Arif Ali  ( Department of Research, DUHS, Karachi )
Abdur Rasheed  ( Department of Research, DUHS, Karachi )
Syed Muhammad Hussaiin Zaidi  ( Final Year MBBS, DMC, DUHS, Karachi )
Syed Muhammad Ashraf Jahangeer Alsaani  ( Department of Com. Medicine, DMC, DUHS, Karachi )
Hasham Naim  ( Final Year MBBS, DMC, DUHS, Karachi )
Haris Hamid  ( Final Year MBBS, DMC, DUHS, Karachi )
Salman Farrukh  ( Final Year MBBS, DMC, DUHS, Karachi )

Objective: To determine career choices of medical students of public-sector medical universities and factors affecting their career choices.
Methods: The cross-sectional study was conducted at Dow University of Health Sciences and Jinnah Sindh Medical University, Karachi, from May 2015 to May 2016, and comprised 4th and 5th year medical students and house officers. A self-administrated structured questionnaire was used to collect data which was entered and analysed using SPSS 20.
Results: Of the 445 Subjects, 314(70.6%) were females. There were 206(46.3%) 4th year students, 194(43.6%) were from the 5th year and 45(10%) were house officers. Top 15 medical specialties were ranked according to the respondents' top three choices. Internal medicine 67(15.1%), cardiology 47(10.6%), paediatrics 46(10.3%) and general surgery 40(9.0%) were the four highest ranked specialties. Overall, 377(84.7%) subjects said prestige in working in that field was the reason of their respective choices.
Conclusion: Medical students chose a wider range of specialties and stated varying factors affecting their choices.
Keywords: Career choice, House officers, Medical students, Pakistan, Specialty factors. (JPMA 69: 489; 2019)

Introduction

Many countries around the world are experiencing a dearth of doctors, especially in the developing countries.1 Lack of physicians poses a serious threat to the provision of primary healthcare facilities in vulnerable societies.1 There is a decreasing trend of medical students entering primary care residencies and the physicians going into family practice. The need for primary care provider is going to increase because medical students still give preference to hospital-related specialties. In the United States, the dearth of primary care providers is expected to increase to 45,400 by 2020.2 Only one-third of medical students in Canada are interested in family medicine.3 Many types of research have explained this subject and emphasized various reasons for the low proportion of medical specialties like family medicine, radiology and psychiatry.4 In low and middle-income countries (LMICs), the situation is even more critical because trained health personnel are migrating to developed/high income countries (HICs). This is substantial to assist developing countries to attain self-reliance and employ evidence-based practice in healthcare. It is evident from studies that there is a strong association between experience during medical school and postgraduate research initiatives, and career successes in academic medicine.5 In the prevalent shortage of trained physicians, it is important to know the changing trend, interests and expectations among the new generation of medical students. Selecting a medical specialty can be a confusing and complicated experience for medical students and house officers. Few researches have been conducted to estimate the future distribution of medical students among medical specialties and factors accountable for that distribution.6 There are many problems, factors and incentives such as the desire to earn a high income, family responsibilities, interest in one specific field, prestige related to certain specialties, years of training etc. that influence an individual's choice when deciding a career.1 Some studies in the past have even suggested that career preference at the beginning of medical school may be a predictor of student's eventual career.7 All medical institutions in Pakistan have a five-year MBBS programme of which during the first two years the primary focus is on basic health sciences, with steadily increasing exposure to clinical rotations for the remaining three years, and after that there is one-year mandatory internship at a teaching hospital. Literature exhibits that few researches have been conducted in Pakistan also to explore specialty selection. A study8 was conducted in 2007 in two private and public institutions, and showed that a high proportion of medical students and fresh graduates in Karachi chose the same medical specialties. This might lead to saturation in that specialisation and leave the population underserved in other important fields. Another study was conducted at a private institution in Pakistan, but the sample size was not large enough and it was done at a single centre.9 Medical specialties within an institution may influence the students' career choices and that hands-on experience in a specific field is a main factor encouraging a student's interest in a specific specialty. The current study was planned to determine the career choices of medical students of two publicsector medical colleges in urban Pakistan, and to see the factors affecting the choices.

Subjects and Methods

The cross-sectional study was conducted from May 2015 to May 2016 at Dow Medical College (DMC), Dow University of Health Sciences (DUHS), and Sindh Medical College (SMC), Jinnah Sindh Medical University (JSMU), Karachi. Fourth and fifth year medical students and house officers were included, while students of the first three years were excluded as they had limited clinical exposure. Foreign students and those who were not present at the time of data collection were also excluded. All study participants were selected through non-probability, purposive sampling technique. Ethical permission was taken from the DUHS review board, and written informed consent was obtained from the subjects. A self-administrated structured questionnaire was developed in the English language. Data was collected regarding gender, age, socioeconomic status, study year, future work preference (inland, abroad) and satisfaction with the medical profession (satisfied or not satisfied). Socioeconomic status was observed as defined in the Pakistan Institute of Developing and Economics (PIDE) working paper.10 Respondents were asked to mention their 1st, 2nd and 3rd choices of medical specialty and mention factors affecting their choice. Sample size was calculated by taking percentage of 48.111 of factor opportunity to contribute to society, 95% confidence level and 5% margin of error. A total 384 participants were required, but 15% more were enrolled to account for possible non-respondent rate. The collected data was entered and analysed using SPSS 20.

Results

Of the 445 subjects, 260(58.4%) were from DMC and 185(41.6%) were from the SMC. The overall mean age of the sample was 22.02±1.77 years, and 314(70.6%) were females. Besides, 389(87.4%) subjects belonged to the middle class, 41(10%) were from the upper class, and 15(3.4%) belonged to lower or lower middle class. There were 206(46.3%) and 194(43.6%) students from 4th and 5th year respectively, and 45(10%) were house officers. While answering the question about satisfaction with the medical field, 54(12.1%) subjects said they were not satisfied. There was no significant difference between the mumber of students who wanted to work inland and abroad (Table 1).



Top 15 medical specialties were ranked according to the respondents' top 3 choices (Table 2).



Internal medicine 67(15.1%), cardiology 47(10.6%), paediatrics 46(10.3%) and general surgery 40(9.0%) were the four highest ranked specialties. Cardiology was the top-ranked second-choice specialty 61(13.7%), followed by paediatrics 50(11.2%), internal medicine 48(10.8%) and neurology 41(9.2%). For the third choice, internal medicine was the most popular choice 44(9.9%), followed by paediatrics 43(9.7%), neurology 27(6 .1%), and cardiology 26(5.8%). There were 271(61%) subjects who reported that they did not choose the specialty to secure a job in that field (Table 3).



There were 318(71.5%) students who denied that they chose the specialty because of feasible working hour conditions, and 178(40%) confirmed that they preferred to treat emergency cases. The majority 377(84.7%) reported that prestige in working in that field was the reason of their respective choices. Also, 121(27%) subjects said the reason of their choice was a lack of physicians or surgeons in that specialty in Pakistan.

Discussion

In the current study, internal medicine, cardiology, paediatrics and general surgery were the four highest ranked specialties as the first choice. In another study conducted in Pakistan, internal medicine was also the favourite of 20.5% medical students, followed by surgery (15.0%), paediatrics (13.5%), and obstetrics and gynaecology (9.3%).8 A study12 conducted at DMC to compare differences in career preference between first and final year students also revealed internal medicine (17%) as the top-ranked specialty, followed by cardiology (12.5%) and paediatrics (11%). A cross-sectional study13 in Kenya reported that internal medicine was among the top four ranked specialties of first choice. In another study14, the preference of specialty choice among Korean medical students was internal medicine, psychiatry and paediatrics. However, a study conducted in Karachi15 showed contrasting findings, where more than half of students preferred surgery and its associated sub-specialties followed by internal medicine (26.8%) as their first choice. Another cross-sectional study16 conducted in Karachi also showed surgery as the top most choice of students in terms of career preference. Evidence cited indicates a shifting trend in medical students' career preferences in the last 10 years in Pakistan. The current study's findings showed that cardiology was the top-ranked specialty of 2nd choice, which is not consistent with results of a study8 in which internal medicine was the most prominent specialty for 2nd choice. Our findings also confirmed that internal medicine was again the most highlighted 44(9.9%) specialty of 3rd choice. These findings were not quite different from those reported from a medical university in Pakistan.9 In Pakistan, doctors' career choices are characterised by a tough competition to secure the market share in profitable fields of medical practice, like cardiology. Largely, no health policies have been seen from the government about medical regulatory authorities and organisations to put up a career direction for the new graduates or future doctors; though slight improvements have been observed. Several medicine fields, such as endocrinology, anaesthesia, family medicine, forensic medicine and radiology, were not found as high-priority choices among the subjects in the current study. Therefore, substantial manpower shortages in such fields may occur. Developing countries are also facing shortage of manpower in basic medical and research faculty.9 In our study, most of the medical students stated that job security and feasible working hours did not influence their choices. However, a notable proportion of medical students confirmed that preference of emergency treatment influenced them and a high proportion of study participants also reported that prestige in working in their chosen field was the reason of their choice. Opportunity to treat and help people was highlighted by 95% medical students of King Saud Bin Abdul Aziz University as the factor affecting their career choice specialty.17 Helping patients, interest in the medical field and having a prestigious career were the most highlighted reasons of choosing the medical profession among the 2nd year students at King Abdul Aziz University.18 Lack of physicians or surgeons was also a stated reason for specialty choice of three-fourths of medical students. Factors identified in our study are not consistent with earlier findings19 that reported lifestyle and income as more important factors for medical students in their career choice. However, a study20 also reported the nature of patient care as an important factor along with educational experiences and lifestyle. Prediction and judgment of specialty choices of medical students is a complex process and further research is required to explore this subject.21 Dissimilar factors are also found in a study22 in Sudan which reported that personal interest was the most common reason among students while choosing their specialty. Moreover, studies conducted in Turkey and Jordan 23,24 showed financials, prestige, the intellectual content of the specialty and the individual's competence were the driving factors. A well informed health policy regarding career choices and personnel-deficient medical fields may provide a career direction to future doctors towards understaffed fields such as primary care. The overall health system economic benefits have been observed in population where a higher number of primary care physicians practice.25

Conclusion

Medical students chose a wider range of specialties and stated varying factors affecting their choices. The findings need to be pondered upon by medical councils to work on certain factors and promote the interest of future doctors considering their needs in respective developing countries and the burden of patients in those fields. There is a need to continue such studies to detect the shifts in trends and to work on the causes to ensure uniform distribution of health workforce in all fields.

Disclaimer: None.
Conflict of Interest: None.
Source of Funding: None.

References

1. Puertas EB, Arósquipa C, Gutiérrez D. Factors that influence a career
choice in primary care among medical students from high-, middle-, and low-income countries: a systematic review. Revista Panamericana de Salud Pública 2013; 34: 351-8.
2. Kirch DG, Henderson MK, Dill MJ. Physician workforce projections in an era of health care reform. Ann Rev Med 2012; 63: 435-45.
3. Vanasse A, Orzanco MG, Courteau J, Scott S. Attractiveness of family medicine for medical students. Canad Fam Physician 2011; 57: e216-27.
4. Wigney T, Parker G. Medical student observations on a career in psychiatry. Aust New Zealand J Psychiatry 2007; 41: 726-31.
5. Brancati FL, Mead LA, Levine DM, Martin D, Margolis S, Klag MJ. Early predictors of career achievement in academic medicine. JAMA 1992; 267: 1372-6.
6. Lawrence J, Poole P, Diener S. Critical factors in career decision making for women medical graduates. Med Educ 2003; 37: 319-27.
7. Wright B, Scott I, Woloschuk W, Brenneis F. Career choice of new medical students at three Canadian universities: family medicine versus specialty medicine. Canad Med Assoc J 2004; 170: 1920-4. 8. Aslam M, Ali A, Taj T, Badar N, Mirza W, Ammar A, et al. Specialty choices of medical students and house officers in Karachi, Pakistan. East Mediterr Health J 2011; 17: 74-9.
9. Khan H, Taqui AM, Khawaja MR, Fatmi Z. Problem-based versus conventional curricula: influence on knowledge and attitudes of medical students towards health research. PLoS One 2007; 2: e632.
10. Durr-e-Nayab. Estimating the middle class in Pakistan. Pak Development Rev 2011; 50: 1-28. 11. AsIam F, Mujtaba M. Factors influencing specialty selection among doctors working in Punjab, Pakistan. Rawal Med J 2015; 40: 315-8.
12. Aslam M, Majid A, Zaheer M. Comparison of difference in career preferences between first and final year medical students. Int J Res 2015; 2: 601-14.
13. Dossajee H, Obonyo N, Ahmed SM. Career preferences of final year medical students at a medical school in Kenya-A cross sectional study. BMC Med Educ 2016; 16: 5.
14. Kim YY, Kim UN, Kim YS, Lee JS. Factors associated with the specialty choice of Korean medical students: a cross-sectional survey. Human Resources Health 2016; 14: 45.
15. Rehman A, Rehman T, Shaikh MA, Yasmin H, Asif A, Kafil H. Pakistani medical students' specialty preference and the influencing factors. J Pak Med Assoc 2011; 61: 713-8.
16. Akhund S, Shaikh ZA, Kolachi HB. Career related choices of medical students from an International Medical College of Karachi, Pakistan. JLUMHS 2012; 11: 180-4.
17. Al Subait A, Ali A, Andijani AI, Altuwaijry MA, Algarni SM, Alduhaimi TS, et al. Factors Influencing the Career Choices among Medical University students of King Saub bin Abdulaziz University, Riyadh Saudi Arabia; A Cross-sectional Study Design. Saudi J Dent Res 2017; 8: 73-8.
18. Ayuob NN, Sindi AH, ElDeek BS. Medicine as a career choice: a cross-sectional study on undergraduate medical students at King Abdulaziz University. Int J Res Med Sci 2016; 4: 593-601.
19. Newton DA, Grayson MS, Thompson LF. The variable influence of lifestyle and income on medical students' career specialty choices: data from two US medical schools, 1998-2004. Acad Med 2005; 80: 809-14.
20. Hauer KE, Durning SJ, Kernan WN, Fagan MJ, Mintz M, O'Sullivan PS, et al. Factors associated with medical students' career choices regarding internal medicine. JAMA 2008; 300: 1154-64.
21. Bethune C, Hansen PA, Deacon D, Hurley K, Kirby A, Godwin M. Family medicine as a career option. Canad Fam Physician 2007; 53: 880-5.
22. Alawad AAMA, Khan WS, Abdelrazig YM, Elzain YI, Khalil HO, Ahmed OBE, et al. Factors considered by undergraduate medical students when selecting specialty of their future careers. Pan Afr Med J 2015; 20: 102.
23. Khader Y, Al-Zoubi D, Amarin Z, Alkafagei A, Khasawneh M, Burgan S, et al. Factors affecting medical students in formulating their specialty preferences in Jordan. BMC Med Educ 2008; 8: 32.
24. Fevzi Dikici M, Yaris F, Topsever P, Muge Filiz T, Serdar Gurel F, Cubukcu M, et al. Factors affecting choice of specialty among firstyear medical students of four universities in different regions of Turkey. Croatian Med J 2008; 49: 415-20.
25. Scott I, Gowans MC, Wright B, Brenneis F. Why medical students switch careers. Canad Fam Phys ici an 20 07; 53 : 94 -5.