Graduate status and age at entry to medical school as predictors of doctors' choice of long-term career

OBJECTIVE: To determine whether graduate entry to medical school, taking an intercalated degree during medical school, and age at entry to medical school are related to choice of eventual career. DESIGN: Postal questionnaires. SETTING: United Kingdom (UK). SUBJECTS: All doctors who qualified in the UK in 1993 or 1996. RESULTS: We analysed whether graduate status and age on entry to medical school, and taking an intercalated degree during medical school, were predictors of the choice of eventual career, adjusting for differences by sex, year of qualification and medical school. General practice was the career choice of 27.0% (79/293) of graduate entrants and 21.6% (1095/5073) of non-graduate entrants, a difference of borderline significance (P=0.04). Of the non-graduate entrants, general practice was the career choice of 15.3% (319/2081) of doctors who took an intercalated degree and 25.9% (776/2992) of doctors who did not (P < 0.001). Within the hospital specialties, those who took an intercalated degree were more likely than others to choose the hospital medical specialties or pathology. Age alone was not a predictor for choice of any area of practice. CONCLUSIONS: There was no evidence of an association between age at entry to medical school and choice of eventual career. Graduates at entry to medical school were a little more likely than non-graduates to choose general practice but the relationship was not a strong one. In these respects, changing the entry profile of medical students is unlikely to result in major shifts of career choice towards general practice.     

Career preferences and career outcomes of Australian medical students

Students entering three Australian medical schools were followed over a 15-year period to trace both movement into the profession and the longer-term outcomes of early career aspirations. A variety of student entry characteristics are examined together with aspirations, attainments and self-images. The results indicate that women, rather than men, are more likely to enter medical school with aspirations that involve specialty training. As they proceed through medical school, both groups move away from the idea of pursuing specialty training, although women tend to decide earlier than men that specialty practice is not for them. Women students are more likely than men to attain career goals if these involve general practice and less likely to if these involve specialization. The results indicate that although at graduation women medical practitioners have the same career goals and desires as men, if additional training is required women are unlikely to have their aspirations fulfilled.     

Effect of managed care and financing on practice constraints and career satisfaction in primary care

BACKGROUND: The shift away from third party insurers to risk-sharing arrangements affecting care management and clinicians could be the most fundamental change in the health care system. Analysis was undertaken to study how managed care, practice setting, and financial arrangements affect physicians' perceived impact on their practice. METHODS: Data were taken from the Community Tracking Study (CTS) physician survey, a national survey of active physicians in the United States fielded between August 1996 and August 1997. Survey instruments were completed by 7,146 primary care physicians in internal medicine (2,355), family practice (3,168), and pediatrics (1,623). The dependent variables are career satisfaction and perceived limitations and pressures on time spent with patients, clinical freedom, income, and continuity. To study the unique effect of financing and gatekeeping arrangements and practice setting, the dependent variables were regressed on gatekeeping, practice revenue, individual physician compensation, practice setting, specialty, age-group, sex, international medical graduate, board certification, and recent change in practice ownership. RESULTS: Total managed care revenue, or individual physician incentives, have no effect on career satisfaction and relatively limited effects on time pressure, income pressure, or patient continuity. In contrast, primary care gatekeeping has a highly significant adverse effect on the same outcome measures. After controlling for financial factors, demographic characteristics, and training differences, physicians in solo and 2-physician practices are significantly more likely to be dissatisfied with their medical career, more likely to report no clinical freedom, and more likely to feel income pressure than physicians in group practices, staff model HMOs, medical schools, or other settings. CONCLUSION: Physicians in solo and 2-physician practices were least satisfied with their careers and reported more constraints on their clinical freedom and income than physicians in other settings. Physicians in group practices or staff model HMOs are more likely to report time pressure than physicians in solo or 2-physician practices. Family practice falls between internal medicine (less satisfied, more practice constraints) and pediatrics (more satisfied, fewer practice constraints).     

Career satisfaction and professional accomplishments

Medical Education 2010: 44 : 969–976 Context Research on doctor career satisfaction has often focused on factors such as income, specialty, gender, work hours, autonomy, patient load, lifestyle preferences, work environment, and insurance regulations. Other educational, personal and professional factors have not received sufficient empirical attention. Objective This study was designed to test the following five hypotheses that doctors’ career satisfaction is associated with: (i) Higher satisfaction with their undergraduate medical education; (ii) Greater academic and clinical competence; (iii) More involvement in teaching and research activities; (iv) Higher orientation toward lifelong learning; and (v) Increased professional accomplishments. Methods A survey was mailed in 2006 to a national sample of 5349 doctors in the United States who graduated from Jefferson Medical College between 1975 and 2000; 3170 (59%) returned completed surveys. Based on responses to a career satisfaction question, doctors were classified into three groups: Highly satisfied (top third, n = 1078); moderately satisfied (middle third, n = 1031); and least satisfied (bottom third, n = 1061). These groups were compared on a number of variables. Results All five research hypotheses were confirmed. Additionally, no significant association was observed between career satisfaction, age, years in practice, gender, or ethnicity; however, career satisfaction was associated with doctors’ specialties. Conclusions The findings suggest that factors such as satisfaction with medical education, medical school class rank, assessments of clinical competence, teaching, and research activities, orientation toward lifelong learning, and professional accomplishments should be considered for a more comprehensive understanding of doctors’ career satisfaction.     

The malpractice crisis and the doctor-patient relationship

Abstract The current medical malpractice crisis in the United States provides an opportunity to explore the medical profession's response to threats to its autonomy of practice. Drawing on commentary in medical journals, I reveal the way in which physicians, and some lawyers, have explicitly targeted doctor-patient interaction as a seat for malpractice reform. A good deal of attention is being given to developing a better rapport with patients, providing information and involving the patient in decision-making about care. Such reforms should be welcomed. But any benefits need to be weighed against the possibility that changes in the doctor-patient relationship may also have a covert purpose; as reform is focused at the interactional level, attention is drawn away from medical practice to the patient as the source of negligent injury. This can have negative consequences for patients who, in responding to this interactional gloss, may fail to gain compensation for the real errors of medical practice.     

The primary care physician workforce: ethical and policy implications

PURPOSE We undertook a study to examine the characteristics of countries exporting physicians to the United States according to their relative contribution to the primary care supply in the United States.METHODS We used data from the World Health Organization and from the American Medical Association Physician Masterfile to gather sociodemographic, health system, and health characteristics of countries and the number of international medical graduates (IMGs) for the countries, according to the specialty of their practice in the United States.RESULTS Countries whose medical school graduates added a relatively greater percentage of the primary care physicians than the overall percentage of primary care physicians in the United States (31%) were poor countries with relatively extreme physician shortages, high infant mortality rates, lower life expectancies, and lower immunization rates than countries contributing relatively more specialists to the US physician workforce.CONCLUSION The United States disproportionately uses graduates of foreign medical schools from the poorest and most deprived countries to maintain its primary care physician supply. The ethical aspects of depending on foreign medical graduates is an important issue, especially when it deprives disadvantaged countries of their graduates to buttress a declining US primary care physician supply.     

Influence of a Rural Primary Care Clerkship on Medical Students'' Intentions to Practice in a Rural Community

The purpose of this study is to examine the relationship of a rural clerkship to medical students' interest in establishing careers in rural communities. The Association of American Medical Colleges Medical School Graduation Questionnaire (GQ) for years 1988 through 1997 was examined to compare the career plans of students graduating from Morehouse School of Medicine (MSM) with those of all students graduating from United States medical schools before the period 1988 through 1992 and after the period 1993 through 1997, after the inception of the rural clerkship at MSM. Select GQ data items examined include student demographics, medical school experiences, and career plans. Statistical analyses were used to compare pre- and post-clerkship responses for MSM students and to compare their responses with the national trends. Results indicate that, following a transition period, MSM students showed an increased preference for a future career in a rural community. A smaller upward trend in the national data was observed. There appears to be an association between the rural clerkship experience at MSM and the stated preferred career choices of the students.     

Variation by medical school in career choices of UK graduates of 1999 and 2000

OBJECTIVE: To report on how newly qualified doctors' specialty choices, and factors that influenced them, varied by medical school. DESIGN: Postal questionnaires. SETTING: United Kingdom. SUBJECTS: All doctors who graduated in the UK in 1999 and 2000. MAIN OUTCOME MEASURES: Choices of eventual career expressed 1 year after graduating, and factors influencing their choices. RESULTS: There were some significant differences between medical schools in the career choices made by their graduates. For example, the percentage of respondents who expressed the choice of general practice was significantly low among graduates of Oxford and Cambridge and high among graduates of Birmingham and Leicester. There was also significant variation between medical schools in choices for hospital medical and surgical specialties. There were significant differences, too, between medical schools in the extent to which career choices had been strongly influenced by graduates' inclinations before starting medical school and by their experience of their chosen specialty, particular teachers and departments at medical school. As well as the differences, however, there were also many similarities between the schools in graduates' career choices. DISCUSSION: Medical schools currently provide students with a broad training suited to any subsequent choice of specialty. We suggest that the similarities between schools in the career choices made by graduates are generally more striking than the differences. We raise the question of whether there should be any specialisation by individual schools to train students for careers in particular branches of medical practice.     

Cross‐Sectional Study of U.S. Interns' Perceptions of Clinical Nutrition Education

Background. Medical students have historically perceived a lack of training in clinical nutrition. Rapid advances in medical science have compelled significant changes in medical education pedagogy. It is unclear what effect this has had on student's perceptions. Objective. To assess interns' perception of clinical nutrition education during medical school. Design. A cross‐sectional survey of medical, surgical, and obstetric interns from 6 academic hospitals across the United States during the middle of their first year in November of 2010 (n = 289). Bivariate analysis and logistic regression was used to describe interns' perceptions and evaluate for factors that determined these perceptions. Results. A total of 122 interns responded to the survey, for a response rate of 42%. These interns represented 72 different medical schools. Only 29% of interns reported they had been sufficiently trained in nutrition. On average, interns who reported being prepared reported a mean of 4 ± 3.4 weeks of training during medical school, while unprepared interns reported a mean of 2 ± 2.6 weeks of training (P = .02). Interns with prior graduate training in nutrition (n = 18) almost exclusively reported that medical school training was insufficient (94%, P = .02). After adjusting for age, gender, internship, undergraduate training, and being a foreign graduate, only the number of weeks of training remained significantly associated with perceived preparation (P = .03). Conclusion. Most interns in medicine, surgery, and obstetrics feel unprepared to handle cases requiring knowledge of clinical nutrition. Interns feel that medical school is not adequately preparing them for the needs of clinical practice.     

Medical students'' attitudes towards ageing and death: a cross-sequential study

This study presents an analysis of possible changes in attitudes towards older persons and in attitudes towards personal death anxiety that might occur over the course of undergraduate medical education. Three entering classes of medical students at a university in the Mid-western United States completed an attitudes towards old people scale, a death anxiety scale, and a standard personality inventory. As graduating seniors, they again completed the attitudes towards old people scale and the death anxiety scale. Significant changes did not occur. In comparison with baseline data from a group of 212 university graduate students in the USA, these 234 medical undergraduates had significantly more positive attitudes towards the aged; in another comparison, their death anxiety was significantly lower than a group of 599 from the general population. Implications are discussed.     

On whose shoulders we stand: lessons from Exemplar medical educators

The hiring of educators in medical schools (faculty who study the educational process and prepare others to become educators) has been one of the most successful educational innovations ever. Starting in 1954, through a collaboration between the Schools of Medicine and Education at the University of Buffalo, the innovation has spread to over half of the medical schools in the United States and to medical schools in several other countries. Practically every medical school and specialty now hires educators to conduct faculty development, evaluate learners, and develop or revise curricula. This article focuses on lessons learned by six-first-generation educators hired in medical education. These individuals made unique contributions that improved the process of educating and evaluating future physicians. Among their most important contributions have been the use of standardized patients, faculty development to improve instruction, and the use of clinical decision making theory. In addition, these professional educators created a home and career path for other professionals and nurtured protégés to continue the work they started. Ten lessons are reported from structured interviews using a standardized protocol. These lessons will hopefully inform current and future medical educators to help them sustain the effective collaboration between medical schools and educators.     

Premedical training, personal characteristics and performance in medical school

Despite concern over the concentration on science in pre-medical education and the selection of medical students in the United States, no major changes have been made. The present study compares attrition rates and clinical competence levels of medical students who vary in pre-medical training, age, and sex, in order to determine the risk attached to accepting applicants with different background characteristics. No differences were found in levels of clinical competence, although the groups varied in average science scores on the medical college admission tests (MCATs). Students with non-science undergraduate majors had lower scores on this test than science majors. Younger women had relatively high attrition rates, but high performance on the MCAT science sub-test and in medical school science courses. It was concluded that all groups had adequate science preparation for medical school, and there was no greater risk of producing doctors with low levels of clinical competence associated with accepting students from groups with lower science performance.     

Using a symbolic interactionist approach to role and identity to illuminate medical student avoidance of primary care

A symbolic interactionist approach is presented and analyzed in reference to helping solve the problem of medical students not choosing primary care practice for a career. The concepts of "Role" and "Identity" are examined in the social interaction context of pre-med and med students and the larger environment in the United States. Recommendations for application of these findings in selection of students and their training are included.     

Early medical career choices and eventual careers

The revised structure of hospital specialist training being introduced in the United Kingdom means that a doctor wanting a career in a hospital specialty will need to be confident that his or her early career choice, made within 3 years of qualification, is realistic. Using data from a longitudinal study of the 1983 cohort of UK medical graduates, the early career choices made by over 2000 doctors were compared with their employment 11 years after qualification. At year 11 65% of the doctors were working within the first choice they had expressed towards the end of their pre-registration year, and 79% were employed in their year 3 first choice. There was, however, important variation within this general picture: lower predictive value was associated with choices made by women; choices for hospital mainstreams rather than for general practice; and choices that were less than definite. The recent drop in popularity of general practice as a career choice of new graduates in the UK, and the steady increase in the proportion of women graduates, mean that the predictive value of the career choices of recent graduates may prove to be lower than that of the 1983 cohort.     

Career interruptions and hours practiced: comparison between young men and women physicians

This study compares current level of workforce participation and number, type and length of career interruptions since entering medical school reported by young men and women physicians. By 10 years from medical school entry, one third of the women studied had taken a maternity/child care leave and 24% had taken time away from their careers for other reasons while only 11% of men had interrupted their careers. The average time taken and reasons given for non-maternity-related career interruption were similar for men and women. Both men and women in the types of medical careers that historically have attracted more women work shorter hours than those in medical career types where women are under-represented. Across career types, women worked shorter hours per week than men and the presence of children further reduced hours of work for women only. Although the women studied are more active professionally than previous generations during their childbearing/rearing years, a considerable gap in the participation level remains.     

Medical school entrance and career plans of Malaysian medical students

This study investigates the reasons for entry to medicine and the career perspectives of phase III medical students of the Universiti Sains Malaysia (USM). The majority of the students were Malays from low socio-economic backgrounds who entered medical school after completing a 2–year matriculation course. An interest in medicine and helping people were the two main stated reasons for entry to medical school. A group of students wishing to work in private practice was identified. In comparison to the rest of the study body, students in the group were: not well prepared to enter medical school; dissatisfied with the course; and subject to family influences. A desire for monetary gain motivated their choice of medicine as a career. Overall, 13% of the students wished to change career because they were dissatisfied with their experience of medicine as undergraduates.
The study did not find a significant difference in career intentions between female and male medical students. However, women were less likely to seek entrance into private practice or pursue formal postgraduate education. The choice of surgery as a career was confined to men. About 90% of the students had already decided on their future specialty. Four well-established specialties were their most popular choices. The gender of the students had no significant influences of the decision to continue into postgraduate education. The proportion of female students who wished to marry doctors was significantly higher than for male students.     

Critical thinking: change during medical school and relationship to performance in clinical clerkships

The development of critical thinking, the ability to solve problems by assessing evidence using valid inferences, abstractions, and generalizations, is one of the global goals advocated by most medical schools. This study determined changes in critical thinking skills between entry and near the end of the third year of medical school, assessed the predictive ability of a test of critical thinking skills, and assessed the concurrent validity of clerkship components and final grade. The Watson–Glaser Critical Thinking Assessment (WGCTA) was administered to one class of students at entry to medical school and near the end of year 3. Performance data for those students who completed their clinical clerkships on schedule were also recorded. Critical thinking improved modestly but significantly from entry to medical school to near the end of year 3. The ability of a critical thinking test to predict clerkship performance was limited; the correlation between WGCTA total score at entry and the components and final grade of five major clerkships ranged from near 0 to 0·34. The concurrent validity of clerkship components and final grade was also limited; correlations with WGCTA total score near the end of year 3 ranged between 0·08 and 0·49. The correlation between WGCTA total score and United States Medical Licensing Examination Step 2 was higher at year 3 than at medical school entry. Critical thinking skills improve moderately during medical school. Used alone, tests of critical thinking may be of limited value in predicting which students will be successful in clinical clerkships. Clerkship evaluation components and final grade have limited concurrent validity when a test of critical thinking is the criterion.     

Academic and professional career outcomes of medical school graduates who failed USMLE Step 1 on the first attempt

This study sought to determine the academic and professional outcomes of medical school graduates who failed the United States Licensing Examination Step 1 on the first attempt. This retrospective cohort study was based on pooled data from 2,003 graduates of six Midwestern medical schools in the classes of 1997–2002. Demographic, academic, and career characteristics of graduates who failed Step 1 on the first attempt were compared to graduates who initially passed. Fifty medical school graduates (2.5 %) initially failed Step 1. Compared to graduates who initially passed Step 1, a higher proportion of graduates who initially failed Step 1 became primary care physicians (26/49 [53 %] vs. 766/1,870 [40.9 %]), were more likely at graduation to report intent to practice in underserved areas (28/50 [56 %] vs. 419/1,939 [ 21.6 %]), and more likely to take 5 or more years to graduate (11/50 [22.0 %] vs. 79/1,953 [4.0 %]). The relative risk of first attempt Step 1 failure for medical school graduates was 13.4 for African Americans, 7.4 for Latinos, 3.6 for matriculants >22 years of age, 3.2 for women, and 2.3 for first generation college graduates. The relative risk of not being specialty board certified for those graduates who initially failed Step 1 was 2.2. Our observations regarding characteristics of graduates in our study cohort who initially failed Step 1 can inform efforts by medical schools to identify and assist students who are at particular risk of failing Step 1.     

Relationship between US medical school admission policy and graduates entering family practice

Rural areas in the United States continue to lack an adequate supply of primary care doctors, particularly family physicians, despite the oversupply of physicians nationally. Previous studies have provided strong evidence that students from rural backgrounds, as well as those who expressed an interest at the time of medical school admission for a career in family medicine, are significantly more likely to eventually practise family medicine in rural areas than their peers. US medical schools were classified into three groups based on their written selection factors for preferentially admitting students into the graduating class of 1982. Of those schools with selection factors for students from both a rural background and an interest in a future career in family medicine, 23.7% of their graduates entered family medicine training programmes. This compares with 14.5% of graduates from schools with a preference for students from a rural background, and 12.4% from all other schools (P less than 0.001). Coupled with previous data which shows that family physicians from rural areas are more likely to eventually practise in rural areas than their peers, preferentially admitting students from rural backgrounds interested in a career in family medicine could help to solve the problem of the shortage of primary care physicians in rural areas in the US.     

Graduate entry to medical school? Testing some assumptions

BACKGROUND: Debate abounds regarding the most appropriate candidates to admit to medical school. This paper examines whether there is any advantage to admitting 'graduate' entrants over secondary school leavers on selected medical school and practice outcomes. AIM: To compare the medical school experiences, research and academic achievements and practice outcomes of graduates who entered 1 medical school in Australia directly from high school (secondary school entry) to those of graduates who entered with tertiary level education (tertiary entry). DESIGN AND METHODS: Cross-sectional study using a mail-out survey to graduates from the first 16 graduating years (1983-98 inclusive) of the University of Newcastle Medical School. RESULTS: Secondary school entrants were, on average, 8 years younger than tertiary entrants and were less likely to have received rural-based schooling. However, there were no differences with respect to gender or type of secondary school attended (public or private). Motivations for studying medicine did not generally differ according to entry type, except that more secondary students were motivated by parental expectations and more tertiary entrants were motivated by the need for professional independence and the desire to prevent disease. A greater proportion of tertiary entrants experienced stress at medical school. However, secondary students experienced more stress due to doubts about being a doctor, while tertiary entrants experienced more stress due to lack of leisure time, finances and balancing commitments. There were no significant differences between the groups in terms of academic performance (as measured by the award of medical school honours) or research outcomes (as measured by completion of a research degree during or after medical school training, publication of scientific papers or holding career posts in the research sciences). There were no differences in career positions held by clinicians, choice of general practice or another specialty as a career, practice location (rural or urban) or employment sector (public or private). CONCLUSION: There is no clear advantage, at least on the outcomes measured in this study, to limiting medical school entry to either those candidates from secondary school or those with tertiary backgrounds. Medical schools could reasonably broaden their selection criteria to include more graduate entry candidates in addition to secondary school leavers without compromising medical school and practice outcomes.