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| Journal of the New Zealand Medical Association,
17-February-2006, Vol 119 No 1229
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Career choices of New Zealand junior doctors
Andrea Zarkovic, Stephen Child, Gill Naden
In the last10 years, most
countries have seen increasing shortages of hospital junior doctors. Changing
population demographics and alterations in the practice of medicine have
resulted in relative shortages of various specialty groups. As a result,
workforce-development programmes have been created in most Western countries
with considerable focus on the areas of medical education, workforce planning,
role development, and variations in practice.
Over the past 30 years, many
groups have studied the career aspirations of varying levels of medical
graduates.1–14 Literature exists on career preference dating back to the
1970s1 with surveys covering choices made at pre-medical school8 to postgraduate
level. Changing work practices, lifestyle factors, and education/service
delivery result in variations in career survey results over time.
Over 50%
of the New Zealand hospital workforce is staffed by doctors trained in countries
other than New Zealand, which makes the issue of workforce planning acutely
important in the delivery of healthcare in this country. While two studies,6,11
have looked at the career aspirations of medical students in New Zealand, no
review has looked at postgraduate career choices.
In this
cross-sectional overview, we surveyed final medical year students, early
postgraduate junior doctors, and registrars in Auckland to determine their
intended career path and those factors that primarily affected their decision
process.
MethodsA seven-question survey was distributed between March
2003 and May 2003 by direct mail to junior doctors’ work address at
hospitals covered by Auckland District Health Board, Waitemata District Health
Board, and Counties Manukau District Health Board. Each doctor in postgraduate
year (PGY) 1–4 received three copies of the questionnaire and an
accompanying letter asking them to fill out one copy of the questionnaire for
themselves. This letter also asked their registrar and final year student to
fill out the other copies of the questionnaire.
In addition, questionnaires were directly distributed
at the major teaching sessions and career information evenings involving junior
doctors. The questionnaire was also available on the intra-hospital website
(intranet) and a small advertising campaign was conducted.
All questionnaires were anonymous, although respondents
were asked their training level and gender. All questionnaires were received and
collated by the principle author. Ethics approval was not requested for the
study but the questionnaire followed extensive consultation with key stakeholder
groups.
ResultsResponse
rate—Of the 400
questionnaires distributed, 271 were returned. Fifteen responses were excluded
from analysis for being incorrectly filled out. As shown in Table 1, of the
possible 240 PGY 1-4 doctors in the Auckland region, 160 responses were
received. This suggests that we sampled more than 60% (95%CI: 54–66) of
the doctors in this area.
Table 1. Responses to the questionnaire
*Note that percentages of
male and female doctors do not add up to 100% because some doctors failed to
specify their gender as requested in the questionnaire; PGY=postgraduate
year.
Career
choices—Table 2 illustrates the career preferences and level of
certainty for each of the major vocational groups. Decisions regarding surgery
appear the most “concrete.”
Table 3
showed the favourable responses for major specialties, and compares these
between male and female doctors. Results suggest that internal medicine and its
related specialties are the most preferred career choice whereas a career in
obstetrics & gynaecology is the most undesired. No major gender differences
were found, although more female doctors appear to be interested in paediatrics
and obstetrics & gynaecology. Of 256 responders, 18 expressed interest in
anaesthetics and 11 in radiology; 8 were interested in psychiatry and pathology
each.
Ophthalmology
and sexual health were favoured by four respondents each, and three doctors
wanted to pursue emergency medicine. Two favourable responses were obtained for
radiation oncology, research, and management, respectively. One person expressed
interest for each of the following specialties: occupational health,
microbiology, orthopaedics, intensive care, neurosurgery, public health, sports
medicine, and urology.
Table 2. Certainty of career preferences of junior
doctors for five major specialities
GP=general
practice, O&G=obstetrics and gynaecology.
Table 3. Numbers (percentages) of respondents who
expressed probable or definite interest in mainstream specialties
*Note that the numbers of
male and female doctors don't add up to total numbers because some respondents
did not specify their gender as requested in the questionnaire; GP=general
practice; O&G=obstetrics and gynaecology.
Factors
affecting choices—Figure 1 indicates those factors that most
affected career choice. Interest in a specialty appears to be most important
regardless of career choice. There is some variation between other factors.
Figure 2 records those factors
that most influenced the choice of a career. This result appears to favour the
influence of prior experience, but results were fairly evenly spread.
Figure 1. Relative importance of factors influencing
the choice of different specialties
 Figure 2. Factors that influence career decisions of
junior doctors
 Timing
of career choice—Out of all respondents, 45% (95%CI: 39–51%)
believed they had already made a career choice. The majority of final year
students (70%; 95%CI: 64–75%) had not made a definite career decision, and
just over half of PGY 1 doctors (52%; 95%CI: 41–63%) were still undecided.
After the first postgraduate year, the number of doctors still undecided on
their career path gradually declined, with 45% (95%CI: 33–60%) of PGY 2,
17% (95% CI 9–33) of PGY 2+, and 12% (95%CI: 6–26%) of registrars
reporting no definite career choice.
The most common
reason—reported by 68% (95%CI: 62–73%) of respondents—for not
yet making a career choice was the wish to gain more exposure to a wider range
of medical specialties before making a decision. Indeed, almost a third of
respondents (29%; 95%CI: 24—35%) stated that they liked many specialties
and were finding it difficult to make a choice. About 25% (95%CI: 21–32)
stated that part of the reason for not making a definitive decision was because
they were considering leaving medicine.
Of the 141
doctors who had chosen their career path, 44 (31%; 95%CI: 24–39%) doctors
appear to have done so while still in medical school; 23 (16%; 95%CI:
11–23) in their first postgraduate year; and the rest in their second and
subsequent postgraduate years.
Overseas
expectations—Of the 256 responders, 177 (69.1%; 95% CI:
63–75%) stated that they plan to work outside of New Zealand whereas 60
(23.4%; 95%CI: 19–29%) stated that they would not work overseas. The rest
(5.9%; 95%CI: 4–9%) were still undecided. It should be noted, however,
that the question did not distinguish long-term work preferences from a short
experience overseas.
Interest in travel (70%; 95%CI: 63–76%) and
professional training (58%; 95%CI: 51–65%) were the most common reasons
listed for going overseas. None of the respondents listed financial gain as a
sole reason for leaving New Zealand, but 36% (95%CI: 25–49%) of junior
doctors listed it as part of the reason. About 20% (95%CI: 15–26%) of
respondents wanted to work overseas for family reasons.
DiscussionThe most popular career choice amongst junior doctors was
internal medicine, although their career path was usually not chosen until the
second postgraduate year.
Many studies have been published internationally regarding
career choices of medical students and early postgraduate doctors.15–23
The changing nature of healthcare delivery, societal values, and medical school
selection suggest that factors influencing career choices among medical
professionals vary rapidly over time and between healthcare systems.
Although
extensive literature exists internationally on career choices of junior doctors,
we believe our study is only the third study specifically looking at New Zealand
doctors.6,11 Although only the Auckland area was sampled, it is likely that the
results are fairly representative of New Zealand as a whole. Indeed, in the
previous Otago Medical School-based studies, the authors surveyed the future
career intentions of medical students in New Zealand.
Results of
those studies are very similar to our study—ranking internal medicine,
surgery, and general practice as the preferred career intentions of medical
students. It should be noted, however, that those studies listed financial
reasons as the most important reason to leave New Zealand secondary to the high
levels of student debt. Our study revealed fewer financial motives for overseas
career aspirations. This may be explained by the improving financial rewards
given to hospital doctors in New Zealand over the past 3 years as well as the
reduced financial concerns felt by doctors who are more advanced in their career
path.
All
studies, including our study, suffer from the subjective nature of such surveys
as well as the change in attitudes of this flexible workforce. Indeed, Lambert
et al5 showed that (overall) 74% of respondents retained their Year 1 career
choice by Year 3, thus indicating approximately a quarter of doctors changed
their minds regarding career choices in their early postgraduate years.
In a
previous paper by the same group,10 it is interesting to note that 18 years
after their selection, 58.9%, 78.2%, and 86.6% of doctors’ career choices
matched career aspirations held at years 1, 3, and 5 postgraduation
respectively. These results would suggest that the career aspirations and
choices of medical students, and indeed those in their first 3 years
postgraduation, are extremely flexible, with approximately one-quarter to
one-half of those students ultimately ending up in different careers. About a
third of the respondents from our study who appeared to have made their career
decisions did so while still in medical school. Based on other studies, it is
likely that a considerable proportion of these choices will change over
time.
Taken
together with the length of medical training, this would indicate that
extrapolation of data from all career choice surveys must be done with extreme
caution before making major changes to healthcare delivery. Similarly, however,
the results would suggest the need for continued flexibility in career pathways
for junior doctors as well as better career guidance at all stages of a medical
career.
This study
suggests that internal medicine and its related sub-specialties are the most
popular choice of junior doctors in New Zealand, followed by surgery,
paediatrics, and general practice. When reviewing the vocational register from
the Medical Council of New Zealand,24 the preferences for vocational specialties
by junior doctors rank in a similar order to the number of vocational
specialists registered by the council. In other words, the greatest number of
junior doctors wished to do those specialties which had the greatest number of
jobs available in New Zealand.
Despite
the uncertainty of career choices made by junior doctors at this level (as
listed in the above comments), it is still of interest to note that doctors are
either ‘strongly favourable’ or ‘unfavourable’ with
regards to surgical career choices whereas responses for other specialties show
less polarity. This result, taken together with the studies of Gelfand et al2
and Ranta et al3 would suggest a perceived image of surgery as a vocation that
either does or does not have a strong career match with individual junior
doctors. This might imply that if a recruitment problem existed with regards to
surgery, then what must first be tested, is the perception of junior doctors for
this vocation and the accuracy of this perception.
The
earlier New Zealand medical student studies support the high degree of financial
concern (mainly in regards to student debt acquired at medical schools).6,11 In
our study, the junior doctors’ stated interest in a specialty was of
greatest importance in career selection, and financial matters appeared to have
little impact. Again, these results are consistent with those in overseas
studies.1,4
All
studies support the conclusion that lifestyle factors are significantly
important in vocational choice. Unfortunately, we could not find any previous
relevant New Zealand data to investigate whether there has been a relative
increase in the influence of lifestyle choice, as may be expected through
changing societal values.
Workforce
planning for the future needs to include those factors that influenced career
choice the most. It would appear fairly evenly split between having
“individual role models” or having either a “personal
experience of working in a specialty”, or “reports from others
working in a specialty.” This would support the suggestion that
recruitment to specific vocations must ensure not only early training experience
but also work experience prior to training within a specialty. These results
also correlate well with the findings that showed high importance of having an
individual mentor in assisting with vocational career selection.
At
present, New Zealand offers clinical rotations of 3 months in the early
postgraduate years, which limits the exposure to specialties to four per year.
Internationally, the length of early postgraduate clinical work experience is
quite variable, varying from 2-week experiences in some North American hospitals
to 6-month exposure in United Kingdom hospitals.
The results from our study strongly suggest that most junior doctors are
still undecided about their career paths when they leave medical school.
Moreover, most doctors felt that clinical exposure to a wide range of
specialties is essential in aiding the decision process. Therefore, a current
system that includes shorter rotations for the first few postgraduate years
appear to be ideal for career selection.
ConclusionsIn summary, this New Zealand
survey has reiterated international results regarding career selection choices
of junior doctors. Adequate career guidance should be provided to evolving
healthcare professionals throughout all levels of training. Caution should be
practised by all healthcare planners wishing to reduce flexibility for length of
training inherent in current systems.
While a large number of doctors remain undecided or
change their mind about career choices in their early postgraduate years, most
are still attracted to the high volume specialties and remain focussed on their
academic interest in a specialty and pursuit of a rewarding career.
Author
information: Andrea Zarkovic, Non Vocational Registrar in Opthalmology;
Stephen Child, Director of Clinical Training; Gill Naden, Manager, Clinical
Education and Training Unit; Auckland City Hospital, Auckland
Correspondence:
Andrea Zarkovic, 7 Awatahi Place, Greenhithe, Auckland. Fax: (09) 4137170;
email: andrea_d_z@yahoo.com
References:
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