CHOICE OF MEDICAL SPECIALTY ANALYSIS OF STUDENTS' NEEDS '

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Psychological Reporfs, 1992, 71, 215-224. O Psychological Reports 1992 CHOICE O F MEDICAL SPECIALTY

ANALYSIS OF STUDENTS' NEEDS

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PAUL HENRY FREDERICK T. L. LEONG

School of Medicine The Ohio State University Southern Illinoir UniuersiQ at Carbondak

ROGER ROBINSON

School of Medicine

Southern Illinois UniversiQ af Carbondale

Summary.-The purposes of thls study were to assess the career development needs of entering medical students as measured by the Medical Career Development Inventory and to examine gender differences in responses to the inventory. A total of 115 entering medical students (representing two entering classes) took the inventory two months prior co matriculacion. Analysis suggested that this sample of entering stu- dents had formed a vocational identity and that they had evaluated the suitability and viability of a commitment to a physician's career. However, the participants had not formed a clear picture of their specialty interest and goals. No significant gender differences were indicated. A recommended career assistance workshop is presented as ap- propriate for these students' needs.

Few decisions required of medical students can have as long and lasting an effect on an individual as the choice of which career direction to pursue. In a sample of 314 first-, second-, and third-year medical students, 81% indicated that specialty selection is the most important decision they face in medical school (Glaxo, Inc., 1987). Yet, choosing a medical specialty and selecting a residency can be a confusing and complex process (Steere, 1989). The confusion, in part, is due to the growth and complexity of medical information, which has led to an increase in medical subspecialties. The number of specialties has grown from 10 to 80% since 1931 (University of New Mexico, 1974). Currently, physicians in training must choose from among 63 specialty and subspecialty alternatives (Savickas, Alexander, Osi- pow, & Wolf, 1985).

The sheer number of available choices has made it difficult for medical students to decide on a specialty with some certainty. The lack of certainty and indecision is reflected in the limited stability of specialty choices made in the first year of medical school (Gough, 1979) as well as the effects of students' attitudes (Furnham, 1986) and experiences (Paiva, Vu, & Verhdst, 1982) in later years. This problem of indecision is greatest during the first two years of medical education and represents a major source of anxiety for medical students (Savickas, et al., 1985). Relatively few medical schools pro-

'Address enquiries to P. Henry, School of Medicine, Southern Illinois University at Carbondale, Carbondale, IL 62901-4323.

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vide formal assistance designed to reduce the anxiety about such decisions experienced by many students (Steere, 1989).

The literature regarding career choices within medicine has concentrated primarily in six basic areas of concern: (1) background factors (i.e., sex, parental occupation, school, family and social background, nationality, and marital status); (2) personality and attitude factors (i.e., physician's attitude toward patients, death, problem solving, team work, decision-making and the exercise of authority); (3) factors related to the educational system (i.e., sec- ondary school record, career advice, the selection system, examination per- formance, the medical training system, and the student's image of the various specialties); (4) career factors (i.e., pay and the chances of distinctive awards, income relativities, promotion prospects, possibilities of emigrating, opportunities for private practice and prestige); (5) working conditions (i.e., area of residence, type of hospital, equipment and facilities available, length of working day, regularity of hours and effects on family life); (6) intrinsic differences between the specialties themselves (i.e., amount of patient con- tact, the extent to which they are research- or science-oriented, their relative success rates in terms of curing, the skills they require and the lunds of satisfaction, social or intellectual, to be derived from them) (Hutt, 1976). More recently, similar categories of the career choice were presented by Davis, Bouhuijs, Dauphinee, McAvoy, Alexander, Coles, Donaldson, Hoftvedt, Wakeford, and Warren (1990).

Several authors have produced studies related to the present investiga- tion, studies which have identified various students' needs regarding specialty choice. I n these surveys the need for advice and information about careers were the areas most often studied. The studies regarding the availability and use of career advice have produced mixed results. M e n (1988) conducted a national career survey of doctors in the UK and reported that 1% of a sample of 1966 graduates and 20% of a sample of 1981 graduates (N = 640) had career advice during medical school. I n a study of preclinical and clinical students ( N = 45) and preregistration house officers Warren and Wakeford (cited by Davis, et a l . , 1990, p. 5 ) reported that 66% wanted more advice about medicine as a career both at school and at all stages of medical training. O n the other hand, Parkhouse and Ellin (1988), after a follow-up survey of doctors who graduated from British medical schools in 1974 and 1977, contended that career advice or the lack of it has little effect on career choice.

Studies of the need for career information for deciding on a medical specialty field produced consistent results and clearly suggested more information was needed. I n a national survey of first-, second-, and third-year medical students, Glaxo, Inc. (1987) reported that 80% of the students felt that they currently did not have enough information upon which to base a

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CHOOSING MEDICAL SPECIALTIES 217 decision regarding a specialty. Taggart, Wartman, and Wessen (1988) also conducted a nationwide survey of American medical schools and found that 52% of the students indicated information on specialties was not available in their schools. These authors further reported that students who had access to information from medical professionals (faculty members, deans, and staff physicians) felt they had greater access to information than did students who utilized sources such as an informal network and official directories. Savickas, Alexander, Jonas, and Wolf (1986) surveyed first-, second-, thud-, and fourth-year medical students and identified the following areas which may be interpreted as important: equal appeal of several specialties, diverse interests, a lack of support in making a decision, not knowing one's interest and abilities, and the lack of information about specialties.

According to Zimny and Thale (1970) knowledge of the specialty stereotypes held by medical students is important because such stereotypes can contribute to students' choices. These authors assessed the attitudes of 62 graduating medical students toward four specialists (Surgeon, Pediatrician, Internist, and Psychiatrist) and reported that the students had quite different stereotypes of these specialists. The authors noted that the specialist stereotype contributes to the formation of the student's model of each medical specialty. In a similar study Zimet and Held (1975) surveyed the beliefs of medical students in the freshman, sophomore, and senior year toward each of five specialists with respect to status, social attractiveness, and simi- larity to self. Although there was no direct causal relationship between students' beliefs and their career choices, it was the authors' contention that students' beliefs strongly influence decisions about specialty.

The effects of gender differences in regard to beliefs, personality characteristics, and specialty choices were reported by McGrath and Zimet (1977). After surveying 95 female and 166 male medical students, these authors reported significant differences between men and women on choice of specialty, ratings of status and social attractiveness of the specialties, and personality characteristics. The authors also noted that for female medical students specialty choices and general personality have changed to less tradi- tional and less stereotypical positions in recent years.

Not only are there differences among women and men in the way various medical specialty fields are viewed and chosen but also women expe- rience unique challenges as practitioners. Cartwright (1978) examined career satisfaction and role harmony in a sample of young women physicians. The author reported that career satisfaction was extremely high with about 88% indicating that they were satisfied or very satisfied. Over half, however, indicated that they had experienced at least a moderate amount of strain in integrating professional and sex roles. More recently in a sample of predorni- nantly white women physicians Cartwright (1987) noted that the pattern of

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combined roles (referred to as role montage) was related to the women's reported stress. Depending on the role montage adopted by the women, stress could be virtually nonexistent or extremely high. The author identified three common patterns that the women in her sample used to combine their multiple roles: (1) Super-woman-this woman aims to have a family and a very active full-time career; (2) Career of limited ambition-this woman has placed her family first and elected a less taxing role in medicine, usually part-time work in a salaried position; and (3) Medicine is my lust-this woman puts medicine first and decides to forego family for a variety of reasons. The author noted a need for more observation and delineation of various role integrations, so that costs and benefits of these patterns can be observed over time.

Zimny and Thale (1970) suggested that the development of testing and counseling procedures that can be used to provide medical school students with meaningful and objective guidance i n their selection of a specialty should be a practical goal of research. There is limited research concerning the effectiveness of formal career assistance programs that incorporate testing and counseling and are designed to help medical students choose a specialty. Perhaps the lack of research in this area is because relatively few medical schools have such programs (Steere, 1989). However, an example of an effec- tive career assistance workshop was reported by Leong, Gaylor, and Ford (1991). These authors offered a workshop to three consecutive classes of second-year students enrolled at a northeastern medical school. A total of 161 students participated in the workshop which consisted of two three-hour sessions. To assess the effects of the workshops, a comparison of the participants' pre- and postworkshop ratings were collected at each workshop. The authors reported significant increases in the participants' certainty and satisfaction with their specialty choice.

The literature seems to indicate clearly that medical students need assistance in career decision-making. The limited data regarding the effectiveness of programs designed to help medical students choose a specialty field is an indication that research designed to evaluate such programs should be under- taken. Warner (1975) has pointed out that all too often counseling intervention programs are designed to satisfy the institution's needs rather than those of the students. Perhaps an identification of students' expressed needs prior to designing a program to assist in choosing a medical specialty field would be an important first step.

The work of Glaxo, Inc. (1987) is one in which students (first-, second-, and thud-year) were surveyed prior to designing a career intervention program. The examination of pre-entry needs, however, represents a somewhat different approach. The present study was designed specifically to (1) assess developmental level decisions about careers of entering medical students and (2) to examine the effects of gender o n career development.

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CHOOSING MEDICAL SPECIALTIES

Instrument

The Medical Career Development Inventory (Savickas, 1984) was designed to measure both vocational development and the readiness to cope with the developmental tasks encountered in a physician's career. The inventory includes 35 items on coping behavior germane to vocational tasks in career development for physicians. Examinees respond on each item to one of five alternatives in Likert format.

The inventory measures responses to vocational tasks. Two cycles of tasks, in exploring physicians' vocational development, comprise the inventory: (I) the career cycle (crystallize and specify a career preference and implement a career choice) and (2) the occupational cycle (crystallize and specify an occupational preference and implement an occupational choice). The first task, establishing and stabilizing a position of practice, is also in- cluded in the inventory to ensure an adequate "ceiling" for samples of student-physicians and residents (Savickas, 1984).

The content outline of the inventory is composed of seven vocational developmental tasks and time periods. Five items for each task/time period were grouped to form seven homogeneous clusters of subscales. The seven groups of items (35 total items) are presented in the following sequence: Scale I. Crystallize a career preference, Scale 11. Specify physician as a career preference, Scale 111. Implement physician as a career choice, Scale IV. Crys- tallize a specialty preference, Scale V. Specify a specialty preference, Scale

VI. Implement specialty choice, Scale VII. Stabilize (Savickas, 1984). Scores for the seven scales and a total score may be computed from the 35 items. A scale score is the arithmetic sum of responses to the five items in a scale. The scale scores, ranging from 5 to 25, indicate the focus of vocational development. A score of 20 or more suggests that a subject has coped with the task represented by that scale. A score from 15 to 19 suggests that the task is the focus of coping, whereas a score from 10 to 14 suggests that the task is the subject of concern and reflection. A score below 10 suggests that the task has not been encountered. The total score is the sum of the seven scale scores and indicates vocational development, that is, the place reached on the continuum of vocational development tasks of early adult- hood (Savickas, 1984).

The initial evaluation of the inventory's psychometric properties, reported by Savickas (1984), with a sample of 160 student physicians sup- ported the content validity of the items, construct vahdity of the items, construct validity of the scales, and the criterion validity of the inventory. Subjects and Procedure

The Medical Career Development Inventory was mailed to first-year medical students at a midwestern university medical school two months prior

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to their matriculation. Two entering classes were surveyed. Of the 148 mail- ings, 115 (77%) students completed and returned the inventory (66 men and 49 women, ranging in age from 2 1 to 38 years; M = 25). The return rates for the two years were 81% and 76%, respectively.

Research Questions and Data Analysis

The following questions were addressed in the present study: (1) What is the mean level of career development of the first-year medical students in this sample as measured by the inventory? To address this question descrip- tive statistics were calculated for each subscale and the total inventory. (2) Is there a significant difference between the men's and women's responses to the inventory? A t test for mean differences was used.

RESULTS

The means and standard deviations for each of the subscales and total are presented in Table 1. The mean values for Career Crystallization and Ca- reer Specification (20.81 and 20.63, respectively) suggest that the students as a group have coped with the behaviors constituting these scales. That is, the students have formed a vocational identity and evaluated the suitability and viability of a commitment to a physician's career.

TABLE 1

MEANS AND STANDARD DEVIATIONS ON THE MEDICAL CAREER DEVELOPMENT INVENTORY FOR FIRST-YEAR MEDICAL STUDENTS ( N = 115)

Periods M SD Range Career Crystallization 20.81 3.41 8.00-25.00 Career Specification 20.63 3.30 10.00-25.00 Career Implementation 18.82 3.63 9.00-25.00 Occupational Crystallization 15.16 4.67 5.00-25.00 Occupational Specification 12.78 4.51 5.00-24.00 Occupational Implementation 9.77 3.62 5.00-19.00 Stabilization 9.17 3.33 5.00-16.00 Total 107.14 19.04 5.00-151.00

The Career Implementation and the Occupational Cryst&zation subscales produced mean values (18.82 and 15.15, respectively) which indicate that the behaviors associated with these subscales are the students' current focus of coping. That is, the implementation of a physician's career as well as coping behaviors related to one's specialty interest, abilities, and goals are the current focus.

The mean value for the Occupational Specification subscale (12.78) suggests that the behaviors (i.e., behaviors that involve the selection of an occupational role to which one feels committed with some assurance and for whlch one actually looks in a residency position) are the subject of concern and reflection. The Occupational Implementation and the Stabilization sub-

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CHOOSING MEDICAL SPECIALTIES 22 1

scales (i.e., implementing a specialty choice and stabilizing in a practice position) yielded means of 9.77 and 9.17, respectively, which indicate that these tasks have not been encountered.

The total score mean (107.14) indicates the place in vocational development reached. Comparing the total score with that of others in the same age group shows whether the subject is more or less mature than peers. The range of raw scores on the subscales in Table 1 indicates the diverse back- grounds of this sample. The largest ranges are observed on the Occupational Crystallization and the Occupational Specification Scales (5.00 vs 25.00 and 5.00 vs 24.00, respectively).

Further examination of the means indicates a decrease across the subscales from crystallization to stabihzation. This is consistent with Savickas' (1984) hypothesis that ordering the scales by their means indicates the tem- poral sequence underlying vocational development. Means should consistent- ly decrease from Scale 1 through Scale 7.

The differences between men and women are shown in Table 2. While the men produced higher mean scores, the ratio across subscales and the total were not significant (p<0.05). The men and women in this sample re- sponded similarly to the inventory.

TABLE 2

COMPARISON OF DIFFERENCES BETWEEN MALE AND FEMALE FIRST-YEAR MEDICAL STUDENTS

ON T.HE MEDICAL CAREER DEVELOPMENT INVENTORY (N = 115)

Per~od Men, n = 66 Women, n = 49 t+ P

M SD M SD Career Crystallization Career Specification Career Implementation Occupational Crystallization Occupational Specification Occupational Implementation Stabilization Total *AU comparisons ns. DISCUSSION

The purposes of the present study were to assess the career developmental level of entering medical students and to examine the association of gender. Analysis yielded no significant gender differences and suggested these students have formed a vocational identity and evaluated the suitability and viability of a commitment to a physician's career; they have not formed a clear picture of their specialty interest and goals.

These findings are similar to the results reported by Savickas, et a/.

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begun to engage in self-exploration and specialties. They reported that the difficulties experienced by first-year students were the result of a lack of information about the specialties, lack of support in making decisions, not being interested in the specialties with which they are familiar, learning that getting a desired specialty was not possible, and feeling lost when thinking about how to choose a specialty. The authors concluded that these difficulties reflect a lack of readiness to choose a specialty on the part of the first-year medical student, which is probably appropriate.

Implications

The major implication of the present results as well as the Savickas, et al. (1986) study is that students have concerns regarding choosing a medical

specialty. While the lack of readiness to choose a specialty in the first year may be appropriate, students need assistance in addressing some of their first-year concerns. Perhaps initiating career-planning assistance during the first year would prevent students from feeling lost when thinking about how to choose a specialty.

A second related implication was suggested by Gough (1979), who found that only 22% of medical students pursue the specialty during their residency that they chose during their first year of medical school, and programs for assisting students with their specialty choice are clearly warranted and should be initiated early in the student's medical training. It is recog- nized, however, that attitudes toward medical specialties (Furnham, 1986) and one's applied experiences such as clinical clerkships (Paiva, Vu, & Ver- hulst, 1982) are also related to choice of specialty.

A third implication is that, when provided feedback on how their personality types, interests, and values matched those of physicians in various medical specialties, medical students can make more satisfying specialty choices. Because choice of specialty has been shown to be influenced by numerous external factors such as exposure to faculty members, elective courses, and relative prestige of certain specialties, it is important for medical students to be able to partial out the influence of such factors on their choice and to be more informed on how their personalities, vocational interests, and values match those of the various medical specialties (Hutt, 1976). Thus a workshop designed to help medical students narrow the diverse specialty fields and identify those that are more congruent with their personality types and values might be helpful.

Recommendations

Based on present results and several implications, a workshop aimed at providing medical students with psychographic data to help them with a specialty selection is recommended. The format of the workshop consists of three 2-hr. sessions. The purposes of the first session (first year) are to orient students to the decision-making process, identify qualified faculty and staff

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CHOOSING MEDICAL SPECIALTIES 223 who can provide career guidance, and to reassure students that career assistance is also available individually. During the second session (second year), the participants would complete the Gough Medical Specialty Preference Scale (1979), the Myers-Briggs Type Indicator (1962), the Values Scale (Su- per & Nevill, 1986), and a questionnaire which assesses demographic characteristics and the participants' certainty and satisfaction with their choice of medical specialty. During the third session, which would follow four to six weeks later, the process of choosing would be discussed and the participants provided their scores from the three scales. Instructions for interpreting each instrument would be provided along with sample interpretations.

After the participants review their own profiles from the above material, the participants would be divided into s m d groups to discuss which instrument they consider to be the most or least useful, any conflicts or con- firmations between how they view themselves and what the scales indicated, and how they might use the information provided by the workshop. During the last part of the third session the participants would complete evaluations of the workshop to assess their certainty and satisfaction with their choice of medical specialty.

A similar workshop was conducted at a northeastern medical school. I t was observed that the participants were more certain of and more satisfied with their specialty choice after completing the workshop. I n addition, although not tested for statistical significance, the participants seemed to consider the information related to their Myers-Briggs type as most useful in facilitating their choice of a specialty. This is somewhat consistent with Sa- vickas, et al.'s (1986) finding, w h c h indicated the possibility that medical students have a vague awareness of their interests and need additional information (e.g., how their personality traits related to the introversion-extro- version dimension match those of practicing physicians) to help them judge for which specialty (or specialties) they would be best suited. Additional in- formation about this career workshop is given by Leong, et al. (1991).

Several limitations of the present study should be noted. Because this study was conducted at one medical school, the results should not be gener- alized to other student populations. Further, the value of our recommended workshop would be assessed when evaluation data, including longitudinal data, become available. These data will provide information regarding participants' reactions to the workshop, actual choice of specialty, stability of choice, and satisfaction with choice.

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