Factors Influencing Medical Student’s Specialty Choice: A Longitudinal Study Rachel Bramson, MD, MS Scott and White Clinic, College Station, Texas Family & Community Medicine, College of Medicine Texas A&M Health Science Center (in collaboration with Texas Tech College of Medicine) Iftekhar Ahmed, MA, Betsy G. Jones, EdD, Robert Wiprud, MD, Fiona Prabhu, MD, Shannon DeShazo, MD, Mark English, MD & Samuel Forjuoh, MD, MPH, DrPH

Background Concerns about a decline in medical graduates’ interest in primary care have persisted for many years While this topic has been studied extensively, many questions remain unanswered Most previous studies have examined variables at a fixed point in time or over a short period of time This longitudinal study investigated the influence of previously identified factors on a cohort of medical students over the course of their pre-doctoral training

Method Participants were members of the class of 2007 at two public medical schools in the State of Texas Collected data on students’ characteristics, attitudes, and behaviors 5 survey points throughout their 4-year enrollment in medical school A total of 503 responses have been recorded

Method (cont.) Number of participants throughout the study period 1 Survey # Key point Year School 1 School 2 Total 1 Orientation, Year 1 2003 71 86 157 2 End Year 1 2004 66 137 4 End Year 3 2006 50 45 95 5 March Year 4 2007 74 40 114

Method (cont.) Survey instruments were developed, pre-tested, and modified based on test results Five survey questionnaires were developed for five key time points There were similarities and differences among surveys Similarities were recurring questions used to assess change in perception/attitude over time Differences included questions appropriate to a particular time point over the four year curriculum

Method (cont.) Sample size was manipulated using multiple imputation to sustain the longitudinal nature of the study 134 responses that were present in both the first two survey points were selected as the base Missing responses in time points 3 and 4 were imputed based on the core 134 responses 44/134 and 33/134 responses were imputed in surveys 3 and 4, respectively

Result Specialty Choice (number of responses) throughout survey time points Survey # Time Point Family Medicine Internal Medicine Pediatrics Non-Primary Care 1 Orientation, Year 1 20 9 85 2 End Year 1 21 10 83 3 End Year 3 4 11 107 March Year 4 104

Individual Agreement* throughout Time Points (%) Result Students’ Perception (% of agreement*) of factors influencing specialty choice decision (very influential factors) Factors Individual Agreement* throughout Time Points (%) Orientation Year 1 End Year 1 End Year 3 March Year 4 Flexible lifestyle 117 124 126 125 Location of practice 121 120 On-call schedule 108 112 122 Ability to do procedures 109 107 115 111 Ability to provide comprehensive care Malpractice issues 104 106 114 * Agreement was calculated by combining Strongly Agree and Agree response scores

Individual Agreement* throughout Time Points (%) Result Factors rated less highly during the early years but gained importance over time Factors Individual Agreement* throughout Time Points (%) Orien-tation Year 1 End Year 1 End Year 3 March Year 4 Diverse patient population 89 90 114 119 Salary 79 93 115 113 Ability to provide ambulatory care 81 80 109 Approach similar to physician in that specialty 68 116 105 Low stress level 72 87 110 103 Length of residency 85 112 96 * Agreement was calculated by combining Strongly Agree and Agree response scores

Result Students’ Perception (% of agreement*) of various factors influencing students’ specialty choice decision (other factors) Factors Individual Agreement* throughout Time Points (%) Orientation Week - Year 1 End Year 1 Year 3 March Year 4 Adult population 43 67 107 104 Prestige/recognition 45 50 90 85 Patient relationships 128 126 65 79 Child patient population 58 59 40 Ability to participate in research project 31 23 29 28 Types of payors 47 51 36 * Agreement was calculated by combining Strongly Agree and Agree response scores

Key Factors of Consideration Increased importance of Prestige/recognition over the course of training Decreased importance of Patient Relationships over the course of training Influence of society (increased career emphasis on personal lifestyle rather than service)? Influence of culture of medicine (emphasis on technology and depth of knowledge in a narrow area)?

Limitations Longitudinal studies with multiple time points more burdensome to subjects Decreased interest in research participation as students near graduation? Missing data required use of multiple imputation Both public institutions Only one state represented

Suggestions Following topics need to be addressed in future studies: Trend away from Family Medicine and Pediatrics into Non-Primary Care Pediatric Population not an influential factor High influence of Adult Population factor Meaning of this in the social/legal context of medicine

Questions?