Does examining job market awareness among medical students provide insight into the specialty selection process?

Abstract

Background

The future composition of a country’s physician workforce depends on medical students’ choices of specialties. Students’ familiarity with the job market (the healthcare system) they are about to enter and the influence job market conditions have on their choices has not been well explored. This study focuses on whether and how the healthcare system’s employment landscape is taken into consideration by medical students and whether this facet adds information about the specialty selection process.

Methods

Fifth-year medical students completed a questionnaire querying their knowledge and perceptions of the national healthcare system, selection criteria for choosing a specialty and a post-residency work position. Data were analyzed with two-tailed Student’s t-tests and multivariable regression analysis.

Results

The questionnaire was completed by 242 students (49% women). Forty per cent were interested in a specialty where it is ‘easy to find work’ and 64% in a specialty that ‘provides job security’. Only 12% were attracted to specialties with empty positions due to a workforce shortage. A high salary was considered an important selection criterion by 45% of students, who were also not deterred by specialties with surplus workforce, especially, if accompanied by high salaries or controllable lifestyles. Only 17% thought it would be easy to find a residency in any hospital in the specialty they chose, reflecting the low rate (3%) of positive responses to the statement that ‘there are sufficient residency positions in all specialties’.

Conclusions

This study demonstrated the utility of querying medical students about their market awareness when investigating the specialty selection process. Students’ poor rating of selection criteria, such as specialties with ease in finding jobs because they are suffering workforce shortages and have empty positions, provide insights and concerns for healthcare leaders. It should aid them in approaching the challenge of attracting students to specialties with workforce shortfalls.

KEY MESSAGES

• This study demonstrated the feasibility and potential value of adding queries about market awareness when investigating the medical student specialty selection process.

• Medical students were more interested in a specialty that provides job security than one where it is easy to find work.

• It could be useful for the healthcare leadership and medical educators in all countries to learn what medical students know about their national healthcare system and whether they need to add more healthcare delivery and system subjects to their curricula.

Keywords:

• Medical Students
• Job Market
• Medical Specialties
• Market Awareness
• Job Security
• Choice of Medical Specialty
• Healthcare System

Introduction

The future composition of a nation’s physician workforce depends on medical students’ choices of medical specialties. Specialty selection involves students gaining experience with multiple specialties during required and elective clerkships, while amassing information from teachers, colleagues, the internet and the medical and popular literature. Such information forms the basis for students’ perceptions of the various specialties which they then match with their interests, skills and socioeconomic circumstances [1,2]. This process is similar to consumers (students) purchasing a product (medical specialty) from a vendor (residency programs). Purchases occur when consumers match their needs and wants with their perceptions of a product’s characteristics. In our prior publications such marketing research concepts were used to examine association between students’ selection criteria and their perceptions of different specialties. However, the influence of job market conditions on their selections has yet to be explored [3–5]. Therefore, it is possible to hypothesis that job market conditions, such as future salary and job availability, would be among the important factors influencing selection of a medical specialty.

This study, thus, examines students’ opinions about and familiarity with the job market (the healthcare system) they are about to enter and whether market conditions (availability and location of jobs) play a role in their decisions. The parallel marketing situation is that when making major purchase decisions, e.g. financial investments, purchase houses or automobiles, or switch employment, consumers examine and consider overall market conditions, i.e. they display market awareness [6]. Similarly, job market conditions are among the considerations when college and non-medical graduate students make career choices. For example, British business students chose chartered accounting, rather than fields such as management, partially due to the ease in finding jobs [7,8]. Examining whether and to what degree market conditions influence medical students’ selection of a career specialty is especially important when developing strategies to attract students to specialties suffering workforce shortages. Such specialties generally have many job openings so that it is relatively easy to find residency and post-residency positions.

Previous studies found that influencers (clerkship experiences, mentors, junior and senior physicians), lifestyle (life:work- balance), personal attributes (personality, interests, gender, marital status), socioeconomic considerations (future earnings, loan repayments) and perceptions of the various specialties are important criteria when choosing a specialty and a residency program [9–12]. This study thus explores the utility of adding another variable, job market conditions, to the study of the specialty selection process. We, thus, examined whether adding job market-associated criteria might provide further insights into the specialty selection process. The focus was whether and how the healthcare system’s employment landscape was a consideration or contributing factor when students choose medical specialties and post-residency positions. Others have indirectly examined this issue by exploring students’ knowledge of salaries and conditions in rural areas and the private sector [13,14]. We studied 5th-year medical students in a 6-year program, a group in which we previously investigated the influences of family, personal interests and remuneration on specialty selection [15–17]. The current research extends these studies by exploring students’ knowledge and perceptions of the country’s healthcare system and its job market in order to ascertain whether such information provides additional insight into the specialty selection process. The hypothesis tested was that students are attracted to specialties where it is easy to find work and there are open positions.

Materials and methods

A prospective cohort study using a questionnaire to collect information about the medical specialty selection process from a group of 5th year medical students at the Hebrew University – Hadassah School of Medicine was performed after approval (Number: 0672-12-HMO) from the Hadassah Medical Organization Institutional Review Board (IRB). Completion of the questionnaires was considered tacit informed consent. No incentives were provided to participate and there was no way to know which of the students chose to or chose not to complete the questionnaire.

The conceptual framework of the study was based on exploring how a series of independent variables, specialty selection criteria and demographic data, influence two separate independent variables: selecting a medical specialty and choosing a post residency position. More specifically, the study examines a gap in the current literature related to how job market conditions influence medical students’ selection of a medical specialty and a post residency position. To study this topic, a quantitative questionnaire-based study used a questionnaire adapted from those used in our two previous studies of 5th year medical students [15–17]. In this third iteration of the questionnaire, we substituted new queries related to market awareness and interest in technology, while leaving some of the previously used questions to allow for comparison with previous studies [18]. The data pertaining to interest in technology has been published [18]. The questionnaire queried:

1. (Knowledge and perceptions of the Israeli healthcare system (10 5-point Likert Scale questions).

2. Selection criteria for choosing a medical specialty (21 5-point Likert Scale questions).

3. Criteria for choosing a place of work after completing residency (21 5-point Likert Scale questions).

4. Issues surrounding working conditions (4 multiple choice questions)

5. Potential challenges in securing a residency (7 yes/no questions)

6. Whether they had already considered a specialty for residency and which specialty or specialties were being considered (free-text)

7. Demographic information -

Data collection

After to two small (12 students each) pilot trials and minor adjustments, the questionnaires were distributed to 5^th-year students rotating through their required anesthesiology clerkship during three consecutive academic years (2016–2017, 2017–2018 and 2018–2019). The students were asked to complete an anonymous paper questionnaire that took about 12–15 min to complete. Students were allowed as much time as they needed to complete the questionnaire and, thus, all questionnaires were completed.

Data analysis

The data were entered into Excel (Microsoft Inc., Redmond, WA) spreadsheets and analyzed using Excel and Systat 12 (Systat, San Jose CA).

An a priori decision was made to compare the replies of men and women students. This decision was based on prior investigations [15,16]. Another a priori decision was to compare the group of students rating the specialty selection criteria ‘easy to find work’ and ‘job security’ as important/very important to the group rating them not important/not at all important. Following initial analysis, a post-hoc decision was made to compare the group of students which was concerned about not finding a residency in a specialty that interests them much with the group that did not have such concerns.

All 5 response points of the Likert Scale were used in the analysis when the responses were deemed continuous variables. The Likert Scale replies were reduced to three groups when they were considered categorical variables. The two end-points denoting negative tendencies and the two denoting positive tendencies were each combined plus the mid-point. We then calculated the percentage of responses for each group.

Answers to multiple choice questions were reported as percentages. Two-tailed Student’s t-tests were used to compare continuous variables while χ2 tests were employed to analyze categorical data.

Three separate multiple variable regression analyses were performed using as the dependent variables the selection criteria ‘easy to find work’, ‘job security’ and the demographic variable female students. The independent variables were the specialty and post-residency job selection criteria plus the demographic data. A P value less than 0.05 was considered statistically significant.

Results

The purpose of this study was to examine whether adding job market-associated selection criteria to questionnaires querying medical students about how they choose a medical specialty, might provide further insights into the specialty selection process. The questionnaire used in this study was completed by 242 5th-year medical students (84% response rate). One hundred nineteen (49%) were women and 165 (68%) were single.

Comparisons between male and female students are presented in Tables 1 and 2. The female students were more interested in pediatrics and obstetrics/gynecology than the male students. The male students were more interested in surgery and internal medicine than the female students. Moreover, only 16 (13.6%) of the women students thought that the Israeli healthcare system provides ‘equal care to all sectors of society’ as compared to 38 (30.6%, p < 0.05) of the male students.

Table 1. Comparison of women and men students – demographics and opinions on the Israeli healthcare system compared.

		ALL	Women	Men		Multivariable Reg
		(n = 242)	(n = 118)	(n = 124)	P	Coef	P
AGE	< 21	0.0%	0.0%	0.0%
(years)	21–23	25.2%	28.8%	21.8%
	24–26	21.9%	25.4%	18.5%
	26–29	34.7%	33.9%	35.5%
	30–32	12.8%	6.8%	18.5%
	32+	5.4%	5.1%	5.6%	0.05	0.138	0.0014
GENDER	Female	48.8%	--------	--------
	Male	51.2%	--------	--------
MARITAL	Single	68.2%	68.6%	67.7%
STATUS	Married	31.4%	30.5%	32.3%
	Divorced	0.4%	0.8%	0.0%	NS
HAVE YOU
CONSIDERED	Yes	86.0%	86.4%	85.5%
A SPECIALTY?	No	14.0%	13.6%	14.5%	NS
WHICH	Internal Medicine	15.8%	11.3%	19.5%
SPECIALTIES	Pediatrics	18.6%	22.6%	15.3%
HAVE YOU	Surgery	22.4%	18.1%	26.0%
CONSIDERED?	Family Medicine	2.8%	2.3%	3.3%
	OB/GYN	12.8%	23.7%	3.7%
	Psychiatry	3.6%	4.5%	2.8%
	Other	24.0%	17.5%	29.3%	0.007
THE ISRAELI	Provides high quality care	84.3%	84.7%	83.9%	NS
HEALTHCARE	One of the most successful healthcare systems in the world	47.5%	42.4%	52.4%	NS
SYSTEM	I know much about the system	20.7%	16.1%	25.0%	0.03
	I am familiar with the workings of the system	8.7%	5.9%	11.3%	NS
	Supports the professional development of young physicians	27.3%	26.3%	28.2%	NS
	The system invests much in teaching and developing young physicians	24.0%	20.3%	27.4%	NS
	Provides equal care to all sectors of society	22.3%	13.6%	30.6%	0.05
	There are sufficient residency positions in all specialties	2.9%	4.2%	1.6%	NS
	The system has a physician surplus	4.1%	3.4%	4.8%	NS
	The system needs reorganization	45.5%	49.2%	41.9%	NS

Multivariable Reg: Multivariable Regression - Women are the dependent variable; Coef: Coefficient.

Table 2. Comparison of men and women students – specialty selection and post-residency job criteria.

		ALL (n = 242)		Women (n = 118)		Men (n = 124)		P	Multivariable Reg*
									Coef	P
SELECTION	Provides job security	64.0%		61.0%		66.9%		NS
CRITERIA	Easy to find work	39.7%		37.3%		41.9%		NS
FOR	Has a workforce shortage	10.7%		8.5%		12.9%		0.04
CHOOSING A SPECIALTY	Has a workforce shortage and empty positions	11.6%		11.9%		11.3%		NS
	High salary	44.6%		33.9%		54.8%		0.003	0.090	0.050
	Much controllable lifestyle but surplus workforce	20.7%		21.2%		20.2%		NS
	High salaries but surplus workforce	16.9%		13.6%		20.2%		NS
	Much demand in the periphery	17.8%		12.7%		22.6%		NS
	Free time > work ratio	51.7%		56.8%		46.8%		NS	–0.118	0.005
	Work > free time	36.4%		35.6%		37.1%		NS	–0.073	0.047
	Requiring constant updating	58.1%		55.1%		61.0%		NS
	Work only in the hospital	38.6%		46.6%		30.9%		0.04
	Work only in a community clinic	12.4%		13.6%		11.4%		NS
	Combined hospital and clinic	76.3%		80.5%		72.4%		NS
	Work only in a private clinic	10.4%		7.6%		13.0%		0.05
	Only in the public sector	17.0%		18.6%		15.4%		NS
	Salaried in the public sector	27.0%		33.9%		20.3%		0.03
	Combined private and public	67.6%		66.9%		68.3%		NS
	Academic faculty	44.6%		38.1%		51.2%		0.04
	Administrative position	33.2%		31.4%		35.0%		NS
CRITERIA	Member of a multidisciplinary team	55.8%		65.3%		46.7%		0.0005	–0.134	0.000
FOR	Spending time in the operating room	41.9%		44.9%		39.0%		NS	–0.064	0.009
CHOOSING A	Located in the periphery	19.5%		19.5%		19.5%		NS	0.088	0.007
POSITION	Caring for weak populations	28.2%		31.4%		25.2%		0.01	–0.088	0.011
AFTER RESIDENCY	Provides a positive relationship between free time and work	60.6%		65.3%		56.1%		NS
SPECIALTY	Interests me much yet hard to find a job due to a workforce surplus	90.1%		89.0%		91.1%
	Interests me less but has a workforce shortage so easy to find a job	9.9%		11.0%		8.9%		NS
RESIDENCY	In periphery with added salary	27.3%		22.9%		31.5%
	In country’s center but without added salary	72.7%		77.1%		68.5%		NS	–0.162	0.034
		YES	NO	YES	NO	YES	NO
Residency	I am afraid I will not find a residency in a specialty that interests me much	49.2%	50.8%	55.1%	44.9%	43.5%	56.5%	NS
Residency	I am afraid I will not find a residency in the area I wish to live	50.0%	50.0%	56.8%	43.2%	43.5%	56.5%	0.04
Residency	I am ready to wait 3–4 years to begin a residency in a specialty the interests me much	20.7%	79.3%	19.5%	80.5%	21.8%	78.2%	NS
Residency	I am sure that I will easily find a residency in a subject that interests me much	34.3%	65.7%	27.1%	72.9%	41.1%	58.9%	0.02
Residency	The are too many medical school graduates therefore I will have a problem finding a residency in my chosen specialty	47.1%	52.9%	51.7%	48.3%	42.7%	57.3%	NS
Residency	It will be easy for me to find a residency in any hospital in the specialty I choose	17.4%	82.6%	15.3%	84.7%	19.4%	80.6%	NS
Residency	I am worried that I will need to do a residency in a peripheral hospital in order to get a residency in the specialty I choose.	53.3%	46.7%	59.3%	40.7%	47.6%	52.4%	0.05

* Multivariable Reg: Multivariable Regression - Women are the dependent variable; Coef: Coefficient.

The healthcare system

Both male and female students had positive opinions about the quality of care provided by the country’s healthcare system, which approximately half deemed one of the world’s more successful systems (Table 1).

Many students were worried about finding residency positions in their first-choice medical specialty while acknowledging that there were insufficient residency positions in all specialties (Tables 1 and 2). About half were worried that they might have to accept a position in a peripheral hospital in order to secure a residency in their preferred specialty.

The job market

Ninety-six (40%) students were interested in a specialty where it is ‘easy to find work’ and 155 (64%) were interested in a specialty that ‘provides job security’. Nonetheless, few students were attracted to specialties with a workforce shortage, even if such a specialty had empty positions (Table 2). They were also not deterred by specialties with surplus workforces especially if accompanied by high salaries or controllable lifestyles.

Interest in a specialty where it is ‘easy to find work’

Compared to students not interested in a specialty where it is ‘easy to find work’, those interested in such a specialty were more interested in a specialty affording a controllable lifestyle and a post-residency position with a ‘positive relationship between free time and work’ (Figure 1(a,b)). Multiple variable regression analysis demonstrated positive associations between the specialty selection criterion (dependent variable) ‘easy to find work’ and the selection criteria (independent variables) ‘job security’, ‘specialties with workforce shortages’ and a post-residency job with stable hours. There were similar proportions of male and female medical students in each of the two groups. Furthermore, the students in the two groups did not differ in age.

Figure 1. (a) The comparisons between the positive replies to queries about the importance of various criteria used for choosing a specialty and post-residency positions of students interested and not interested in a specialty where it is ‘easy to find work’ are displayed. The graph shows the percentage of positive responses for the interested and not interested groups. (b) The positive replies to questions about finding a residency program for students interested and not interested in a specialty where it is ‘easy to find work’ are shown. Displayed are the percentage of positive responses for the interested and not interested groups. * - interested vs not interested groups (p < 0.01).

Interest in a specialty providing job security

Using two-tailed t-tests, the replies of students not interested in a specialty that ‘provides job security’ with the replies of students interested in such a specialty. The latter more often reported as important, the cluster of specialty selection criteria ‘easy to find work’, ‘a specialty with a workforce shortage’ and ‘a specialty with a workforce shortage and empty positions’. In addition, those interested in a specialty that ‘provides job security’, were more interested in post-residency salaried positions in the public sector and positions that combine public and private practice (Figure 2(a,b)). This was also found on multiple variable regression analysis which demonstrated positive associations between the specialty selection criterion (dependent variable) ‘provides job security’ and the selection criteria (independent variables) ‘work only in a community clinic’, ‘salaried in the public sector’ and ‘combined private and public practice’. There were similar proportions of male and female medical students in each of the two groups. Furthermore, the students in the two groups did not differ in age.

Figure 2. (a) The positive replies to queries about the importance of various criteria used for selecting a specialty and a post-residency position for students who considered a specialty that ‘provides job security’ important and not important are displayed. The graph shows the percentage of positive responses for the important and not important groups. * - important vs not important groups (p < 0.05). (b) The positive replies to questions about finding a residency program for students who considered a specialty that ‘provides job security’ important and not important are shown. Displayed are the percentage of positive responses for the important and not impotent groups. * - important vs not important groups (p < 0.05).

Concern about finding residency in a specialty that interests them much

More female than male students were concerned that they would not find a residency in a specialty that interests them much (Table 2, Figure 3(a,b)). Students with these concerns also expressed concerns that they would not find a residency in the geographic area they wished to live in (Figure 3(b)). Instead, they thought they would need to do a residency in a peripheral hospital in order to find a residency in their preferred specialty.

Figure 3. (a) The positive replies to queries about the importance of various criteria used for selecting a specialty and a post-residency position for students who worried and did not worry about finding ‘a residency in a specialty that interests me much’ are displayed. The graph shows the percentage of positive responses for the worried and not worried groups. * - worried vs not worried groups (p < 0.05). (b) The positive replies to questions about finding a residency program for students who worried and did not worry about finding ‘a residency in a specialty that interests me much’ are shown. Displayed are the percentage of positive responses for the worried and not worried groups. * - worried vs not worried groups (p < 0.02).

Summary

The results show the students’ poor rating of job market related selection criteria, such as specialties with ease in finding jobs due to their suffering workforce shortages and having empty positions. The results also report that the student’s have insufficient knowledge about the workings of their national healthcare system.

Discussion

This study demonstrated the feasibility and potential value of adding queries about market awareness when investigating the medical student specialty selection process. The students had both positive and negative opinions about the job market, i.e. the national healthcare system, they are about to enter, while they afforded minimal importance to certain market conditions such as specialties with easy job availability and those suffering workforce shortfalls with empty positions. These latter observations provide healthcare leaders with insights, but also concerns, such as how to attract students to specialties with workforce shortages. The results also direct the leaders to areas that might require remediation during the medical education continuum. For instance, the students reported that they had insufficient knowledge about the workings of the national healthcare system indicating their need to receive more information about the system and its operations. Such information is not elicited when more conventional specialty selection criteria are used to study the specialty selection process.

Querying medical students about their knowledge and opinions of the local healthcare market is relevant to many national healthcare systems. These including healthcare systems with job market conditions, physician workforce issues and residency opportunities different than those in Israel. Determining students’ knowledge and opinions of the local healthcare market could be especially important in nations facing workforce shortages in certain specialties and emigration of young physicians to other countries. It is also relevant to countries where the selection of residencies is through the free market, i.e. where there is no formal organized nation-wide residency selection system and students apply to individual hospital departments. In such countries it is important for the physicians and others responsible for recruiting residents to understand how students perceive the job market in order to better develop strategies to attract sufficient and quality medical students to their residency programs. Better understanding the expectations, concerns and wants of potential residents using surveys, provides objective data to aid in developing recruitment and marketing strategies. Healthcare systems where there are either matches for individual specialties (as in the US) or systemwide allocation of residency positions (as in France), the market conditions are different and thus the type of information healthcare leaders might wish to collect might also be different. However, it could be useful for the healthcare leadership and medical educators in all countries to learn what medical students know and think about their national health care system and whether they need to modify or add specific subjects to their medical school curricula.

The healthcare system

The various components of a country’s healthcare system will be the future employment and remunerational environment for most medical students. Therefore, ascertaining their perceptions of the system should provide insight into how they see their interactions with their future professional milieu. In the current study, most students answered that the national system provides high quality care, but less than a quarter reported that it provides equal care to all sectors of society. This viewpoint is not unexpected. Although the system provides easy access to quality medical care at the community and hospital levels, especially in large urban centers and the country’s center, there is a large private sector that lower socio-economic groups can less afford, plus there is less access to higher-level care (e.g. tertiary hospital care) in the country’s periphery [19–22]. Paradoxically, only a little more than a quarter of students replied that caring for society’s weaker (underprivileged) segments was an important criterion for choosing a post-residency job. There may be a number of explanations for this observation. Some studies have found that, in general, altruism among medical practitioners is declining, while others observed it to decease as students progress through their medical studies, likely due to increased cynicism, loss of compassion and exposure to the legal and economic aspects of medicine [23,24]. This observation might also be partially ascribed to the reduced altruism found among Israelis belonging to Generation Y (born in the 1980s and 1990s, [25]). These findings should be noted by the country’s medical educators who should examine whether curricula should include more discussions about diversity and health disparities, as has been done in other countries [26–28].

Some of the students’ opinions about the healthcare system were especially disquieting. Few students reported that they knew much about the healthcare system and were familiar with its workings even though they and their families are consumers of a system affording universal healthcare. Furthermore, during their initial two years of medical school they had a course that introduced them to various aspects of the system and in their fourth-year they had both in-patient and community clinical experiences [29]. These results, although possibly unique to the institution in which this study was performed, appear to indicate that they might not yet have a sufficient grasp of the job market they are about to enter. These findings are not unique, since similar surveys of US and French medical students found significant gaps in their knowledge about health care funding, reimbursements and costs [30,31]. Therefore, further investigation is warranted to identify areas where Israeli students feel they lack knowledge, why they perceive that they lack such knowledge and whether Israeli medical schools, like their US counterparts, should add more healthcare delivery and system science to their curricula [31–35].

Another worrisome finding was that the students did not have positive opinions of the healthcare system’s support and investment in teaching and developing young physicians. This should put hospital directors, department chairs and residency program directors on notice to improve their teaching methods, their training of faculty members as clinical educators and their approaches towards trainees [36–38]. It is behooven on all national healthcare systems to examine whether their medical students have such negative perceptions so that corrective actions can be taken.

The healthcare market

The Israeli job market for residency is an open market where initially students apply to the departments in multiple hospitals for a position in their preferred specialty. If they fail to obtain a residency position in that specialty, they either apply for a position in another specialty or spend some time working as a general physician and apply again to their favored specialty.

The healthcare system’s employment market already concerned medical students during their fifth year of a 6-year program. They acknowledged its complexity with its many specialties and geographic locations, by replying that there were insufficient residency positions in all specialties especially in prime geographic locations in the county’s center. Furthermore, half the students were worried that they would not find a residency in the specialty that interests them most and in the geographic location they wish. These observations agree with current market conditions where an increase in medical school graduates did not trigger a sufficient increase in residency positions [39]. These results thus demonstrate that 5th-year students have, at the least, a basic awareness of the residency market. They also demonstrate that healthcare systems must balance the supply of residency positions with the number medical school graduates.

The students’ concern that they would not find a residency in the specialty that interests them most is especially problematic since the most important specialty selection criterion is finding a specialty ‘interesting and challenging’ [15]. This was further supported by one of our previous studies which found that Israeli students are even willing to enter residency programs in peripheral hospitals in the specialty that most interests them, rather than choose a less interesting specialty in a hospital in the country’s center [17,40–42]. The latter was reinforced in the present study where over half of the students were worried that they would need to do a residency in a peripheral hospital to get a residency in the specialty they chose. This apprehension is likely compounded by our previous findings showing the importance of geographic location when choosing a residency program, especially among women and married students wishing to live near their families [16]. In the reciprocal, two-thirds of students responded negatively to the statement ‘I am sure that I will easily find a residency in a specialty that interests me much’ and over 80% replied negatively to the statement ‘It will be easy for me to find a residency in any hospital in the specialty I choose’. Paradoxically, only 40% indicated that a specialty where it is easy to find work was an important selection criterion. These results confirm that despite a potentially problematic job market, a variety of personal and professional factors were more important when choosing a career specialty than ease in finding work.

The job market

With only 40% of students reporting that ‘ease in finding work’ was an important selection criterion, our hypothesis that students are attracted to specialties where it is easy to find work and there are open positions was not supported. This proportion is lower than the 47% of nursing students and 57% of tourism and hospitality students who rated ease of finding a job as important when they chose a career [43,44]. Forty-seven percent of Finnish senior physicians reported that ‘good prospects for employment’ had been an important consideration in their specialty choice [45]. However, in the present study selection criteria ‘a specialty with a workforce shortage and empty positions’ was important to only 12% of students. This was reinforced by 90% choosing the hypothetical situation ‘a specialty that interests me much but with a workforce surplus and hard to find a job’ over ‘a specialty that interests me less with a workforce shortage and easy to find a job’. This again emphasizes the overwhelming importance of finding a specialty ‘interesting and challenging’ when choosing a specialty [46]. These, results should temper the marketing strategy often used by leaders of specialties suffering workforce shortages emphasizing the ready availability of jobs after residency completion.

Why some students were interested in a specialty with ‘ease in finding work’ was not readily apparent, especially since there was no gender predominance nor were there differences in age or marital status when compared to students without such interests. This contrasts with a study of Polish medical students. In that study female students were more instrumentally motivated (immediate mercantile goals such as employment security, greater comfort at work and lower workload with less on-call duty) than male students when choosing a medical specialty [47]. The male students were more autotelicly (professional considerations) motivated [47]. Greater instrumental than autotelic motivation might be among the characteristics of students interested in a specialty with easy job availability. One might also speculate that the students interested in a specialty with easy job availability were more risk aversive, less competitive and less self-confident than their colleagues who rated ease in finding work as not important. The latter were more interested in competitive careers as evidenced by positive replies to queries about becoming academic faculty and administrators [48]. This idea was reinforced by the positive association of ‘ease in finding work’ with ‘specialty with a workforce shortage and empty positions’. Further study of the differences between students interested and not interested in a specialty where it is easy to find work should be performed since the former group might be more easily recruited to the periphery and to specialties with workforce shortages. However, almost paradoxically, such students also placed much importance on a high salaried specialty.

In summary, this study demonstrated the positive and negative aspects of querying medical students about their market awareness when investigating the specialty selection process. Furthermore, it showed the potential usefulness for the healthcare leadership and medical educators to learn what medical students know and think about their national healthcare system and whether there is a need to modify or add specific subjects to their medical school curricula.

Strengths and limitations

This study’s strength is that it demonstrates the feasibility and added value of also examining market-related factors when studying the process of selecting specialties and post-residency positions. Moreover, this approach can be applied to larger studies, performed in other countries and in multiple medical schools, especially since curricula may vary between schools. This approach can also be used when studying final-year medical students and interns. It promises to provide healthcare leaderships with added data about specialty and post-residency job selection. For example, the present study provided the information that many students felt that their knowledge of the workings of the healthcare system was deficient and pointed out that there are students with concerns about finding post-residency positions who might be recruited to specialties with workforce shortfalls. This study’s limitation is that it was performed on 5th year students from a single medical school, although it was performed over a three-year period.

Conclusions

Previous studies showed that intrinsic issues, such as personality, interests and career goals, and extrinsic factors, such as mentorship and experiences during clinical rotations, were influential criteria used by medical students when choosing a career medical specialty. However, the present study failed to show a similar level of importance for job market-associated criteria, although professionals in other fields often utilize such criteria when choosing a job [49–52]. The differences between them and medical students is that medical students are not directly entering the final job market, but are entering the temporary training phase of their career, which has been likened to a secondary selection of a profession given the vast differences between various specialties, e.g. psychiatry vs. surgery [53]. The combined training/employment nature of residency was demonstrated in previous studies by the combined importance of training program criteria such as teaching program attributes (department reputation, didactics, attending-resident relations, patient population) and hospital-type (academic, community); and criteria used when entering the job market such as location (urban, rural), working conditions (on-call schedules) and personal considerations (family location, time for childcare and family) [54,55]. Therefore, when examining the influence of the job market on the career choices of medical students and interns it appears prudent to query them about how the job market will influence their selection of a post-residency position, as was done in the present study, and not just about how the job market affects their choosing a residency program. This should better align job market queries with the job market-associated criteria used by other professionals who are seeking jobs and not training positions. Such an approach is supported by our previous studies, where 5th-year medical students replied that when selecting a specialty, working conditions after residency were more important than those during residency [15]. Therefore, adding market awareness queries to traditional questionnaires provides further insight and information on specialty selection, but more importantly on post-residency job selection. Therefore, to gain greater understanding as to the influence of the job market, future studies could examine the experiences of young physicians with the job market when looking for post-residency positions. These studies would be analogous to those performed by others [56–58]. Furthermore, studies, similar to those performed in other professions, contrasting pre-market expectations and preferences with post-market outcomes, could also be performed among junior physicians [59].

Author contributions

YRZ: contributed to the concept, assisted in designing the questionnaire and aided in writing and editing the manuscript. CW: contributed to the concept, collected and analyzed the data and participated in writing the manuscript. AA: contributed to the concept, helped formulate the questionnaire and reviewed the manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors thank the medical students who participated in this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The authors confirm that the data supporting the findings of this study are available within the article.

Additional information

Funding

The study was funded by a grant from The Israel National Institute for Health Policy Research [2016/28/r].