Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 49, Num. 3, 2003, pp. 197-201

Journal of Postgraduate Medicine, Vol. 49, No. 3, July-Sept, 2003, pp. 197-201

Factors Influencing the Selection of Surgical Specialty among Pakistani Medical Graduates

Avan BI, Raza SA, Hamza H, Khokhar S, Awan F

Department of Surgery, Faculty of Health Sciences, Medical College, The Aga Khan University, Stadium Road, P.O.Box 3500, Karachi 74800
Correspondence Address: Department of Surgery, Faculty of Health Sciences, Medical College, The Aga Khan University, Stadium Road, P.O.Box 3500, Karachi 74800 ahsan.raza@aku.edu

Code Number: jp03057

ABSTRACT

CONTEXT: The delineation between selection of surgery and non-surgery residency programmes could provide a pragmatic view of the influences on medical graduates’ careers. This would also help coordinators and educators of residency programmes in surgery to further understand the dynamics of specialty selection. AIMS: To identify the different factors that influence the graduates to select surgical specialties in Pakistan. SETTINGS AND DESIGNS: A cross-sectional survey was conducted in 4 teaching hospitals of Karachi between July 1999 and January 2001. SUBJECTS and METHODS: A total of 455 residents in 1-5 years of residency programmes were contacted. Three hundred and forty-one residents consented to the interview. Residents who were registered both with the College of Physicians and Surgeons of Pakistan (CPSP) and the Post Graduate Medical Education (PGME) office of the selected hospitals were included in this study. STATISTICAL METHOD USED: Logistic regression analysis. RESULTS: Final multivariate analysis identified 4 factors that remained significantly associated with the selection of surgical specialty: deriving gratification from direct patient care (adjusted odds ratio [aOR] = 5.79; 95% confidence interval [CI]: 1.24, 26.99), procedure-based medical practice (aOR = 2.85; 95% CI: 1.23, 6.61), nature of clinical problems (aOR = 3.39; 95% CI: 1.47, 7.84), and lack of consideration of stress during professional work (aOR = 2.27, 95%CI: 1.25, 4.13). CONCLUSIONS: Direct patient care is perceived to be an integral part of surgery residency and immediate patient outcome is a positive influence in selecting surgical specialty. The inclination towards surgery appeared to be determined by the type of procedures and technical skills involved in its practice. The nature of clinical problems is an important determinant of the choice of specialty. Stress was not perceived to be an important influencing factor for those who decided to select surgical specialties.

Keywords: Surgery, Residency, Training, Stress, Logistic regression

Surgery is a challenging profession involving long work hours and commitments that could interfere with an individual's personal life.[1],[2],[3],[4],[5] Several studies over the years have explored perceptions and preferences of doctors who select surgery as a specialty for their postgraduation.[6],[7],[8] Different factors have been considered important in determining specialty preferences such as demographic, socio-economic,[9],[10],[11] and behavioural factors.[12],[13] Among behavioural factors, lifestyle has been suggested as one of the most important factors in selecting a surgical career, and many graduates tend to opt for specialties that offer a more controllable lifestyle.[11],[12],[14],[15],[16] Intellectual challenge in the job and procedure-based medical practice were given more importance in studies conducted to evaluate the influences on the choice of career of residents.[6],[13],[17],[18],[19]

This study was conducted to determine the factors that persuaded the residents to select surgical specialties after their graduation from medical school. The delineation between selection of surgery and non-surgery residency programmes could provide a pragmatic view of the influences on medical graduates' career choices.

SUBJECTS AND METHODS

A cross-sectional survey was conducted in 4 teaching hospitals of Karachi between July 1999 and January 2001. The selection criteria for these institutions were the availability of a comprehensive infrastructure for major residency programmes, and their location in safe areas of Karachi. These institutes were recognized for their postgraduate training by the College of Physicians and Surgeons of Pakistan (CPSP).

A total of 455 residents in 1-5 years of residency programmes were contacted. Three hundred and forty-one residents consented to the interview. Residents who were registered both with the CPSP and with the Post Graduate Medical Education (PGME) office of the selected hospitals were included in the study. These residents were from internal medicine, family medicine, neurology, paediatrics, psychiatry, obstetrics and gynaecology, general surgery, urology, neurosurgery, paediatric surgery, orthopaedics, anaesthesiology, radiology, pathology, and community medicine. These programmes were divided into surgical and non-surgical residencies for purpose of analysis.

A detailed questionnaire was developed to assess the residency programmes, and information was collected on demographic, psychological, behavioural and socio-economic factors after an extensive review of literature. The questionnaire was improved after pre-testing on interns who were not part of the target population.

Data was analysed using the Statistical Package for Social Sciences (SPSS version 11.0). Descriptive statistics were computed, and the relationship between surgical specialty and categorical variables (gender, marital status, hospital, year of residency) were evaluated using Pearson Chi square test; t-test was used for continuous variables (work hours and year since graduation). Residents from selected programmes were categorised into surgery and non-surgery residency programmes for univariate and multivariate analysis. Univariate analysis was carried out by computing odds ratios (OR) and their 95% confidence intervals (CI) to compare surgery and non-surgery residency programmes for each factor of interest. Multivariate analysis was done to identify factors independently associated with the choice of residency programme.

RESULTS

[Table-1] shows the comparison of demographic factors of surgical and non-surgical residents. Demographic variables included gender, marital status and time since graduation. There was no difference between the 2 groups in relation to the 4 hospitals (p = 0.09). The average interval between graduation and initiation of residency was more among non-surgical residents as compared to the surgery residents (3.15 vs. 2.54 years, p = 0.09). Residents in surgery had the highest average working hours compared to non-surgical residents (82.03 vs. 68.54, p < 0.05).

Among psychological factors [Table-2], deriving gratification from patient care by residents was significantly associated with the selection of surgery for specialty training (OR = 7.53, 95% CI: 1.73, 32.77). Graduates who had an inclination towards procedure-based medical practice were more likely to choose surgical specialty (OR = 3.13, 95% CI: 1.45, 6.75). Similarly, those who perceived stress in the specialty as less important, were more likely to select surgery (OR = 1.73, 95% CI: 1.05, 2.84) compared to those who perceived it as more important. Lack of control over lifestyle did not show any significant association with the selection of surgical specialty (OR = 1.58, 95% CI: 0.84, 3.03). Among behavioural factors [Table-3], graduates who thought that they wanted to be more in direct contact with the patients were 3.35 times more likely to select surgery residency (95% CI: 1.56, 7.21). Graduates who perceived the specific nature of a clinical problem as important were 3.2 times more likely to select surgical specialty (OR = 3.2, 95% CI: 1.54, 6.67). Although the odds of 'opportunity for intellectual stimulation' among those who selected surgery residency were 2.63 times the odds among those who selected non-surgery residency, this variable could only achieve marginal statistical significance (95% CI: 0.95, 7.29). Other perceived behavioural factors were not associated with the selection of surgical specialty, including personal skills and abilities (95% CI: 0.44, 6.81), and opportunity for growth (95% CI: 0.53, 3.19). None of the economic (high income prospects), and social factors (prestige, encouragement from faculty, senior colleagues, and peers) showed significant association with the selection of surgical specialties [Table-4].

On multivariate analysis [Table-5], 4 factors remained significantly associated with the selection of surgical specialty. Deriving gratification from patient care, procedure-based medical practice, specific nature of clinical problem, and lack of consideration for stress were identified as factors associated with the selection of surgical specialty. In the final model, those residents who thought that stress in the specialty did not affect their choice of residency were 2.27 times more likely to choose surgery residency for specialty training (95% CI: 1.25, 4.13) after adjusting for all other factors in the model.

DISCUSSION

Determinants of specialty choices have been examined by various studies[1],[4],[16] but few of them have focussed on the evolution of these choices or the reasons behind decisions to join surgical specialty. The finding that receiving gratification from patient care is significantly associated with the selection of surgical specialty [Table-5] implies that patient care is perceived to be an integral part of surgical residency that also allows a meaningful doctor-patient relationship to grow in the long run. About 99% of residents in surgery expressed that gratification from patient care was an influencing factor in choosing surgery. Importantly, 90% from among non-surgical residents also gave a similar response [Table-2]. This finding is in contrast with the previous studies[1],[17] where deriving satisfaction from patients and an opportunity to provide care were identified as important determinants of medical, and not surgical specialty. This may indicate that an immediate patient outcome in surgery is perceived as a positive influence in selecting surgical specialty compared to other specialties.

From the final model that shows an association between procedure-based medical practice and the selection of surgery as a specialty, it appears that future surgeons were more inclined towards their choice of specialty because of the technical skills involved in their specialty [Table-5]. This finding also supports the results reported by Lieu et al[1] where students who selected surgery among other technology-oriented specialties gave higher ratings to the opportunity to perform procedures.

Perceptions about the nature of clinical problems in a specialty are also important influencing factors for most of the residents. Only 7% of the residents in surgery think that the type of clinical problem is not an influencing factor compared to 19% in the non-surgical specialty [Table-3]. However, 86% of all the residents perceived that the nature of clinical problems is, in fact, an important determinant of the choice of specialty. Further characterisation of the nature of clinical problems in both surgical and non-surgical residents would help to know the residents' perception of this factor and also about the predictability of specialty selection.

Stress was not considered to be an important influencing factor by those residents who had decided to join surgery. This seems to reinforce the belief that residents who choose non-surgical residency are discouraged by the amount of stress in the surgical specialty.[7] Studies have suggested that this factor, in fact, has some influence, especially for those who are uncertain about their choices of specialty or change their career pathway during residency training. Though one of the reasons for rejecting surgical specialty as a career among graduates in some previous studies, was lack of control over one's lifestyle such as having less time for family and leisure activities,[11],[12],[14] in this study we found that lack of control over lifestyle did not dissuade many residents from selecting surgery as their career. Income is not a statistically significant influencing factor in our study [Table-5] and this is similar to the finding from a previous study.[1] In fact, income was the lowest-rated variable by medical graduates intending to join surgery thus contradicting the findings that this factor attracts graduates towards surgery and other technology-oriented specialties.

The findings from this study have propositions for career planning within the medical profession as a whole. The identification of factors influencing the selection of surgical specialties gives some credence to the strengths, flexibility and versatility of surgical residency training programmes. The information gained from this study can be used in developing recruitment materials, and upgrading the surgery residency programmes.

 REFERENCES

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