Clinical experiences: do they make a difference on specialty choice decision?

Article

Reference

Clinical experiences: do they make a difference on specialty choice decision?

VU, Nu Viet, PAIVA, Rosalia E., VERHULST, Steven J.

VU, Nu Viet, PAIVA, Rosalia E., VERHULST, Steven J. Clinical experiences: do they make a difference on specialty choice decision? Annual Conference on Research in Medical Education, 1981, vol. 20, p. 89-94

PMID : 7347550

Available at:

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CLINICAL EXPERIENCES: DO THEY MAKE A DIFFERENCE ON SPECIALTY CHOICE DECISION?

Nu Viet Vu, Ph.D., Rosalia E. A. Paiva, Ph.D., and Steven J. Verhulst, M.S.

Department of Medical Education

Southern Illinois University - School of Medicine REVIEW OF LITERATURE AND PURPOSE OF THE STUDY

Research in the area of physicians' specialty choice has often investigated factors which influence those choices. In general, these factors can be grouped into several categories: biodemographic characteristics, personality and attitudes, educational background, work conditions, and· inherent differ- ences between the specialties (Hutt, 1976). Although studies have shown that most medical students' choice of specialty is usually well decided by the mid- dle or end of the clinical years (Parmeter, 1978, Sachs, 1977), there has been limited systematic assessment of factors extrinsic to the individual during the years when students make their final choices. The purpose of this study was

to investigate students' experiences during the clinical years to determine the extent and direction in which they affect students' specialty choice. The factors of influence assessed in this study include persons, significant events, and the order of clinical clerk~hips. Other factors explored are:

students' financial considerations and educational debts, and length of post- graduate training.

METHODOLOGY

Subjects. Subjects were all medical students in two different classes at a midwestern School of Medicine: the class of 1980 (N • 72) and the class of

1981 (N ^a 72).

Instruments. The data were collected from two different instruments:

a) Ca~eer Rating and Preference Questionnaire (CRPQ). This instrument is administered at various points in the training program to determine students' current career choices and factors affecting those choices. CRPQ information used for this study were: responses to questions on the influence (positive or negative) of persons and events experienced during previous sections of the curriculum upon current specialty preferences; responses to items on the im- portance of financial factors, length of post-graduate training and debts on specialty choice decision; and descriptive statements and explanatory comments on these responses.

b) Clerkship Track Preference Form (CTP). The CTP, completed prior to enter- ing the clerkship period (Sequence III), requires students to list their in- tended specialty choice and to rank their six most preferred clerkship rotation tracks. Because of the three-year program, students are forced to make career decisions before completing all required clinical experiences. Approximately half-way through the clerkships, applications must be submitted for residency positions and arrangements for interviews must be made about three quarters of the way through the clerkships. Therefore, the sequence of clerkships becomes the first important decision in regard to specialty choice: most students tend

Reprints are available from Nu V. Vu, Ph.D., Department of Medical Education, Southern Illinois University, School of Medicine, P.O. Box 3926, Springfield, IL 62708.

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to select tracks where they can experience their preferred specialties in the first half of the clerkship period. On the basis of the information students provide in the CTP and availability of positions within each track, students are assigned usually to one of their three top-rated clerkship tracks or, rarely, their fourth track choice.

The CRPQ and CTP used in this study were administered at the following points in the curriculum:

-End of basic sciences period/Sequence I: CRPQ -End of clinical sciences period/ Sequence II: CTP -Near end of clerkship period/Sequence III: CRPQ

Analysis. Data analysis proceeded in three stages. First, we as~essed stu- dents' perceptions of the degree of influence of the various factors upon spe- cialty choice, at the end of Sequences I and III. Influence was rated on a

four point scale where 1

=

very much, 2

=

some, 3 • little, and 4

=

none. The hypothesis of no difference between the two curriculum sequences for each

factor was tested via paired t-test. Second, factors of major influence upon final (NRMP) specialty choice were studied in relation to change and stability of choice from the beginning to the end of the clerkship period. A log linear model which results in a series of chi-square tests was used to test the hy- pothesis of no relationship between factors {Dixon, 1979). This analysis is analogous to performing a three-way (change/no change, event and person) analysis of variance on categorical data. Last, factors of major influence were studied by specialty area to determine differential effects of the clerkship period upon end of medical school specialty choice.

~LTS AND DISCUSSION

Basic Sciences Year vs. Clerkships. The influence of various factors during the basic sciences (Sequence I) and clerkship (Sequence III) periods upon specialty choice is presented in Table 1. Return rates for the CRPQ were 100%

(N • 144) at the end of Sequence 1 and 88% (N • 127) at the end of Sequence III; only those students with data in both occasions are included in the table.

The factors are listed in order of ove~all degree of influence, from most to least influential.

Specific events and persons had a substantially stronger overall effect upon specialty choice than the last three factors. Additionally, comparison of re- sponses between curriculum sequences shows that both events and persons were more influential during Sequence III than Sequence I. Concerning events en- countered, the number of students who were very much influenced by particular events more than doubled from one occasion to the other (13.9% and 32.4%

respectively). Thus, if any specific event experienced by the students had a significant influence on their specialty choice, it did so priaarily during the clinical clerkships. Students' written comments further indicated that the specific events of influence occurred most frequently during the clerkships they enjoyed the •ost. Examples of such comments are "I enjoyed the Psychiatry clerkship significantly more than others", "The clerkship in Peds influenced me positively", or "Clerkship reinforced F~mily Practice."

When asked if any person, within or without the medical school, had influenced their specialty preference, "very much" or "some" influence was reported by more than half of the students at the end of the basic sciences year and by

close to three-fourths toward the end of the clerkships. Analysis of the type

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of persons affecting specialty choice showed that, during the basic sciences period, students were much •ore influenced by clinical associates (47%) than by full-tiae faculty (16%), class.ates (10%), residents (10%), relatives (1%), or other persons (16%). During clerkshipa, full-tiae faculty (58%) had more influence than clinical associates (23%), classaates (1%), residents (12%), relatives (3%) or others (3%). These results clearly point out the role mod- eling effect which occurs in aedical school: the overriding influence on spe- cialty preference comes from clinical teachers whether they are clinical associates or full-time clinical faculty. Students' written co..ents further indicated that the influence they received was positive in the large .ajority of cases.

None of the last three factors -- debts for education, financial considerations or length of residency training -- had a aajor influence upon specialty pref- erence: five was the largest nuaber of students who rated any of the• as having

11very au:h" influence either at the end of Sequence I or Sequence III. This result is particularly interesting in regard to debts, since the large aajority of the students (84%) acknowledged owing loans for their •edical school educa- tion at the end of Sequence III. Notwithstanding the minimal influence of the three factors, students perceived financial considerations as significantly more iaportant in their specialty choice at the end of the clerkship period than at the end of the basic sciences year (t•-2.32,p<.03).

~

Changes During Clerkships. To determine the relative influence of events and persons (mostly faculty) on end of medical school choice of specialty, we as- sessed these variables in relation to specialty changes during clerkships.

Clerkship& constitute that section of the curriculum when students receive ex- tensive exposure to patients and intensive clinical instruction. Comparison of the specialty students listed on the CTP (end of clinical sciences period or Sequence II) and specialty as per MRHP results (applied for by students at the end of the clerkship period or Sequence III), was used to divide students into a change and a non-change group. Approximately half (48%) of the 144 students changed and half (52%) maintained their pre-clerkships choices.

Thirty-four students who had been undecided at the end of Sequence II were included in the change group.

Results of the log-linear model analysis confirmed that the distributions of students' ratings for the influence of event• and persons during the clerkship year were significantly different froa expected values (X2•8.45, df•J, p<.04 and x2•23.28, df•l, p<.OOl, respectively). Since students divided evenly as to change and no change of specialty, their distribution was not significant.

Based on the same analysis all three first-order interactions between pairs of the variables (change of specialty, person and event) were significant. The

second-or~er interaction (all three factors) was not significant. Table 2 presents the summary data for the three first-order interactions. Only those subjects with complete data on all variables were included in the analysis.

Section A of Table 2 shows the different effects of specific events or clerk- ship experiences on students who changed and did not change specialty choice (X2•13.70, df•l, p<.004). Approximately half (52%) of the students who

changed specialty but fewer than one-fifth (18%) of those w~th stable choices reported having been influenced "very awch" by an event during the clerkship period.

Table 2, Section B, presents faculty influence in relation to specialty change Oc²··14.11, df•l, p<.OOl). As with events, faculty influence was highest

(61%) among students who changed specialty.

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The interaction of influences by clerkship events and by faculty (X2•22.06, d£•9, p<.009) is shown in Section C of Table 2. This distribution of ratings indicates that the encounter of specific experiences combined with exposure to particular individuals results in .ajor influence on the specialty choice of one out of 5 students (21%). These students who acknowledged very .uch influ- ence from both events ~ persons represent (a) half of the 42% highly affect- ed by an individual, (b) three-fifths of the 34% highly affected by an event.

I

The CTP data was then analyzed to determine whether the sequence of clerkships experienced by students bad any effect upon specialty changes. No specific pattern of effect was observed. However, 77 percent of the students who changed did so by switching into specialties experienced in the first half of the clerkship period. This finding is not unexpected in that students aust start application for residencies approximately halfway through the clerkship period.

Influences by Specialty. Table 3 shows the influence of events and faculty during the clerkship period in relation to the students' specialty choice at match.

Consistent with the findings already presented, faculty appear to have greater influence on specialty than events do during the clerkshipa. However, ratings of "very much" influence for events vary from 25 percent among students choos- ing radiology to 67 percent of those who chose psychiatry. Aasuaing that the events of influence rated by the students occurred during the clerkships they chose for their specialty, it might be concluded that, at our school, partic- ular experiences in the psychiatry and pediatrics clerkships affected rela- tively .ore students than experiences in other specialties. These data need further replications at other schools to perait any generalizations.

The influence of faculty was considerably greater in the leas popular special- ties, including anesthesiology, obstetrics/gynecology, pathology, psychiatry and radiology. Students who entered the more popular specialties of medicine and surgery were affected by faculty to a much lesser extent. Although this study did not assess whether the faculty influencing students were in the sa.a specialty chosen by the students, tbe {esults confira previous findings by Coker and his colleagues (1960). These authors found that faculty influence was greater in Psychiatry, Pediatrics, Pathology and Obstetrics/Gynecology than in Surgery or Medicine.

Changes and Influences by Specialty. Factors of influence during Sequence III were further examined for students who changed specialty choice. The results showed that, of the students reporting "very much" and "some" influence, 39 percent listed faculty, 18 percent listed an event or experience associated with the clerkships and 44 percent indicated both faculty and an event during the clerksbips. When these data were broken down by specialty it was found that the effects of faculty and of faculty in co.bination with clerkship event were greater than the clerkship experience by itself for sa.e specialties.

These specialties include anesthesiology, faaily practice, medicine, obstetrics/gynecology, pediatrics and psychiatry.

COHCLUSIONS AND IMPLICATIONS

The data presented have implications for the understanding of specialty cboice decisions by .edical students. Personality factor• have long been considered

as being at the core of the specialty decision-making process. Beyond these and other factors intrinsic to the individual, such as motivation, attitudes,

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values, expectations and the like, extrinsic factors do appear to exercise considerable influence particularly when they occur at important points in the process.

Six extrinsic factors of possible influence during the clerkship year upon specialty choice were assessed in this study. Of them, debts, financial con- siderations and length of residency have little overall effect on medical students' decisions, even though financial matters grow in importance as stu- dents progress through medical school. Order of clerkshipa is of particular relevance for the undecided students, as most of them end up selecting a specialty they encounter during the first few months of the clinical year.

Events or experiences during clerkship& and persons throughout medical school significantly influence the choice of specialty. Among the persons of influ- ence, clinical teaching faculty exercise a strong role modeling effect. Such effect results in either strengthening some students' prior decisions or in- ducing changes in others' choices. Faculty seem to be aware of their influ- ences in that their role was found to be particularly significant in tradi-

tionally less popular specialties.

REFERENCES 1.

2.

3.

4.

5.

~ Peraone

!vente or

Coker, R.E., Back, K.W., Donnelly, T.G., and Killer, N. Patterns of Influence, Medical School Facult~ Members and Values and Specialty of Interest of Medical Students. Journal of Medical Education 35:518-527,

1960. --

Dixon, W.L. (Ed.) Biomedical Computer Programs. Berkeley, California:

University of California Press, 1979.

Hutt, R. Doctors Career Choice: Previous Research a~d ita Relevance for Policy-Making. Medical Education 10:463-473, 1976.

Parmeter, J.T., Haf, J., Scheifley,

V:,

and Boger, M. The Cooperative Michigan Longitudinal Study of Medical Student Career Choice: Research Design and Preliainary Results. Research in Medical Education

Proceedings, 145-150, 1978.

Sachs, L.A. Medical Specialty Choice: Replications and Extensions.

Research in Medical Education Proceedings, 215-220, 1977.

Segue nee I Ill I

Percentase Dietributiona, Keane and t-te•t• for Student•' a.tinga of Factor• of Influence Upon Specialty Choice, at End of the Basic Science•

Year (Sequence I) and End of Cler~shipe (Sequence Ill) a.tins•

Very

Huc:h so- Little Hone

(1) (2) (3) (4) He an ....!!..

15.6 38.5 15.6 30.3 2.61 122

43.4 30.3 13.9 12.3 1.95

13.9 25.0 14.8 46.3 2.94 108

_t_

-s.:JJ

-3.17

~

.0001

.002

Experience• lit 32.4 20.4 17.6 29.6 2.44

Finaneial I .9 11.2 35.3 52.6 3.40 116 -2.32 .on

Con• idera tiona I l l 1.7 24.1 25.0 49.1 3.22

Educational I 1.8 13.4 14.3 70.5 3.54 112 1. 71 N.S.

Debu I l l .9 8.9 14.3 75.9 3.65

Lenath of I 2.6 31.3 30.4 35.7 2.99 115 1.37 II.S.

Residency III 4.4 24.3 24.3 47.0 3.13

N.S. • Non •ianificant

!ill.!...1

P~rc~ntag~ Distributions of Ratings for Specialty Change by Event, Specialty Change by Person, and Person by Event

A. CHANCE IIY EVENT

(X~t,3•9.33, p•.02S) Event

Very Total

~ ~ Little _~ M 1

Change 24.6a 7.0 7.0 8.8 ~ 47.4

(Sl.9)b (14 .8) (14.8) (18.5)

Specialty No Change 9.6 12.3 9.6 21.1 60 52.6

Change (18.3) (23.3) (18.3) (40.0)

Total M 39 22 19 34 114

1 34.2 19.3 16.7 29.8 100.0

II. CHANGE BY P&aSOM

<x3f,3•9.74, p•.021) Peuon

Cha11ge 28.9 11.4 3.5 3.5 ~ 4?.<\1

(61.1) ( 24 .l) (7.4) (7.4)

Specialty No Change 13.2 19.3 9.6 IO.S 60 5%.6

Cha111e (25.0) (36.7) (18.3) (20.0)

Totel N 48 35 IS 16 Ut

1 42.1 30.7 13.2 14.0 100.0

c. PERSON BY EVENT

(X~t,9•17.69, p•.039) Event

Very 21.0 7.0 J.S 10.5 48 42.1

Much (50.0) 06. 7) (8.3) (2S.O))

SoiiM! 7.9 9.6 7.0 6.1 35 30.7

(25.7) (31.4) (22.9) (20.0)

Penon Little • 3.5 2.6 3.5 3.5 IS 13.2

(26.7) (20.0) (26.7) (26.7)

None 1.8 o.o 2.6 9.6 16 14.0

(12.5) (0.0) (18.7) (68.8)

Total H 39 22 19 34 114

1 34.2 19.3 16.7 29.8 100.0

a Percentages basad

b Rov Percentagee. on total nuoober of subject• (N •114). _~

~

Percentage Distribution• of Event and Persona Ratings by Specialty Choice

Event (N • 111) Person (N • 120)

Very Very

seccialt)! Choice n Much Some Little None n Much So• Little Hone

Anesthesiology 2 100.0 2 100.0

Fa•ily Practice 19 31.6 26.3 10.5 31.6 20 40.0 30.0 10.0 20.0

Medicine 34 23.S 14.7 20.6 41.2 37 29.7 37.8 lJ.S 18.9

Obstetrics/Gynecology 10 30.0 10.0 30.0 30.0 10 50.0 30.0 10.0 10.0

Pathology 6 33.3 16.7 so.o 6 so.o 16.7 33.3

Pediatrics 11 45.4 18.2 36.4 13 46.2 23.1 7.7 23.1

Psychiatry 9 66.7 11.1 11.1 11.1 10 70.0 20.0 10.0

Radiolo&Y 4 25.0 so.o 2S.O 4 7S.o 25.0

Surgery 16 37.5 25.0 25.0 12.5 17 35.0 41.0 24.0

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Dona L. Harris, Ph.D. Paul Ebbert, M.D.

Department of Family and Community Medicine University of Utah College of Medicine

PERSONALITY TYPES OF FAMILY PRACTICE RESIDENTS AS MEASURED BY THE MYERS-BRIGGS TYPE INDICATOR

Introduction.

Health manpower legislation in the United States has required that one-half of medical school

1graduates enter training programs in primary care specialties by 1980. This legislation is an attempt to increase the ratio of generalists to subspecialists and to provide physician man- power to underserved rural and inner city areas. To meet these goals medical educators have had to seek ways of changing a system which has promoted ever increasing specialization over the past twenty years. One factor which may prove important in increasing the number of primary care physicians is being able to determine which prospective physicians are more likely to choose a career doing primary care.

Isabel Briggs Myers and Junius Davis, using the Myers-Briggs Type Indicator, showed in 1964 that

2certain personality types were more likely to ch~o~e primary care fields, an a~sertion supported by later studies as well. ' It has also been shown that those personality types most likely to choose prim2ry care are at a disadvantage in gaining acceptance to medical school becguse of the instruments involved· in selection; i.e., MCAT scores and GPA and because of the preponderance of other2p~rsonality

types on medical school faculty, thus on selection committees. '

The purpose of this paper is to test the hypothesis that the personality types currently choosing family practice residencies are likely to be

different from those types previously shown to prefer general practice.

This hypothesis was tested in large part to determine what, if any, impact has occurred with Family Practice now requiring a three-year residency.

Instrument

The Myers-Briggs Indicator (MBTI) describes an individual in terms of his basic orientation toward his environment (i.e., introversion vs.

extraversion), his attitude toward his environment {i.e., judging vs.

perception), the way in which he prefers to perceive the environment (i.e., sensing vs. intuition), and the way in which he prefers to make decisions (i.e., thinking vs. feeling). A brief description of these alternative preferences is given in Table 1. Space does not permit a thorough discussion of these preferences and preference combinations.

Myers' original study showed that the ESTJ personality types had a higher percentage of it's members in General Practice and she hypothesized that this "business type" chose General Practice primarily for the econ2mic advantage of being able to start practice immediately after internship.

The most consistent difference between General Practice-Family Practice types and faculty types has been that the former has had a higher percentage of sensing types as opposed to more intuitives for the latter. It is said that sensing types tolerate routine better than intuitives who prefer problem solving and theory.

Reprints: DonaL. Harris, Ph.D., Department of Family and Community Medicine University of Utah College of Medicine, 50 North Medical Dri~e,

Salt Lake City, Utah 84132

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L

TABLE 1

Preferences Measured by Myers-Briggs Type Indicator⁷

ORIENTATION The Outer World of Actions,

Objects and Persons EXTRAVERSION

The Inner World of Concepts and Ideas INTROVERSION

LEARNING The Immediate, Real,

Practical Facts of Experience and Life by Experience

SENSING

The Possibilities, Relationships and

Meanings of Experiences Through Observatmon

INTUITION

DECISION-MAKING Objectively, Impersonally,

Considering the Causes of Events and Where Decisions May Lead

Logic THINKING

COPING In a Decisive, Planned and

Orderly Way, Aiming to Regulate and Control Events

JUDGMENT

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Subjectively and Person- ally, Weighing Values of Choices and How They.

Matter to Others Value Judgments FEELING

In a Spontaneous,

Flexible Way, Aiming to Understand Life and Adapt to i t

PERCEPTION

D

Methodology

All incoming residents to the University of Utah College of Medicine Family Practice program for the years 1977 through 1980 were given the MBTI. Results were compared to results from a previously selected group of 20 private primary care physicians providing health care to communities of less than 10,000 population.

The MBTI was given to the 55 residents at orientation resulting in a 100% response rate. The MBTI and computer response forms were mailed to the private physicians with a 50% response. Respons~of the

2two groups were compared in each of the four sets of traits using the X test for independence with the Yates correction factor for continuity.

Results

The data are shown in Table 2.

Table 2

Private Physicians

I

Extraversion-rntroversion Sensing-Intuitive

10 10 14 6

Family Practice 17 1R

Residents No Significant Difference

x

²

=

7.70

<

^.0055

Private Physicians _t Thinking-Feeling Judging-Perceptivj

12 8 13 7

Family Practice 11 44 38 17

Residents

x

²

=

9.24 '-. .0024 No Significant Difference

Our group of private physicians in rural areas has a greater number of sensing (S) types than intuitive (N) types

2

^{w~ich is} consistent with types previously sho~to prefer primary care. • Our resident group, however, has significantly more i~t~itives (N) which is consistent with faculty groups in others studies. • A significant number of the

resident group was also of the feeling (F) type as opposed to the thinking (T)

3type which is also true for the faculty group of Quenk and Heffron.

DISCUSSION

The data suggest that the advent of a residency training program in Family Practice has changed the personality types choosing primary care,

I

J

at least for our group of residents. A number of factors may be responsible for this change. One is that the economic incentive mentioned by Myers is less applicable. Other fields offer the prospect of a much higher income than a family practitioner can expect, working fewer hours and without a significantly longer residency. Many ESTJ types may now be choosing other higher paying fields as careers.

Another factor that may attract NF types to Family Practice and primary care is the emergence of providing health care to rural and inner city

areas as a major social issue. Intellectual NF types have traditionally -97-

been very supportive of social issues and may be choosing Family Practice for this reason. Over half of the residents in this study plan are pr are currently practicing in a rural setting, a fact consistent with the impor- tance of primary care as a social issue being a factor in career choice.

Our data, however, do raise some important questions. The intuitive (N) and feeling (F) types that predomina3e

4in our resident group are more like the faculty types in other studies. ' It may be that programs designed to train physicians to provide health care in underserved areas are recruiting the type of individual who is likely to end up in a

teaching position. Our residents, though expressing a desire to practice in rural areas, may become impatient with what they consider a routine practice and seek positions elsewhere as might be expected of intuitive

(N) types. We may be spending millions of dollars training primary care doctors who will never practice primary care.

On the other hand if the NF types do stay in needy areas, according to type theory they should be better at problem solving and at the same time more compassionate and caring. It may be that our next generation of generalists will be more concerned with the patients' needs; choosing primary care because of commitment to provide a needed service rather than for economic reasons.

There are some questions about our data which can only be answered by further research. Our data may in fact be a reflection of the pre- ponderance of NF types on our faculty and therefore on our resident

selection committee. The selection committees of Family Practice programs

~ay be weighted against the personality types most likely to practice in

underserved

4

^a~eas as has been suggested of medical school selection committees. ' Another possibility that we have no way of determining with our present data is that ST types are still choosing family practice as a career and the data are a result of the greater number of NF types accepted into medical schools.

We have initiated further stud~s to answer some of the questions raised by our data. By studying the personality types of medical students and following them throughout residency and into practice it may make it easier for medical educators to plan to meet the health care needs of society.

Conclusions

Our data support the hypothesis that current residency requirements

·can be expected to cause a change in the personality types choosing to be family physicians. It also raises some questions about whether or not family practice residencies are attracting the type of person

that can be expected to practice in a rural area. Our current group

of residents is more like faculty groups in other studies and significantly different from the group of private physicians tested. Type theory

predicts that if the resident types do practice primary care they

should be better problem solvers and be more interested in their patients' values and feelings. Further study is needed to answer these questions.

Determining which physician types tend to choose primary care may be helpful to medical educators as they plan to meet national health care needs as well as provide data in examining admission policies of medical schools and residencies.

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