future work could use a similar survey to evaluate the opinions of these groups.

This study has identified key motivators and barriers towards general surgery among MS and JD. It has also shown there is a perceived over-representation of males and NZ Europeans/Pākehā and an unmet need for mentorship. An acknowledgement of factors influencing a career choice in general surgery could help to improve opportunities in general surgery to diversify our workforce.

View Appendices.

Summary

Abstract

Aim

Increasing diversity among surgeons is a priority of the Royal Australasian College of Surgeons (RACS).[[1]] This study aimed to identify motivators and barriers to general surgery among junior doctors (JD) and medical students (MS) to help guide the recruitment of under-represented minorities into surgical training.

Method

An online survey was sent to 2,170 participants—1,327 JD in New Zealand and 843 MS at The University of Auckland (UA). Participants were asked about motivators or barriers to a career in general surgery.

Results

Twenty-one percent (452/2170) completed the survey. Most were female (65.1%), NZ European (53.6%) and MS (62.4%). Factors guiding career decision include interest in clinical and practical aspects (weighted average 4.43 and 4.34, respectively) and work–life balance (weighted average 4.11). Barriers to training were long hours and feeling overwhelmed (weighted average 4.05 and 3.64, respectively). There were perceived biases with 79.7% reporting a gender bias and 99.7% reporting male over-representation. Similarly, 68.4% reported an ethnicity bias; 97% reporting NZ European over-representation. 92.2% considered mentorship important but only 15.3% have a mentor.

Conclusion

This study identified motivators and barriers to general surgery and perceived gender and ethnicity biases. With demand for a diverse surgical workforce, there should be focus on recruitment of underrepresented minorities and mentorship.

Author Information

Leah Boyle: Department of General Surgery, Tauranga Hospital, Bay of Plenty DHB. Adam Payne: Department of General Surgery, Tauranga Hospital, Bay of Plenty DHB. Sharon Jay: Department of General Surgery, Tauranga Hospital, Bay of Plenty DHB. Jeremy Rossaak: Department of General Surgery, Tauranga Hospital, Bay of Plenty DHB.

Acknowledgements

Dr Robin Willink, Biostatical Group, University of Otago, Wellington.

Correspondence

Dr Leah Boyle: General Surgery SET 1 Trainee.

Correspondence Email

leahimogenboyle@gmail.com

Competing Interests

Nil.

1) Diversity and Inclusion Plan. Royal Australasian College of Surgeons. [Cited October 2021] Available from: https://www.surgeons.org/-/media/Project/RACS/surgeons-org/files/operating-with-respectcomplaints/building-respect/diversity-and-inclusion-plan-2019.pdf?rev=7e1f6c1e120b4ffa9de790eab331dae5&hash=B879F32E416DDAD2A038ED464C0F2ED3

2) Building Respect, Improving Patient Safety RACS Action Plan on Discrimination, Bullying and Sexual Harassment in the Practice of Surgery. Royal Australian College of Surgeons. [Cited September 2021] Available from:

3) https://www.surgeons.org/-/media/Project/RACS/surgeons-org/files/reports-guidelines-publications/action-plans/racs-action-plan_bullying-harassment_f-low-res_final.pdf?rev=364e80a0b46a4db9837f117f548b1513&hash=92FF3C64E63038B4FAE77FE09D7DE020

4) Yang Y, Li J, Wu X et al. Factors influencing subspecialty choice among medical students: a systematic review and meta-analysis. BMJ Open. 2019:9.

5) Sutton PA, Mason J, Vimalachandran D, McNally S. Attitudes, motivators, and barriers to a career in surgery: a national study of U.K. undergraduate medical students. J Surg Educ. 2014;71:662-7.

6) Cochran A, Melby S, Neumayer LA. An Internet-based survey of factors influencing medical student selection of a general surgery career. Am J Surg. 2005;189:42-6.

7) Marshall DC, Salciccioli JD, Walton SJ at al. Medical student experience in surgery influences their career choices: a systematic review of the literature. J Surg Educ. 2015;72:438-45

8) Yeom BW, Hardcastle T, Wood AJ. Recruitment to otorhinolaryngology: opportunities abound. Australian Journal of Otolaryngology. 2020;3:20-27.

9) Laurence C, Elliott T. When, what and how South Australian pre-registration junior medical officers' career choices are made. Med Educ. 2007;41:467-75.

10) Pianosi K, Bethune C, Hurley KF. Medical student career choice: a qualitative study of fourth-year medical students at Memorial University, Newfoundland. CMAJ Open. 2016;19:147-52.

11) Cowan F, Flint S. The importance of mentoring for junior doctors BMJ 2012;345.

12) Villanueva C, Cain J, Greenhill J, Nestel D. "The odds were stacked against me": a qualitative study of underrepresented minorities in surgical training. ANZ J Surg. 2021;91:2026-2031.

13) Klifto KM, Payne RM, Siotos C, et al. Women Continue to Be Underrepresented in Surgery: A Study of AMA and ACGME Data from 2000 to 2016. J Surg Educ. 2020;77:362-368.

14) The New Zealand Medical Workforce in 2018. Medical Council of New Zealand. 2018 [Cited September 2021] Available from: https://www.mcnz.org.nz/assets/Publications/Workforce-Survey/434ee633ba/Workforce-Survey-Report-2018.pdf

15) Activities Report 2019. Royal Australasian College of Surgeons. 2019 [Cited September 2021] Available from:

16) https://www.surgeons.org/-/media/Project/RACS/surgeons-org/files/reports-guidelines-publications/workforce-activities-census-reports/RACS_ActivitiesReport_2019_Final.pdf

17) Surgeons speak about women in surgery. 2021. [Cited February 2022] Available from: https://www.surgeons.org/en/News/News/surgeons-speak-about-women-in-surgery

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Increasing surgical diversity among trainees is a priority of the Royal Australasian College of Surgeons (RACS).[[1]] This fits in with the Building Respect, Improving Patient Safety Action Plan on discrimination, bullying and sexual harassment in surgery, launched in 2015, which supported actively working with medical schools to encourage surgery as a career.[[2]]

However, it is clear that career direction in medicine is a multi-factorial process that involves internal and external factors. Personal or internal factors include academic interest in a field, competencies and lifestyle factors.[[3,4]] External factors include the influence of previous experience on rotations.[[5]] For surgical specialties, systematic review suggests experience in the operating theatre as a student is the single most important factor to promote interest in surgery.[[6]] Despite this, less than 10% of students in a recent New Zealand survey felt their medical school exposure was sufficient for making an informed career choice, raising concern regarding exposure to surgery for junior doctors (JD) and medical students (MS).[[7]]

A positive role model has been shown to guide career choice in general surgery.[[5]] The development of mentorship relationships is important for MS and JD to provide support and guide career decision making.[[5,8,9]] Unfortunately, few students in New Zealand feel they have adequate mentorship, with only 10% in a recent survey of UA students reporting having a mentor.[[7]]

Possible deterrents for a career in General Surgery include poor work–life balance and negative experience on rotations at medical school.[[5]] There are also wider societal and cultural factors influencing a career in general surgery. There is a longstanding over-representation of males and the NZ European ethnicity in medicine in general.[[1,10,11]]

The aim of this study was to identify motivators and conversely the barriers to a career in general Surgery among JD and MS in New Zealand. Understanding these factors may improve recruitment and training opportunities in general surgery and importantly facilitate diversity in general surgical trainees.

Methods

An online survey (Appendix 1) was sent to 2,170 participants (1,327 JD and 843 MS). JD included all doctors employed in a house officer role nationwide. These are predominantly postgraduate years one and two. MS were clinical students at The University of Auckland School of Medicine in years four to six.

The researchers sent an email of invitation (Appendix 2) to the student convener at the University of Auckland (UA) and to the resident medical officer (RMO) coordinators at each of the twenty district health boards (DHBs) in New Zealand. This initial email asked to forward a separate email of invitation (Appendix 3) to MS and JD respectively, as well as reminder emails (Appendix 4). The invitation email sent to participants explained the aim of the study and outlined the consent process. This method facilitated anonymity as the researchers did not have access to the participants emails. The survey remained open for three weeks, with reminder emails to participate sent after one and two weeks.  

In the initial email, the student convener and RMO coordinator were asked to reply to the researchers to confirm receival and participation. Confirmation from the medical school student convenor was immediate. Only three DHBs responded immediately. When the RMO coordinator had not responded to the researchers within the first week, they were telephoned to clarify whether they had received the initial email, and then forwarded it on to participants. The researchers phoned each RMO coordinator a maximum of three times until a response was achieved. This ensured that all twenty DHBs had forwarded the email to participants.

The survey consisted of closed “yes” and “no” questions, multi-choice or Likert response questions on demographic data (age, gender, ethnicity, level of training and about family make-up) and motivators or barriers to general surgery. They were also asked about whether they perceived an ethnicity or gender bias which could include their own self-selection bias, or a perceived bias from selection committees. Respondents were able skip questions and still complete the survey.

Results remained anonymous and were analysed using Excel. Weighted averages were used for questions with Likert scales (1—not at all important; 2—not so important; 3—somewhat important; 4—very important; 5—extremely important). For the key motivators (question 8) and barriers (question 9) analysis was by subgroups of gender and ethnicity (Appendix 1). If participants identified with more than one ethnicity, their response was included in all of the ethnicities they identified with.

Ethical approval was obtained via The University of Auckland Human Participants Ethics Committee (UAHPEC21921).

Results

Demographics

The response rate was 21 % with a total of 452/2170 responses. The demographics of participants are summarised in Table 1. In terms of family, the majority (95.6%, n=431/451) had no children and over half (51.4%, n=232/451) were in a long-term relationship. Twenty-one point five percent (n =97/451) of respondents were very likely or likely to pursue a career in general surgery (Figure 1).

View Table 1 & Figure 1.

Motivators influencing a career in general surgery

Over half of the respondents (66.2%, n=298/450) see their medical student experience as very or extremely important in determining their career choice. In terms of experience to date, almost all respondents (94.3%, n=399/423) have had the opportunity to assist in theatre, and 13.0% (n=55/423) have performed an operation as the primary surgeon. Over half of respondents have had the opportunity to see and assess patients independently, with 59.1% (n=253/423) having experience admitting acute patients and 51.5% (n=218/423) seeing patients in clinic. Twenty-six percent (n=108/423) have had experience with research.

The most important factors guiding career choice were interest in clinical aspects (weighted average 4.43), interest in practical aspects (weighted average 4.34) and work life balance (weighted average 4.11) (Table 2). The least important aspect for career choice was research opportunities (weighted average 2.64). Factors guiding career choice are analysed by gender and ethnicity in Table 2. Of note, females place more importance on family commitments guiding their career choice compared to males (3.86 vs 3.66) whilst males place more importance on income (3.25 vs 2.91).

View Table 2.

Regarding ethnicity when compared to all respondents, Māori place greater importance on a mentor or role model (4.05 vs. 3.87) and experience on prior rotations (4.17 vs 3.96). Importantly, Pasifika peoples place the greatest importance on family commitments when compared to all respondents (4.30 vs 3.78) (Table 2). Almost all respondents (92.2%, n=416/451) consider having a mentor important; 34.6% somewhat important, 39.3% very important and 18.4% extremely important. Despite this, only 15.3% (n=69/451) reported currently have a mentor.

Barriers influencing a career in general surgery

There were perceived gender and ethnicity biases in general surgery among respondents. Seventy-nine point seven percent (n=357/448) reported a gender bias, with 99.7% (n=356/357) of these reporting that males are over-represented. Similarly, 68.4% (n=307/449) reported an ethnicity bias. Ninety-seven percent of these (298/307) reported NZ Europeans as being over-represented.

The most significant barrier for choosing general surgery as a career amongst all respondents was perceived hours of work (4.05) and when broken down by gender, hours was a more significant barrier for females (4.11 vs 3.91) (Table 3).

View Table 3.

Discussion

This study demonstrated key factors, both motivators and barriers influencing career decision for MS and JD with a particular focus on general surgery. Key motivators guiding career choice were interest in clinical aspects, practical aspects, and work–life balance. In terms of barriers, the most important was perceived hours of work. Of note, all six barriers were more significant for females.

This study also demonstrated there is an unmet need for mentorship, with 92% considering mentorship important but only 15% currently having a mentor. A perceived over-representation of males—79.7% (n=357/448); and Pākehā/NZ Europeans—68.4% (n=307/449) were also found.

These results are in alignment with a previous meta-analysis indicating academic interests and lifestyle factors were the most important factors guiding career choice.[[3]]  It is also known that experience as a medical student is important to guide career choice.[[3–6]] This is supported by our findings, with over two thirds of participants seeing their medical school experience as guiding their career choice. Thirteen percent of our participants had performed an operation under supervision as the primary surgeon. As such tailoring medical school and house officer training requirements to ensure adequate surgical exposure may help to attract candidates to general surgery.[[6]]

In terms of barriers to surgical training, our data supports previous studies with perceived hours of work being a big determinant of choice.[[3]] Surgical careers will need to find innovative ways of managing hours at work. Other important barriers were feeling overwhelmed and not feeling good enough. The unmet need for mentorship in this study is similar to prior research also among New Zealand MS.[[7]] This was especially important to Māori respondents. Improving mentorship may help address some of the aforementioned barriers, as effective mentorship is known to support junior staff both psychologically and in career decision-making.[[4,10]]

In this study, all six barriers were more significant for females than males. This is similar to a recent qualitative study evaluating view of minorities in surgical training, where women report being discouraged from a surgical career, in particular due to family commitments.[[11]] Likewise, in this study females also placed more importance on family commitments than males. There was a reported under-representation of females in surgical specialties in this study with which is not a new finding.[[12,13]] Female surgeons make up 25% of the general surgical workforce in New Zealand, and only 13% of senior surgical positions across Australasia.[[13,15]]

Similarly, this study has identified a perceived ethnicity bias in general surgery, with 97% of those who reported a bias, reporting over-representation of NZ Europeans/Pākehā. It is well known that NZ Europeans/Pākehā are over-represented in medicine, particularly in surgery.[[12]] There is no publicly available ethnicity data of general surgeons in New Zealand. Similar to recent interviews with minorities in surgical training, these findings in our study suggest the need to improve diversity in surgical training in New Zealand, aligning with the RACS Diversity Inclusion Plan which one of its goals being “to embrace diversity and foster gender equity’”[[1,14]]

This study is the first of its kind in New Zealand, and has a large sample size involving JD nationwide and MS at the UA. As such it provides unique information to help guide training opportunities in general surgery. The results of this study should be interpreted with respect to its limitations. The response rate was 21%, and it’s possible that MS and JD who had already decided on a surgical career were less likely to participate. To facilitate anonymity, the specific hospital that respondents were working in was not known by the investigators and as such it cannot be established whether exposure and experience in general surgery is different in tertiary hospitals compared to smaller rural hospitals. Knowledge of this difference may enable specific tailoring of mentorship and training opportunities in different regions. Given the role of a JD is reasonably standardised across New Zealand, application of these results outside of New Zealand is unclear. This study did not evaluate the views of training or pre-vocational training registrars. Knowledge of barriers and challenges trainees face is also essential to guide future training programmes. Perhaps and more importantly, a study would benefit from capturing the view of registrars who have initially expressed interest in a surgical career, but then opted for an alternative career. Future work could use a similar survey to evaluate the opinions of these groups.

This study has identified key motivators and barriers towards general surgery among MS and JD. It has also shown there is a perceived over-representation of males and NZ Europeans/Pākehā and an unmet need for mentorship. An acknowledgement of factors influencing a career choice in general surgery could help to improve opportunities in general surgery to diversify our workforce.

View Appendices.

Summary

Abstract

Aim

Increasing diversity among surgeons is a priority of the Royal Australasian College of Surgeons (RACS).[[1]] This study aimed to identify motivators and barriers to general surgery among junior doctors (JD) and medical students (MS) to help guide the recruitment of under-represented minorities into surgical training.

Method

An online survey was sent to 2,170 participants—1,327 JD in New Zealand and 843 MS at The University of Auckland (UA). Participants were asked about motivators or barriers to a career in general surgery.

Results

Twenty-one percent (452/2170) completed the survey. Most were female (65.1%), NZ European (53.6%) and MS (62.4%). Factors guiding career decision include interest in clinical and practical aspects (weighted average 4.43 and 4.34, respectively) and work–life balance (weighted average 4.11). Barriers to training were long hours and feeling overwhelmed (weighted average 4.05 and 3.64, respectively). There were perceived biases with 79.7% reporting a gender bias and 99.7% reporting male over-representation. Similarly, 68.4% reported an ethnicity bias; 97% reporting NZ European over-representation. 92.2% considered mentorship important but only 15.3% have a mentor.

Conclusion

This study identified motivators and barriers to general surgery and perceived gender and ethnicity biases. With demand for a diverse surgical workforce, there should be focus on recruitment of underrepresented minorities and mentorship.

Author Information

Leah Boyle: Department of General Surgery, Tauranga Hospital, Bay of Plenty DHB. Adam Payne: Department of General Surgery, Tauranga Hospital, Bay of Plenty DHB. Sharon Jay: Department of General Surgery, Tauranga Hospital, Bay of Plenty DHB. Jeremy Rossaak: Department of General Surgery, Tauranga Hospital, Bay of Plenty DHB.

Acknowledgements

Dr Robin Willink, Biostatical Group, University of Otago, Wellington.

Correspondence

Dr Leah Boyle: General Surgery SET 1 Trainee.

Correspondence Email

leahimogenboyle@gmail.com

Competing Interests

Nil.

1) Diversity and Inclusion Plan. Royal Australasian College of Surgeons. [Cited October 2021] Available from: https://www.surgeons.org/-/media/Project/RACS/surgeons-org/files/operating-with-respectcomplaints/building-respect/diversity-and-inclusion-plan-2019.pdf?rev=7e1f6c1e120b4ffa9de790eab331dae5&hash=B879F32E416DDAD2A038ED464C0F2ED3

2) Building Respect, Improving Patient Safety RACS Action Plan on Discrimination, Bullying and Sexual Harassment in the Practice of Surgery. Royal Australian College of Surgeons. [Cited September 2021] Available from:

3) https://www.surgeons.org/-/media/Project/RACS/surgeons-org/files/reports-guidelines-publications/action-plans/racs-action-plan_bullying-harassment_f-low-res_final.pdf?rev=364e80a0b46a4db9837f117f548b1513&hash=92FF3C64E63038B4FAE77FE09D7DE020

4) Yang Y, Li J, Wu X et al. Factors influencing subspecialty choice among medical students: a systematic review and meta-analysis. BMJ Open. 2019:9.

5) Sutton PA, Mason J, Vimalachandran D, McNally S. Attitudes, motivators, and barriers to a career in surgery: a national study of U.K. undergraduate medical students. J Surg Educ. 2014;71:662-7.

6) Cochran A, Melby S, Neumayer LA. An Internet-based survey of factors influencing medical student selection of a general surgery career. Am J Surg. 2005;189:42-6.

7) Marshall DC, Salciccioli JD, Walton SJ at al. Medical student experience in surgery influences their career choices: a systematic review of the literature. J Surg Educ. 2015;72:438-45

8) Yeom BW, Hardcastle T, Wood AJ. Recruitment to otorhinolaryngology: opportunities abound. Australian Journal of Otolaryngology. 2020;3:20-27.

9) Laurence C, Elliott T. When, what and how South Australian pre-registration junior medical officers' career choices are made. Med Educ. 2007;41:467-75.

10) Pianosi K, Bethune C, Hurley KF. Medical student career choice: a qualitative study of fourth-year medical students at Memorial University, Newfoundland. CMAJ Open. 2016;19:147-52.

11) Cowan F, Flint S. The importance of mentoring for junior doctors BMJ 2012;345.

12) Villanueva C, Cain J, Greenhill J, Nestel D. "The odds were stacked against me": a qualitative study of underrepresented minorities in surgical training. ANZ J Surg. 2021;91:2026-2031.

13) Klifto KM, Payne RM, Siotos C, et al. Women Continue to Be Underrepresented in Surgery: A Study of AMA and ACGME Data from 2000 to 2016. J Surg Educ. 2020;77:362-368.

14) The New Zealand Medical Workforce in 2018. Medical Council of New Zealand. 2018 [Cited September 2021] Available from: https://www.mcnz.org.nz/assets/Publications/Workforce-Survey/434ee633ba/Workforce-Survey-Report-2018.pdf

15) Activities Report 2019. Royal Australasian College of Surgeons. 2019 [Cited September 2021] Available from:

16) https://www.surgeons.org/-/media/Project/RACS/surgeons-org/files/reports-guidelines-publications/workforce-activities-census-reports/RACS_ActivitiesReport_2019_Final.pdf

17) Surgeons speak about women in surgery. 2021. [Cited February 2022] Available from: https://www.surgeons.org/en/News/News/surgeons-speak-about-women-in-surgery

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Increasing surgical diversity among trainees is a priority of the Royal Australasian College of Surgeons (RACS).[[1]] This fits in with the Building Respect, Improving Patient Safety Action Plan on discrimination, bullying and sexual harassment in surgery, launched in 2015, which supported actively working with medical schools to encourage surgery as a career.[[2]]

However, it is clear that career direction in medicine is a multi-factorial process that involves internal and external factors. Personal or internal factors include academic interest in a field, competencies and lifestyle factors.[[3,4]] External factors include the influence of previous experience on rotations.[[5]] For surgical specialties, systematic review suggests experience in the operating theatre as a student is the single most important factor to promote interest in surgery.[[6]] Despite this, less than 10% of students in a recent New Zealand survey felt their medical school exposure was sufficient for making an informed career choice, raising concern regarding exposure to surgery for junior doctors (JD) and medical students (MS).[[7]]

A positive role model has been shown to guide career choice in general surgery.[[5]] The development of mentorship relationships is important for MS and JD to provide support and guide career decision making.[[5,8,9]] Unfortunately, few students in New Zealand feel they have adequate mentorship, with only 10% in a recent survey of UA students reporting having a mentor.[[7]]

Possible deterrents for a career in General Surgery include poor work–life balance and negative experience on rotations at medical school.[[5]] There are also wider societal and cultural factors influencing a career in general surgery. There is a longstanding over-representation of males and the NZ European ethnicity in medicine in general.[[1,10,11]]

The aim of this study was to identify motivators and conversely the barriers to a career in general Surgery among JD and MS in New Zealand. Understanding these factors may improve recruitment and training opportunities in general surgery and importantly facilitate diversity in general surgical trainees.

Methods

An online survey (Appendix 1) was sent to 2,170 participants (1,327 JD and 843 MS). JD included all doctors employed in a house officer role nationwide. These are predominantly postgraduate years one and two. MS were clinical students at The University of Auckland School of Medicine in years four to six.

The researchers sent an email of invitation (Appendix 2) to the student convener at the University of Auckland (UA) and to the resident medical officer (RMO) coordinators at each of the twenty district health boards (DHBs) in New Zealand. This initial email asked to forward a separate email of invitation (Appendix 3) to MS and JD respectively, as well as reminder emails (Appendix 4). The invitation email sent to participants explained the aim of the study and outlined the consent process. This method facilitated anonymity as the researchers did not have access to the participants emails. The survey remained open for three weeks, with reminder emails to participate sent after one and two weeks.  

In the initial email, the student convener and RMO coordinator were asked to reply to the researchers to confirm receival and participation. Confirmation from the medical school student convenor was immediate. Only three DHBs responded immediately. When the RMO coordinator had not responded to the researchers within the first week, they were telephoned to clarify whether they had received the initial email, and then forwarded it on to participants. The researchers phoned each RMO coordinator a maximum of three times until a response was achieved. This ensured that all twenty DHBs had forwarded the email to participants.

The survey consisted of closed “yes” and “no” questions, multi-choice or Likert response questions on demographic data (age, gender, ethnicity, level of training and about family make-up) and motivators or barriers to general surgery. They were also asked about whether they perceived an ethnicity or gender bias which could include their own self-selection bias, or a perceived bias from selection committees. Respondents were able skip questions and still complete the survey.

Results remained anonymous and were analysed using Excel. Weighted averages were used for questions with Likert scales (1—not at all important; 2—not so important; 3—somewhat important; 4—very important; 5—extremely important). For the key motivators (question 8) and barriers (question 9) analysis was by subgroups of gender and ethnicity (Appendix 1). If participants identified with more than one ethnicity, their response was included in all of the ethnicities they identified with.

Ethical approval was obtained via The University of Auckland Human Participants Ethics Committee (UAHPEC21921).

Results

Demographics

The response rate was 21 % with a total of 452/2170 responses. The demographics of participants are summarised in Table 1. In terms of family, the majority (95.6%, n=431/451) had no children and over half (51.4%, n=232/451) were in a long-term relationship. Twenty-one point five percent (n =97/451) of respondents were very likely or likely to pursue a career in general surgery (Figure 1).

View Table 1 & Figure 1.

Motivators influencing a career in general surgery

Over half of the respondents (66.2%, n=298/450) see their medical student experience as very or extremely important in determining their career choice. In terms of experience to date, almost all respondents (94.3%, n=399/423) have had the opportunity to assist in theatre, and 13.0% (n=55/423) have performed an operation as the primary surgeon. Over half of respondents have had the opportunity to see and assess patients independently, with 59.1% (n=253/423) having experience admitting acute patients and 51.5% (n=218/423) seeing patients in clinic. Twenty-six percent (n=108/423) have had experience with research.

The most important factors guiding career choice were interest in clinical aspects (weighted average 4.43), interest in practical aspects (weighted average 4.34) and work life balance (weighted average 4.11) (Table 2). The least important aspect for career choice was research opportunities (weighted average 2.64). Factors guiding career choice are analysed by gender and ethnicity in Table 2. Of note, females place more importance on family commitments guiding their career choice compared to males (3.86 vs 3.66) whilst males place more importance on income (3.25 vs 2.91).

View Table 2.

Regarding ethnicity when compared to all respondents, Māori place greater importance on a mentor or role model (4.05 vs. 3.87) and experience on prior rotations (4.17 vs 3.96). Importantly, Pasifika peoples place the greatest importance on family commitments when compared to all respondents (4.30 vs 3.78) (Table 2). Almost all respondents (92.2%, n=416/451) consider having a mentor important; 34.6% somewhat important, 39.3% very important and 18.4% extremely important. Despite this, only 15.3% (n=69/451) reported currently have a mentor.

Barriers influencing a career in general surgery

There were perceived gender and ethnicity biases in general surgery among respondents. Seventy-nine point seven percent (n=357/448) reported a gender bias, with 99.7% (n=356/357) of these reporting that males are over-represented. Similarly, 68.4% (n=307/449) reported an ethnicity bias. Ninety-seven percent of these (298/307) reported NZ Europeans as being over-represented.

The most significant barrier for choosing general surgery as a career amongst all respondents was perceived hours of work (4.05) and when broken down by gender, hours was a more significant barrier for females (4.11 vs 3.91) (Table 3).

View Table 3.

Discussion

This study demonstrated key factors, both motivators and barriers influencing career decision for MS and JD with a particular focus on general surgery. Key motivators guiding career choice were interest in clinical aspects, practical aspects, and work–life balance. In terms of barriers, the most important was perceived hours of work. Of note, all six barriers were more significant for females.

This study also demonstrated there is an unmet need for mentorship, with 92% considering mentorship important but only 15% currently having a mentor. A perceived over-representation of males—79.7% (n=357/448); and Pākehā/NZ Europeans—68.4% (n=307/449) were also found.

These results are in alignment with a previous meta-analysis indicating academic interests and lifestyle factors were the most important factors guiding career choice.[[3]]  It is also known that experience as a medical student is important to guide career choice.[[3–6]] This is supported by our findings, with over two thirds of participants seeing their medical school experience as guiding their career choice. Thirteen percent of our participants had performed an operation under supervision as the primary surgeon. As such tailoring medical school and house officer training requirements to ensure adequate surgical exposure may help to attract candidates to general surgery.[[6]]

In terms of barriers to surgical training, our data supports previous studies with perceived hours of work being a big determinant of choice.[[3]] Surgical careers will need to find innovative ways of managing hours at work. Other important barriers were feeling overwhelmed and not feeling good enough. The unmet need for mentorship in this study is similar to prior research also among New Zealand MS.[[7]] This was especially important to Māori respondents. Improving mentorship may help address some of the aforementioned barriers, as effective mentorship is known to support junior staff both psychologically and in career decision-making.[[4,10]]

In this study, all six barriers were more significant for females than males. This is similar to a recent qualitative study evaluating view of minorities in surgical training, where women report being discouraged from a surgical career, in particular due to family commitments.[[11]] Likewise, in this study females also placed more importance on family commitments than males. There was a reported under-representation of females in surgical specialties in this study with which is not a new finding.[[12,13]] Female surgeons make up 25% of the general surgical workforce in New Zealand, and only 13% of senior surgical positions across Australasia.[[13,15]]

Similarly, this study has identified a perceived ethnicity bias in general surgery, with 97% of those who reported a bias, reporting over-representation of NZ Europeans/Pākehā. It is well known that NZ Europeans/Pākehā are over-represented in medicine, particularly in surgery.[[12]] There is no publicly available ethnicity data of general surgeons in New Zealand. Similar to recent interviews with minorities in surgical training, these findings in our study suggest the need to improve diversity in surgical training in New Zealand, aligning with the RACS Diversity Inclusion Plan which one of its goals being “to embrace diversity and foster gender equity’”[[1,14]]

This study is the first of its kind in New Zealand, and has a large sample size involving JD nationwide and MS at the UA. As such it provides unique information to help guide training opportunities in general surgery. The results of this study should be interpreted with respect to its limitations. The response rate was 21%, and it’s possible that MS and JD who had already decided on a surgical career were less likely to participate. To facilitate anonymity, the specific hospital that respondents were working in was not known by the investigators and as such it cannot be established whether exposure and experience in general surgery is different in tertiary hospitals compared to smaller rural hospitals. Knowledge of this difference may enable specific tailoring of mentorship and training opportunities in different regions. Given the role of a JD is reasonably standardised across New Zealand, application of these results outside of New Zealand is unclear. This study did not evaluate the views of training or pre-vocational training registrars. Knowledge of barriers and challenges trainees face is also essential to guide future training programmes. Perhaps and more importantly, a study would benefit from capturing the view of registrars who have initially expressed interest in a surgical career, but then opted for an alternative career. Future work could use a similar survey to evaluate the opinions of these groups.

This study has identified key motivators and barriers towards general surgery among MS and JD. It has also shown there is a perceived over-representation of males and NZ Europeans/Pākehā and an unmet need for mentorship. An acknowledgement of factors influencing a career choice in general surgery could help to improve opportunities in general surgery to diversify our workforce.

View Appendices.

Summary

Abstract

Aim

Increasing diversity among surgeons is a priority of the Royal Australasian College of Surgeons (RACS).[[1]] This study aimed to identify motivators and barriers to general surgery among junior doctors (JD) and medical students (MS) to help guide the recruitment of under-represented minorities into surgical training.

Method

An online survey was sent to 2,170 participants—1,327 JD in New Zealand and 843 MS at The University of Auckland (UA). Participants were asked about motivators or barriers to a career in general surgery.

Results

Twenty-one percent (452/2170) completed the survey. Most were female (65.1%), NZ European (53.6%) and MS (62.4%). Factors guiding career decision include interest in clinical and practical aspects (weighted average 4.43 and 4.34, respectively) and work–life balance (weighted average 4.11). Barriers to training were long hours and feeling overwhelmed (weighted average 4.05 and 3.64, respectively). There were perceived biases with 79.7% reporting a gender bias and 99.7% reporting male over-representation. Similarly, 68.4% reported an ethnicity bias; 97% reporting NZ European over-representation. 92.2% considered mentorship important but only 15.3% have a mentor.

Conclusion

This study identified motivators and barriers to general surgery and perceived gender and ethnicity biases. With demand for a diverse surgical workforce, there should be focus on recruitment of underrepresented minorities and mentorship.

Author Information

Leah Boyle: Department of General Surgery, Tauranga Hospital, Bay of Plenty DHB. Adam Payne: Department of General Surgery, Tauranga Hospital, Bay of Plenty DHB. Sharon Jay: Department of General Surgery, Tauranga Hospital, Bay of Plenty DHB. Jeremy Rossaak: Department of General Surgery, Tauranga Hospital, Bay of Plenty DHB.

Acknowledgements

Dr Robin Willink, Biostatical Group, University of Otago, Wellington.

Correspondence

Dr Leah Boyle: General Surgery SET 1 Trainee.

Correspondence Email

leahimogenboyle@gmail.com

Competing Interests

Nil.

1) Diversity and Inclusion Plan. Royal Australasian College of Surgeons. [Cited October 2021] Available from: https://www.surgeons.org/-/media/Project/RACS/surgeons-org/files/operating-with-respectcomplaints/building-respect/diversity-and-inclusion-plan-2019.pdf?rev=7e1f6c1e120b4ffa9de790eab331dae5&hash=B879F32E416DDAD2A038ED464C0F2ED3

2) Building Respect, Improving Patient Safety RACS Action Plan on Discrimination, Bullying and Sexual Harassment in the Practice of Surgery. Royal Australian College of Surgeons. [Cited September 2021] Available from:

3) https://www.surgeons.org/-/media/Project/RACS/surgeons-org/files/reports-guidelines-publications/action-plans/racs-action-plan_bullying-harassment_f-low-res_final.pdf?rev=364e80a0b46a4db9837f117f548b1513&hash=92FF3C64E63038B4FAE77FE09D7DE020

4) Yang Y, Li J, Wu X et al. Factors influencing subspecialty choice among medical students: a systematic review and meta-analysis. BMJ Open. 2019:9.

5) Sutton PA, Mason J, Vimalachandran D, McNally S. Attitudes, motivators, and barriers to a career in surgery: a national study of U.K. undergraduate medical students. J Surg Educ. 2014;71:662-7.

6) Cochran A, Melby S, Neumayer LA. An Internet-based survey of factors influencing medical student selection of a general surgery career. Am J Surg. 2005;189:42-6.

7) Marshall DC, Salciccioli JD, Walton SJ at al. Medical student experience in surgery influences their career choices: a systematic review of the literature. J Surg Educ. 2015;72:438-45

8) Yeom BW, Hardcastle T, Wood AJ. Recruitment to otorhinolaryngology: opportunities abound. Australian Journal of Otolaryngology. 2020;3:20-27.

9) Laurence C, Elliott T. When, what and how South Australian pre-registration junior medical officers' career choices are made. Med Educ. 2007;41:467-75.

10) Pianosi K, Bethune C, Hurley KF. Medical student career choice: a qualitative study of fourth-year medical students at Memorial University, Newfoundland. CMAJ Open. 2016;19:147-52.

11) Cowan F, Flint S. The importance of mentoring for junior doctors BMJ 2012;345.

12) Villanueva C, Cain J, Greenhill J, Nestel D. "The odds were stacked against me": a qualitative study of underrepresented minorities in surgical training. ANZ J Surg. 2021;91:2026-2031.

13) Klifto KM, Payne RM, Siotos C, et al. Women Continue to Be Underrepresented in Surgery: A Study of AMA and ACGME Data from 2000 to 2016. J Surg Educ. 2020;77:362-368.

14) The New Zealand Medical Workforce in 2018. Medical Council of New Zealand. 2018 [Cited September 2021] Available from: https://www.mcnz.org.nz/assets/Publications/Workforce-Survey/434ee633ba/Workforce-Survey-Report-2018.pdf

15) Activities Report 2019. Royal Australasian College of Surgeons. 2019 [Cited September 2021] Available from:

16) https://www.surgeons.org/-/media/Project/RACS/surgeons-org/files/reports-guidelines-publications/workforce-activities-census-reports/RACS_ActivitiesReport_2019_Final.pdf

17) Surgeons speak about women in surgery. 2021. [Cited February 2022] Available from: https://www.surgeons.org/en/News/News/surgeons-speak-about-women-in-surgery

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