Abstract
Background: Although medical student specialty choices shape the future of the healthcare workforce, factors influencing changes in specialty preference during training remain poorly understood.
Aim: To explore if medical student distress and empathy predicts changes in students’ specialty preference.
Methods: A total of 858/1321 medical students attending five medical schools responded to surveys in 2006 and 2007. The survey included questions about specialty choice, burnout, depression, quality of life, and empathy.
Results: A total of 26% (205/799) changed their specialty preference over 1 year. Depersonalization – an aspect of burnout – was the only distress variable associated with change in specialty preference (OR, odds ratio 0.962 for each 1-point increase in score, p = 0.03). Empathy at baseline and changes in empathy over the course of 1 year did not predict change in specialty preference (all p > 0.05). On multi-variable analysis, being a third year (OR 1.92), being male (OR 1.48), and depersonalization score (OR 0.962 for each point increase) independently predicted a change in specialty preference. Distress and empathy did not independently predict students’ losing interest in primary care whereas being a fourth-year student (OR 1.83) and being female (OR 1.83) did.
Conclusion: Among those who did have a major change in their specialty preference, distress and empathy did not play a major role.
Introduction
Developing a physician workforce that meets society's needs is vital to ensuring the health of the population. As early as medical school, the next generation of physicians begins to shape the future of the healthcare workforce as they start the process of deciding which specialty area of medicine to pursue in residency. Given the projected shortfall of primary care physicians in the USA (Dill & Salsberg Citation2008), a better understanding of factors that influence specialty decision making is needed to inform changes that will ultimately help shape the physician workforce to better align with society's need.
While some previous studies suggest up to 80% of medical students declare a specialty choice at graduation that differs from their anticipated specialty choice at the time of matriculation (Markert Citation1983; Babbott et al. Citation1988; Brooks Citation1991; Forouzan and Hojat Citation1993; McLaughlin et al. Citation1993; Fincher and Lewis Citation1999; Novielli et al. Citation2001) other studies suggest that most specialty choices are made early and are stable (Zeldow et al. Citation1992). Previous longitudinal studies suggest that the stability of specialty choice over time varies by gender (Babbott et al. Citation1988; Forouzan and Hojat Citation1993; McLaughlin et al. Citation1993; Novielli et al. Citation2001), specialty choice (Markert Citation1983; Babbott et al. Citation1988; Zeldow et al. Citation1992; Forouzan and Hojat Citation1993; McLaughlin et al. Citation1993; Novielli et al. Citation2001), clerkship performance (McLaughlin et al. Citation1993; Novielli et al. Citation2001), personal values (Hojat et al. Citation1998; Fincher and Lewis Citation1999; Connelly et al. Citation2003), income expectations (Rosenthal et al. Citation1992; Novielli et al. Citation2001), and role models (Connelly et al. Citation2003). Although these studies provide some insight into the factors associated with students changing their specialty preference during medical school most were conducted over a decade ago and several relied on single institution data.
Medical students today are training in an environment that erodes empathy (Feudtner Citation1994; Bellini et al. Citation2002; Collier et al. Citation2002; Hojat et al. Citation2004; Bellini & Shea Citation2005; Shanafelt et al. Citation2005; West et al. 2006a; Thomas et al. Citation2007; West & Shanafelt Citation2007; Newton et al. Citation2008; Wear & Zarconi Citation2008; Roberts Citation2010) and fuels distress (Dyrbye et al. Citation2006, 2008, 2010b). Other studies have found that decreased interest in primary care (Dorsey et al. Citation2003, Citation2005), an unwillingness to care for the chronically ill (Davis et al. Citation2001; Griffith & Wilson Citation2003), and a loss of desire to care for the underserved (Dyrbye et al. 2010a) parallel the decline in empathy and mental health among medical students (Hojat et al. Citation2004; Spencer Citation2004; Newton et al. Citation2008; Hojat et al. Citation2009) and have been linked to burnout experienced during the training process (Dyrbye et al. 2010a), suggesting empathy and distress could influence stability of students’ specialty preference, but no studies to date have directly evaluated this. Thus, we analyzed data from a prospective, multi-center study to determine if distress or empathy can predict subsequent changes in specialty plans over 1 year of a 4-year medical training program.
Methods
The methods for this large, multi-site study are described elsewhere (Dyrbye et al. Citation2008). Briefly, in the spring of 2006 and 2007, all medical students were surveyed after Institutional Review Board approval at each of the medical schools involved was obtained (Mayo Clinic College of Medicine, University of Alabama School of Medicine, University of Chicago Pritzker School of Medicine, University of Minnesota Medical School, and University of Washington School of Medicine). The survey included validated instruments to assess burnout (Maslach Burnout Inventory) (Maslach et al. Citation1996), symptoms of depression (Primary Care Evaluation of Mental Disorders [PRIME MD]) (Spitzer et al. Citation1994), empathy (Jefferson Scale of Physician Empathy) (Hojat et al. 2002), and quality of life (QOL, Medical Outcomes Study Short Form [SF-8]) (Ware et al. Citation2001).
Burnout encompasses three domains: emotional exhaustion (EE; i.e., feeling emotionally depleted from one's work), depersonalization (DP; i.e., treating people as if they are impersonal objects), and low personal accomplishment (PA; i.e., feeling that one's work is inconsequential). Scores within individual burnout domains were used both as continuous variables and categorized into low, intermediate, and high scores using established cut-offs (Maslach et al. Citation1996). Because high scores on either the EE or DP scales can distinguish clinically burned out from non-burned out individuals (Schaufeli et al. Citation2001), burnout as a dichotomous variable was defined as having high EE and/or high DP.
A positive depression screen is defined as a ‘yes’ response to either of the 2-items on the PRIME MD. The PRIME-MD performs similar to longer instruments (Whooley et al. Citation1997) and has a sensitivity of 86–96% and a specificity of 57–75% for major depressive disorder (Spitzer et al. Citation1994; Whooley et al. Citation1997). QOL was measured using the psychometrically sound SF-8 (range 0–100) with norm-based scoring methods used to calculate mental and physical QOL summary scores (Ware et al. Citation2001; Turner-Bowker et al. Citation2003). The average mental and physical QOL summary scores for the US population are mean (SD) 49.2 (9.46) and 49.2 (9.07), respectively (Ware et al. Citation2001). Additional items inquired about specialty preference (both years), demographics (2006), and life events in the previous 12 months (2007). Unique identifiers were used to link individual responses on the 2006 and 2007 surveys.
Using the approach of previous studies (Schwartz et al. Citation1991; Newton & Grayson Citation2003; Jeffe et al. Citation2007), responses to the specialty preference question were collapsed into primary care fields (internal medicine, family medicine, and pediatrics), surgical fields (surgery, otolaryngology, urology, orthopedic surgery, ophthalmology, and obstetrics/gynecology), and non-primary care/non-surgical fields (anesthesia, dermatology, neurology, psychiatry, radiology, pathology, emergency medicine, physical medicine/rehabilitation, and other). We considered students to have made a major change in their specialty preference if they indicated a 2007 specialty preference that was in a different category than their 2006 specialty preference.
In addition to descriptive summary statistics, we used Kruskal–Wallis tests or chi-squared tests to evaluate for differences between groups. All tests were two-sided with comparison-wise type I error rates of 0.05. Forward and backward stepwise logistic regression evaluated independent associations among demographic variables, life events, scores on the instruments, and major change in specialty preference or loss of interest in primary care. Findings of the stepwise regression were confirmed with a saturated regression model. All analyses were done using SAS® software.
Results
Of the 1321 students eligible for the longitudinal study (i.e., completed the 2006 survey and remained enrolled in the same medical school in 2007), 858 (65%) completed the 2007 survey. There were no differences in age, gender, marital status, parental status, or ethnicity (all p > 0.05) between students who responded to both surveys and students who chose to respond only to the 2006 survey. A total of 59 students in the longitudinal cohort did not indicate their specialty preference on one or more of the surveys and were excluded from the remaining analysis.
Among respondents, 45.1% (385) were male and at baseline (i.e., in 2006) the majority of students were single (60.6%, 519). More than a quarter were married (27.8%, 238), another 10.3% (88) were partnered but not married, and few (1.4%, 12) were divorced. Only 7.9% (68) had children. Most students reported being less than 25 years of age (45%, 386) or between 25 and 30 years of age (48.5%, 416) while the remainder (6.5%, 56) was over 30 years of age. In 2006 (i.e., at baseline) respondents included 314 first-year students (36.7%), 273 second-year students (31.9%), and 238 third-year students (27.8%) as well as a few students (3.5%, 30) pursuing enrichment activities such as research or graduate school work. The majority of students (57.1%, 488) reported total debt of less than $50,000 while fewer (30.9%, 264) had debt between $50,000 and $100,000 and a minority (11.9%, 102) had debt greater than $100,000. Although few students (14.9%, 128) indicated they experienced a positive life event between 2006 and 2007, nearly a third of students (32.2%, 276) had experienced a negative life event in the previous year. At baseline 38.3% (306), 35.5% (284), and 26.2% (206) identified a primary care, non-primary care/non-surgical, or surgical field, respectively, as their specialty preference.
Major change in specialty preference
The specialty preference of the majority of medical students (594/799, 74%) was stable over 1 year. The incidence of a change in specialty preference did not differ based on whether students’ initial specialty preference was primary care (73/306, 24%), a surgical field (59/209, 28%), or a non-primary care/non-surgical field (73/284, 26%). shows students were not more likely to lose interest in one field in comparison to another. Changes in specialty preference varied by year in school (overall p < 0.001). Students who went through the third-year curriculum (when most clerkship experiences take place) were more likely to change their specialty choice than students who finished the second year (88/256 [34%] vs 73/290 [25%], p = 0.019) or fourth year (39/223 [18%], p < 0.0001) of medical school over the course of the year of the study. No association between other demographic variables or recent life events and the incidence of a major change in specialty preference was observed (all p > 0.05).
Figure 1. Change in specialty preference between 2006 and 2007 among a longitudinal cohort of US medical students by initial specialty preference. Note: Figure shows few students changed their specialty preference over the course of 1 year and students are not more likely to lose interest in one field in comparison to another.
EE score, PA score, and burnout at baseline or changes in these measures over the course of 1 year (matched-paired data) were not associated with change in specialty preference (). Each 1-point elevation in DP score, however, was associated with a 4% decrease in the odds of making a major change in specialty preference (OR, odds ratio 0.962, 95% CI, confidence interval 0.929–0.996, p = 0.03). Similarly, QOL score and depression at baseline and changes in these measures over the course of 1 year also demonstrated no association with a change in specialty preference (all p > 0.05). Finally, no relationship was found between empathy score at baseline or change in this measure over 1 year and change in specialty preference (p > 0.05).
Table 1. Relationship between distress and empathy at baseline and changes in these measures and major changes in specialty preference over the course of 1 year
On multi-variable analysis, going through the third-year curriculum during the study (i.e., students who were a second-year student in 2006 and a third-year student in 2007; OR 1.92, 95% CI 1.36–2.72, p = 0.0002), being male (OR 1.48, 95% CI 1.05–2.09, p = 0.03), and DP score at baseline (OR 0.962 for each 1-point increase in score, 95% CI 0.928–0.997, p = 0.03) independently predicted a major change in specialty preference.
Loss of interest in primary care
In the analysis to specifically explore factors related to a loss of interest in primary care, no relationship was found between baseline demographic variables, experience of a recent life event, measures of distress or empathy scores at baseline and changes in these measures over the course of 1 year and switching specialty preference from primary care to other areas (all p > 0.05). On a multi-variable analysis, going through the fourth-year curriculum during the study (OR 1.833, 95% CI 1.066–3.153, p = 0.03) and being a female medical student (OR 1.833, 95% CI 1.098–3.061, p = 0.02) were both independently associated with an increased odds of losing interest in primary care after controlling for other demographic factors, life events, burnout, QOL, depressive symptoms, and empathy.
Discussion
Developing a physician workforce that meets society's needs is vital to ensuring the health of the population. In this large prospective, nationwide study of medical students 26% changed their specialty preference over the course of 1 year. Our study suggests that changes in specialty choice are most likely to occur during the third year of training whereas opting out of primary care occurs most often during the fourth year of training. Apart from sex, no other demographic variable, debt, or personal life event was associated with these changes. In addition, whether or not students experienced burnout or other forms of distress did not strongly influence whether or not they made major changes in specialty choice or opted out of primary care. The only measured aspect of distress associated with a change in specialty preference over the year was the DP domain of burnout. Students with higher DP were less likely to change specialty preference. Perhaps higher DP (feeling callous and hardened or emotionally detached) inhibits the self-reflection and personal activation required for a change in specialty preference. Given the lack of relationship between most measured aspects of distress and change in specialty preference or loss of interest in primary care, distress does not appear to be a significant factor in predicting which students change their mind about their specialty preference. Thus, while improving the mental health of trainees and physicians is important to ensuring the health of the workforce and the quality of care delivered (Shanafelt et al. 2002, 2010), it is unlikely to substantially impact specialty choice or interest in primary care.
Our study suggests that empathy at baseline and changes in empathy over the course of 1 year of training does not predict change in specialty choice or loss of interest in primary care. Previously conducted studies suggest a relationship between: (1) empathetic concern (Interpersonal Reactivity Index) measured at the end of clerkship training and residency specialty area (Borges et al. Citation2009); (2) changes in vicarious empathy scores (Balanced Emotional Empathy Scale) during medical school and residency specialty area (Newton et al. Citation2008); (3) vicarious empathy scores (Balanced Emotional Empathy Scale) and medical students’ specialty intentions; and finally, (4) empathy scores (Jefferson Scale of Physician Empathy) and physicians’ specialty areas (Newton et al. Citation2000; Hojat et al. 2002). Although empathy is a multi-dimensional construct likely to be among the complex array of factors that have a role in specialty choice decision making, our finding of stability of specialty preference for nearly three-fourth of students and no predictive relationship between empathy scores at baseline or changes in empathy scores and changes in specialty preference suggests that the decline in empathy experienced all too often by medical students during training is not having a major role in shaping students’ specialty preference or interest in primary care.
It is also notable that most of the students in our study who shifted their specialty plans did so during the clerkship year (third year). The clerkship year provides a formative opportunity for students to gain insight into the day to day experience of different specialties of medicine. Over one in three students made a substantive change in their anticipated specialty choice after their clerkship year as compared to 18% of students making major shifts during the fourth year of medical school. As movement between specialty categories was relatively equal, it appears that actual clerkship experiences may be the most important factor driving changes in specialty choice (Hauer et al. Citation2008).
The experiences in the third year did not overwhelmingly steer students away from primary care. In fact, there was not a greater exodus from primary care than other fields. Those who lost interest in primary care were not more likely to have experienced increased distress, decline in empathy, or recent life events over the previous year.
Rather we found that the fourth year was an independent predictor of losing interest in primary care. It is during the fourth year when students collect letters of recommendation from their preceptors and finalize their specialty choice decision. In fact, by February of the fourth-year US medical students must submit their rank of residency programs to the National Resident Matching Program. Somewhere during this process, a select group of students are opting out of primary care. Further study is needed to delineate what factors during the fourth year (e.g., away rotations, sub-internships, residency interviews, etc.) are influencing these students to choose other specialty options. However, given the overall stability of students’ specialty choice over 1 year efforts to attract students into specific specialty areas may need to focus on attracting students either very early in medical school training or by specifically selecting students who already are interested in these fields, findings consistent with previous studies showing admission criteria relate to students’ choice of primary care careers (Rabinowitz 1993; Martini et al. 1994; Smith Citation2011).
Our study is limited by several factors. First, although our response rate is typical of large multi-institutional studies involving physicians (Kellerman & Herold Citation2001) and medical students (Dyrbye et al. Citation2006), response bias is a possibility. Second, we collapsed anticipated specialty choices into three groups in order to maintain an adequate sample size in each group. Subtle differences in students’ distress and empathy between specialties within the groups could exist. Our approach, however, is consistent with prior studies that have used similar specialty choice categories (Schwartz et al. 1990, 1991; Burack et al. Citation1997; Fincher & Lewis Citation1999; Woodworth et al. Citation2000; Newton & Grayson Citation2003). Third, students’ anticipated specialty choice during medical school may differ from their ultimate specialty career once in practice. Previous studies suggest that approximately a third of residents who enter internal medicine stay in primary care (West et al. 2006b) and surgery is plagued with a high attrition rate (Neumayer et al. Citation2002). Fourth, we explored a limited number of factors that may be influencing students’ specialty choices. Other experiences during the course of training such as the satisfaction and distress of resident and attending physicians (Schwartz et al. Citation1991; McMurray et al. Citation1993) and gender discrimination and sexual harassment during residency interview (Stratton et al. Citation2005) may also play a role.
Our study has several important strengths. First, it is a large, prospective multi-institutional study. Second, students in this study attended diverse private and public medical schools geographically distributed across the USA and respondents were representative of medical students in the USA. Third, the use of established instruments with solid psychometric properties to measure burnout, depressive symptoms, QOL, and empathy allows for comparison with the general population and other samples of medical students, residents, and physicians. While others have previously explored the relationship between demographic factors, empathy, and specialty choice, to our knowledge, this study is the largest to explore the relationship between anticipated specialty choice and student distress. As few longitudinal, multi-institutional studies have been conducted on this topic in the last decade, these data provide insight into where medical schools attempting to better align the specialty preferences of their graduates with societal need should focus.
Acknowledgments
This study was supported by an Education Innovation award from the Mayo Clinic and an intramural grant from the Mayo Clinic Program in Professionalism and Bioethics. Drs Dyrbye and Shanafelt receive salary support from the Mayo Clinic, Department of Medicine Program on Physician Well-Being. Dr Dyrbye receives additional salary support from the Mayo Clinic, College of Medicine Office of Medical Education.
Declaration of interest: The authors report no conflict of interest. The authors alone are responsible for the content and writing of this article.
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