Brit.3. med. Educ., 1970, 4, 9-12

Student Attitudes Toward Early Career Commitment J. J. PREISS and E. C. L O N G Duke University School of Medicine, North Carolina, U.S.A.

In the early 1960s the faculty of Duke University School of Medicine began discussions relating to their dissatisfaction with traditional patterns of undergraduate medical education. Plans for modernization of the curriculum, in order to bring it into line with the needs of tomorrow’s doctors led to the implementation of the present pro- gramme, beginning with students entering medical school in September 1966. Among the objectives was the desire to provide greater freedom in selecting courses and to encourage students to make earlier decisions about their careers.

While the new curriculum was being planned, studies of the old curriculum were being conducted about the attitudes, prejudices, knowledge of the profession of medicine, and the process by which medical students made up their minds about their careers. These studies have subsequently proved valuable as a basis for observations on students in the new programme. Obviously, any evaluation of the efficacy of the new curriculum in promoting early career decisions must be based upon com- parative studies relating to the same processes within the former curriculum.

Nature of Survey The new programme places increased intellectual stresses upon the students and it tests, far more critically than heretofore, both a student’s commit- ment to the profession of medicine and his ability to develop his role as a ‘physician’. The data reported in this paper have been accumulated from 1961 to 1968 and will form, in part, the base line against which similar studies relating to the new curriculum will be judged. The data have been collected by the use of questionnaires completed at yearly intervals by three contiguous classes of medical students, followed throughout four years of medical school and one year of internship. A

fraction of the information collected is presented in this paper, selected to throw some light upon three important areas related to occupational and career choice. The three areas are as follows (I) students’ doubts concerning their choice of the profession of medicine; (2) the process by which self-identifica- tion in the role of a physician evolves; and (3) the distribution of career-preferences and changes which take place during the medical education processes.

Table I. Medical students’ expressed doubt about occupational choice during medical training ( %)

Year of training

None 41 55 64 66 68 64 Some (includes total range) 58 41 35 34 32 3s No information I 4 I o o I

No. 235 208 209 235 236 170 ~

Doubts About Occupational Choice At the moment that a student accepts a place in a medical school, his commitment toward a career- choice is essentially made. Not all students can make this commitment on a basis that leaves no room for doubts concerning the wisdom of their choice. Table I demonstrates the way in which doubts concerning occupational choice are dis- tributed throughout medical school and internship. ‘Year 0’ data (collected on the f i s t day of medical school) indicate that 58% of 235 freshmen medical students professed doubts ranging from slight to serious concerning the wisdom of their choice. Many of these ‘doubtful‘ students appear to have resolved their opinions firmly in favour of medicine

9

I0 J.J. Preiss and E. C. Long

by the end of the second year of medical studies. But for the remaining three years of medical school and internship the proportion of students having ‘some doubts’ remains remarkably constant at between 32 to 35%.

It is interesting to consider the distribution of doubts concerning occupational choice and thus relationships to levels of work performance. One might hypothesize that a student successful in earning ‘good grades’ would interpret this to mean that he was thereby successful in developing behaviour believed by the faculty to be required for the future physician. Thus, one might expect that students in the upper quartiles of their classes would also be those who have least doubts con- cerning the wisdom of their occupational choice. However, the findings in Table 2 suggest that this hypothesis would not be confirmed. For example, at year o 45% of the students who subsequently

Table 2. Distribution of doubts about occupational choice in relation to levels of actual work performance

Level of work performance (ranking by 0’ I z 3 4 Intern?

Year of training

bygrader) (%I (%) (%I ( Y o ) (70) (%I Quartile I 45 28 27 25 22 13

2 56 35 26 32 36 38 3 60 45 28 36 22 17 4 69 45 40 34 39 21

~~

Those with doubts (total no .) I37 88 74 79 73 s6

~ ~~ -~ -~ ~

*Percentages in this column are based upon level of performance at end of the first year. tPercentages in this column are based upon level of performance at end of the fourth year.

proved to be in the first quartile of their class (based retrospectively on their performance during their first year of medical school) admitted to occupational doubts. Altogether the data show that the distribution of students having doubts relating to occupational choice is very evenly distributed over rank in class by quartiles. While the total percentage of students with doubts diminishes somewhat during medical school, the diminution in those with doubts is not confined to those with demonstrable academic success. Conversely, many students whose academic performance ranks them in the third or fourth quartile do not appear to become more doubtful about the wisdom of their occupational choice. It is possible that many of

these students do not equate academic perform- ance (as a partial measure of opinion) with their own self-image as an effective physician.

Self Doubts and Role Doubts We may further identify the kinds of doubts con- cerning occupational choice by classifying them into two general categories. On the one hand, a student may indicate that his doubts principally centre around his evaluation of his personal capabilities to perform effectively as a physician.

Table 3. Distribution of types of doubt about occupational choice during medical training

Year of training

None 41 55 64 66 68 64 Role 25 16 15 17 20 18

Other IX 15 12 1 1 g 16 Self 2 3 1 4 9 6 3 2

No. 235 208 209 235 236 179

Such doubts, in Table 3 are classified as ‘self’ doubts. On the other hand, a student may base his doubts upon the perceived requirements of the physician’s role itself, rather than his ability to meet these requirements. Such doubts would include whether or not he wishes to perform the work needed to graduate, his reactions to the environment of medical education and practice, his willingness to withstand the duration of training, and his experience with patients. Such doubts are described in the Table as ‘role’ doubts. It is interesting to note that approximately equal percentages of students express self and role doubts at the beginning of medical school. The total of those who expressed doubts concerning the role remains relatively high throughout medical school, whereas the total of those expressing self doubt diminishes, especially after completion of the second year. At this time, in the traditional medical school curriculum, a student would have com- pleted two basic science years and would be about to experience his first major contacts with patients during years three and four. The data suggest that most self doubts have been resolved before clinical experiences begin.

Another parameter that one might expect would relate to the ‘doubt’ variable is the time when the

Student Attitudes Toward Early Career Commitment I1

=: c 50-

Z 40-

z 30-

al 0

a. c

UI

E e

5 20- c v)

10-

0-

IDENTIFICATION AS PHYSICIAN 60 I I I I 1

V. Doubts Concerning Choice =: c 50-

Z 40-

z 30-

al 0

a. c

UI

E e

5 20- c v)

10-

0-

V. Doubts Concerning Choice

year year year year Fig. I. Identification c ~ f physician (from Prkss, 1968).

student adopts the role-identity of the physician. Obviously, when a student enters medical school, with or without doubts concerning his choice, he would not expect to see himself as a ‘doctor’ at that time. However, at a subsequent point in develop- ment, his self-identification as a physician will occur. Figure I presents data relating to the period during which a student identifies himself as a physician as it related to those expressing doubts concerning their career choice.

Figure I shows that students expressing no doubts acquire identification as a physician earlier in their medical school career than those who say they have some doubts. A significant difference between those with no doubts and those with some doubts occurs in the third year of medical school training. But the most striking feature of Fig. I is indicated by the rapid acquisition of the self-image as physician by students expressing some doubts during their last year of medicd school. In this group, at the beginning of the fourth year only 18% of students with doubts have identified as physi- cian. One year later about 50% have so identified. Taking into account the data expressed in Table I, the higher identification in the ‘some doubts’ group during the last year of medical school suggests that many of these students find it necessary to profess such identification as physician even when they do not have it.

Distribution of Career Preferences The two parts of Table 4 indicate the distribution of career preferences within the profession of medicine and the manner in which these prefer- ences are modified throughout the four years of

Table 4a. Distribution of career preference during medical education

Year of training

General practice 11 19 16 g 443 2

Combination (specialty, med. ed.

and/orresearch) g 14 17 17 19.7 8 Undecided 32 14 6 6 3-9 3 No answer ‘5 - - I - I Other ‘5 - 2 1 ‘9 1

Specialty 47 53 59 66 70‘7 85

234 208 207 235 229 164 No.

undergraduate medical training and the internship period. As shown in Table 4a, nearly one third of entering students are undecided concerning their general type of career preference. This proportion is steadily reduced to 3% after completion of the internship, where the category of general practice also practically disappears. Another casualty of general career focus is the category of ‘combina- tion’ after the fourth year. Perhaps this is a result of the practical focus of the internship and the switch of many interns from an academic medical setting to a regular hospital environment. In any event, the research interests of some students seem to weaken rather quickly after they graduate.

Looking further at career choice within the specialty category, Table 4b shows the range of

Table 4b. Distribution of specialization preference durieg medical education

Year of training

0 Specialization (yo) Anaesthesiology - Internal

medicine 9 Ob-Gyn. I Pathology I Paediatrics 2 Psychiatry 3 Radiology - Surgery I4 Undecided 54 Other prefer-

ences or no information 16

I (%I - - 16

I - 8 4 I a 40

22

3 (%I - 21 2 I

I0 7 I

25 15

17‘5

4 (yo) Inrent

’5 ‘5

25 20.5 2 3 2 5 I2 I 2 a 10 2.5 4 28 32 9 4

11 9

I2 3.3. Prkss and E. C. Long

preferences by the major specialties. Of note is the relative plateau of popularity of ‘internal medicine’ after the second year, whereas all of the other specialties continue to gain in popularity as indecision disappears. Surgery emerges as the most attractive specialty, claiming about one-third of the intern group. It is also interesting that the essen- tially diagnostic specialties, such as radiology and pathology, markedly increase from the third year through internship. These specialties are charac- terized by relatively small amounts of contact with patients, and can often be followed during ‘regular’ hours - that is, there are fewer emer- gencies.

Table 5. Career plans and marital s t a t u of female medical students: 1967-68

Marital status Career plans Singre Married or engaged

Complete residency IS 8

Full-time practice I 0 3 Part-time practice 5 5

Career choice : Paediatrics Ob-Gyn. Public health Psychiatry Surgery Medicine Other Undecided

5 4

3 I

I I I I I

I

- - -

- 8 2

NO. 20 9

Women Medical Students Table 5 presents data on a small group of women medical students. It is interesting that the majority of women medical students, whether single, engaged, or married, plan to complete residencies, and the majority of the single women plan to enter the full-time practice of medicine. Paediatrics appears to be the popular career choice, although

more single than married or engaged women are undecided about this career preference. It is not possible, at th is time, to say whether those single women in the ‘undecided’ group remain so because the possibility of marriage impedes a more definite occupational choice. Obviously, the group (29) is too small for definite conclusions to be drawn. However, these data are included to emphasize the fact that the career decision problems of women in medicine have probably been overlooked, or have been assumed to be similar to those of men. The likely increase in the proportion of women in medicine in the near future (it is now much higher in many other countries than in the United States) indicates that the career perspectives of women students in current medical school programmes should be given more specific attention by researchers.

In the new curriculum at Duke University School of Medicine there is a great incentive for the student to make his career decision toward the end of his second year of medical school. It will be important to study whether or not clinical training during the second year of medical school helps significantly to resolve doubts and to accelerate role-identification. If these decisions are based upon better experience and with reduced uncer- tainty, an important objective of the new pro- gramme will be realized.

It is suggested that medical schools planning to change their curriculums by introducing more elective time and affording opportunity for earlier career decision should establish research pro- grammes for investigating the career decision- making process. These studies should be continued into the graduate period with the object of gaining information that would permit us to improve our counselling techniques and help us to maximize the use of elective periods.

Reference Preiss, Jack J. (1968). Self and role in medical education,

in The Self in Social Interaction, Vol. I, edited by C. Gordon and K. Gergen. John Wiley: New York.