gms | German Medical Science

GMS Journal for Medical Education

Gesellschaft für Medizinische Ausbildung (GMA)

ISSN 2366-5017

Role models play the greatest role – a qualitative study on reasons for choosing postgraduate training at a university hospital

research article medicine

Search Medline for

  • author Bonnie Stahn - University Hospital Hamburg-Eppendorf, III. Department of Internal Medicine, Hamburg, Germany
  • corresponding author Sigrid Harendza - University Hospital Hamburg-Eppendorf, III. Department of Internal Medicine, Hamburg, Germany

GMS Z Med Ausbild 2014;31(4):Doc45

doi: 10.3205/zma000937, urn:nbn:de:0183-zma0009374

This is the English version of the article.
The German version can be found at: http://www.egms.de/de/journals/zma/2014-31/zma000937.shtml

Received: January 11, 2014
Revised: July 2, 2014
Accepted: August 2, 2014
Published: November 17, 2014

© 2014 Stahn et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Abstract

Objective: Why physicians choose a certain specialty at a university hospital for their postgraduate training is incompletely understood. Our aim was to identify factors that led physicians from different generations to opt for postgraduate training in a specialty with high or low patient contact at a university hospital.

Methods: We conducted 14 semi-structured interviews with residents and attending physicians from the departments of Internal Medicine (high patient contact) and Laboratory Medicine (low patient contact) at the University Hospital Hamburg-Eppendorf, Germany. We used template analysis to code the interview transcripts and iteratively reduced and displayed the data. Initial codes and concepts were shaped into categories until agreement on the final template was reached.

Results: We identified five main categories of factors that influenced postgraduate specialty selection. Role models with a civilized code of behavior and expertise in their specialty had had the greatest influence on participants’ choice of a specialty across generations. Electives and a doctoral thesis project had also influenced participants’ decisions, mainly because of meeting a role model in their supervisor. Patient contact and intellectual challenges were identified as contributing factors in the selection of a specialty with high patient contact. As reasons for selecting a university hospital for postgraduate education four categories were identified: the possibility to participate in scientific research, a broad spectrum of activities, personal contacts and future career opportunities.

Conclusions: The professional attitudes of teachers as role models were identified as having the greatest influence on postgraduate education choices. Besides other actions to attract students to certain specialties for their postgraduate education, the aspect of being perceived as a role model while teaching requires particular attention when preparing medical faculty for undergraduate medical teaching.

Keywords: internal medicine, laboratory medicine, patient contact, postgraduate education, role model


Introduction

The lifestyle interests of undergraduate medical students and their attitudes about specialty selection have been studied over the past twenty years [1], [2]. Recently, there is growing concern about the appeal of residency programs to young graduates [3]. Attracting graduates to specialty training has become increasingly difficult in specialties with low and high patient contact in North America and Europe [4], [5], and much effort has focused on redesigning residency programs to attract medical students for postgraduate training in internal medicine [6], [7], [8]. Most programs account for the challenges faced by internal medicine education in the 21st century that result from the growing and aging population [9]. In addition, an increasing demand to train more junior scientists in the field of internal medicine has been expressed [10]. The necessity to adapt their postgraduate training programs to these new developments has also been recognized in specialties with less patient contact [11], [12].

Several factors have been identified to influence students’ choice of a specialty for their postgraduate training: lifestyle and income [13], gender and personality traits [14], patient contact [15], positive or negative role models [16], and clerkships [17]. However, almost 30% of graduates from UK medical schools indicated that they had seriously considered but not pursued their original specialty choice [18]. The following factors have been identified to play a role in the fellowship choices of residents: lifestyle, income, prestige of the subspecialty, ability to perform procedures, clinical rotation to a certain subspecialty, exposure to role models in rotations, and influence of a mentor [19], [20], [21]. Taking these factors into account and considering the changing attractiveness of residency programs to young graduates [3], it might be important – in addition to making residency programs more attractive – to identify factors that could be addressed during undergraduate education to enable students to choose a postgraduate education that fits their personal needs and requirements. With respect to the different approaches that have been implemented to modify postgraduate training programs in specialties with high or low patient contact [8], [12], we hypothesized that the amount of patient contact might play a role in the selection of a certain specialty for postgraduate education.

The purpose of this study was to better understand the career paths of physicians from different generations (young residents and experienced attending physicians) in specialties with high and low patient contact at a university hospital, to elucidate the factors that influenced their choice of specialty and their decision to work at a university hospital. Identifiable criteria might provide important insights in terms of counseling students during their transition from undergraduate to postgraduate training. In particular, we addressed two questions:

1.
What caused physicians to choose their respective specialty for postgraduate training? and
2.
Why did physicians choose a university hospital for their postgraduate training?

Methods

Sample and instruments

Fourteen residents and attending physicians from the Departments of Internal Medicine (n=8) and Laboratory Medicine (n=6) at the University Hospital Hamburg-Eppendorf participated voluntarily in a semi-structured interview. The characteristics of the study sample are displayed in Table 1 [Tab. 1]. All of the participants were informed about the purpose of the study, their informed consent was obtained and anonymity was guaranteed.

We used an explorative, qualitative research approach to study the reasons underlying the selection of postgraduate training in internal (high patient contact) or laboratory (low patient contact) medicine at a university hospital. The interview manual covered open questions on the selection of a medical specialty for postgraduate training (e.g., “How come you are working in this specialty?”) as well as more specific questions on the reasons underlying the selection of a specialty and postgraduate education at a university hospital (e.g. “Did high or low patient contact play a role for your choice of specialty?”, “Why did you choose a university hospital for your postgraduate training?”). When certain features such as lifestyle and income, which are known to be relevant to a students’ choice of specialty [13], were not mentioned in the answers provided to open questions, their potential relevance to specialty selection was queried. The same interviewer (BS) conducted all of the interviews. On average, the interviews took 30 to 45 minutes each and were audio-recorded, transcribed verbatim and anonymized (interviews internal medicine: 1IM to 8IM, interviews laboratory medicine: 1LM to 6 LM).

A purposive sampling strategy was employed to achieve a balanced distribution of participants regarding age, gender, and experience (see Table 2 [Tab. 2]). With respect to these characteristics, potential participants from both departments were contacted personally by SH. In the first round of interviews, only attending physicians from the Department of Internal Medicine (n=4) and Laboratory Medicine (n=3) were included because they have been working in their chosen specialty at a university hospital for a certain period of time. Furthermore, the two selected departments represent specialties with large differences in patient contact. In a second round of interviews, only residents from the same departments (Internal Medicine: n=4, Laboratory Medicine: n=3) were interviewed because they represent a younger generation of physicians.

Template analysis was used to code the interviews [22] following an analytical assessment of the content. Sampling, data collection and coding of the interview transcripts were performed simultaneously according to the method of constant comparison [23]. Transcripts from the first round of interviews (attending physicians) were analyzed by both authors individually using line-by-line open-coding to establish initial codes and probable concepts. To specify the concepts further, transcripts from the second round of interviews (residents) were added for comparison, hereby reviewing and modifying the initial concepts. Transcripts from the two different medical departments and from the two physician generations were contrasted and used to determine the range of codes and concepts. Data collection and coding were stopped after the 14th interview, at which time the codes seemed to have achieved an acceptable level of saturation and no new codes had emerged from the resident interviews. Categories were assembled depending on how often and to what extent specific contents were mentioned. The adequacy of the categories was cross-checked against the interview transcripts, and the results are presented according to these categories. Characteristic quotations were translated from German to English and transferred to written language with the original content intact. Ethical approval was obtained from the vice president of the State of Hamburg Physicians’ Ethics Board, who confirmed that the research protocol was safe and in accordance with the Declaration of Helsinki.


Results

Two major themes resulted from the interviews: reasons for postgraduate specialty selection with five main categories and reasons for choosing a university hospital for postgraduate education with four main categories.

Factors influencing postgraduate specialty selection

Five main categories and four subcategories were identified to play a role in the selection of a specific specialty for postgraduate training program (see Table 3 [Tab. 3]). These categories are presented in the text in the same order as they appear in Table 3 [Tab. 3]. Exemplary quotes for the identified categories are listed in Table 4 [Tab. 4]. None of the categories resulted solely from interviews with residents or with attending physicians.

Role models

This category was assigned when participants described interactions with individual physicians or their personal characteristics as having had an influence on his or her choice of specialty. In particular, most of the participants mentioned having met at least one physician during their undergraduate training or while working on their doctoral thesis whom they regarded as a role model. The two most frequently mentioned imitable characteristics of role models that were identified as subcategories were a civilized code of behavior and expertise in their respective specialty. Participants who viewed a supervisor’s behavior as negative became disinterested in their specialty.

Undergraduate education

The category of undergraduate education includes any references made by participants to the aspects of undergraduate medical education that influenced their decision to select their field of postgraduate education. Undergraduate education in general was not mentioned as having had an influence on the decision to pursue a certain postgraduate education. On the contrary, all of the participants mentioned that their current specialty was underrepresented or not well taught during their undergraduate education. However, electives, which in the German medical curriculum are mandatory four-months periods of internal medicine, surgery and a specialty of the students’ choice during the final, so called practice year, were important contributors to the participants’ final decision for or against a certain postgraduate training specialty.

Doctoral thesis

The category of doctoral thesis emerged from any aspects of the doctoral thesis being mentioned by participants as having influenced their choice of a specialty for postgraduate training. Participants who had worked on a doctoral thesis either had had an opportunity to meet a role model or had received deeper insights into specific features of a certain specialty than they had obtained during undergraduate medical education.

Personal experience in a department

Citations were categorized as personal experience in a department when this experience was described as having influenced the decision to apply for a postgraduate position in the respective specialty. We observed different examples of personal experiences in a department (e.g., employment as a nurse or technical assistant to earn money during undergraduate medical education) that led participants to work in a specific discipline at a university hospital.

Specialty features

The category of specialty features resulted from the two subspecialties, internal medicine and laboratory medicine, based on features that could be categorized in a certain specialty as a reason for choosing that specialty for postgraduate training. Among participants from the Department of Internal Medicine, patient contact, practical skills, and intellectual challenge were important criteria for choosing internal medicine for postgraduate training. The greatest advantage mentioned for postgraduate training in laboratory medicine was a balanced duration of daily work.

Selection of a university hospital for postgraduate training

Four main categories were mentioned most frequently as contributing to participants’ decision to pursue their postgraduate training at a university hospital. Eight of the 14 participants named the possibility of conducting scientific research as an important contributor to their decision to apply to a university hospital for a postgraduate position (“I always wanted to do scientific research […] and I am able to do this now”, 2IM).

Seven of the 14 participants were attracted by the broad spectrum of activities provided at a university hospital including patient care, scientific research and teaching (“[A reason to apply for internal medicine at a university hospital was] that one has to deal with much more complex patient cases”, 5IM - „I enjoy teaching [laboratory medicine] very much and wish to continue it“, 1LM).

Five of the 14 participants mentioned better future career opportunities following completion of their postgraduate training at a university hospital (“[It is] always easier to leave a university hospital [and work in a smaller hospital] than vice versa”, 3LM).

Six of the 14 participants had previous personal contact with the department of their choice, as mentioned above, and this contact not only contributed to their choice of a specialty but also to their decision to work at a university hospital (“During my undergraduate training I had a job [as technician in this department] and then I applied for a postgraduate training position [in this department] because it was a nice team”, 8IM).


Discussion

The present study demonstrates that role models with a civilized code of behavior and expertise in their respective specialty are of paramount importance in a graduates’ choice of a specialty for residency. Physicians from the Department of Internal Medicine in particular had met role models during their electives and while working on their doctoral thesis. Furthermore, these periods were characterized by intensive exposure to scientific research, which played an additional role in a graduates’ choice to pursue his or her postgraduate education at a university hospital.

At the time of graduation, students have described to have physician role models whom they met during a time that could have influenced their specialty selection [24], [25]. Despite these findings, much effort is still put into making residency programs more attractive [8] rather than training teachers of undergraduate medical students to act as role models. We discovered that electives, such as clerkships [17], are important times during undergraduate education because they allow students to match their specialty preference with the associated real work situation. Furthermore, according to our findings, electives provide an opportunity to meet role models, which – depending on their behavior – can validate or shatter the student’s choice of specialty. Therefore, faculty development with a special focus on the attitudes and behavior of teachers and supervisors [26] seems to be important in facilitating the specialty decisions of undergraduates, in particular because teachers are often unaware of the impact of their behavior on students [27]. Furthermore, our participants mentioned special features of internal medicine that attracted them to this specialty, e.g., patient contact, practical skills, and intellectual challenges, which should be integrated as specific learning objectives in internal medicine electives [28].

According to the present study, working on a doctoral thesis was another important time to meet a role model, and a bad doctoral thesis mentor has been the most frequently mentioned reason by students for discontinuing a dissertation project [29]. In the present study, the possibility to participate in scientific research was indicated as a very important factor in the decision to apply to a university hospital for postgraduate training. Therefore, early participation in scientific research might be an important feature of the undergraduate medical curriculum [30] for attracting students to university-based postgraduate education. Our participants also described the importance of personal experiences with their current department. Working as a nursing assistant or laboratory technician in these departments for financial support allowed the students greater opportunities to meet role models during their undergraduate studies.

It has been recently discovered that students notice teaching that contradicts their values or that is very inspiring, to the extent that they may reconsider their personal beliefs and realign their careers [31]. This finding and the present discovery that role models are the most powerful factor in the choice of a postgraduate training program indicate that medical faculties should offer staff training programs with a special focus on professional attitudes in addition to teaching skills [32]. Other than a few specialty-specific factors that affected the choice of a specialty with high or low patient contact, we did not discern different categories between residents and attending physicians with respect to the choice of a certain specialty or a university hospital for postgraduate training.

The present findings might be limited because the results were obtained from only one university hospital. In addition, the choice of departments representing a specialty with high patient contact (i.e., internal medicine) and low patient contact (i.e., laboratory medicine) might not be representative enough for these categories. The generalizability of our findings might be limited due to the exploratory nature of this research. However, the categories identified herein could be used for further qualitative explorations at different university hospitals and in other medical specialties to develop a theoretical framework for vocational decision-making with respect to postgraduate medical training. Despite these limitations, our findings shed light on role modeling as the most important factor in choosing a postgraduate training specialty at a university hospital. This finding may cause faculties to focus on certain factors such as electives and doctoral thesis that can be addressed during undergraduate training. In addition, medical supervisors and their teaching attitudes require further development. Of particular importance is an increased awareness among supervisors of the importance of their role modelling for attracting postgraduate trainees, in particular because negative supervisor attitudes appear to be a strong factor in trainees losing interest in a specialty.


Conclusions

The results of the present study reveal physicians’ attitudes and expertise as teachers or supervisors during undergraduate medical education as having an important influence on the decision of graduates to pursue a postgraduate training specialty at a university hospital. Although further studies on a broader scale are needed to develop a framework for vocational decision-making for postgraduate medical training, our findings support a need for increased awareness by medical educators towards being observed as role models by their students and the potential influence this can have on students’ selection of certain specialties for their postgraduate training.


Acknowledgements

We thank all of the physicians from the Departments of Internal Medicine and Laboratory Medicine at the University Medical Center Hamburg-Eppendorf who participated in the interviews.


Competing interests

The authors declare that they have no competing interests.


References

1.
Schwartz R, Haley J, Williams C, Jarecky RK, Strodel WE, Young B, Griffen WO Jr. The controllable lifestyle factor and students' attitudes about specialty selection. Acad Med. 1990;65(3):207-210. DOI: 10.1097/00001888-199003000-00016 External link
2.
Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle n recent trends in specialty choice by US medical students. JAMA. 2003;290(9):1173-1178. DOI: 10.1001/jama.290.9.1173 External link
3.
Schlitzkus LL, Schenarts KD, Schenarts PJ. Is your residency program ready for Generation Y? J Surg Educ. 2010;67(2):108-111. DOI: 10.1016/j.jsurg.2010.03.004 External link
4.
Ford JC. If not, why not? Reasons why Canadian postgraduate trainees chose – or did not choose – to become pathologists. Hum Pathol. 2010;41(4):566-573. DOI: 10.1016/j.humpath.2009.09.012 External link
5.
Turner G, Lambert TW, Goldacre MJ, Barlow D. Career choices for obstetrics and gynaecology: national surveys of graduates of 1974-2002 from UK medical schools. BJOG. 2006;113(3):350-356. DOI: 10.1111/j.1471-0528.2006.00848.x External link
6.
Fitzgibbons JP, Bordley DR, Berkowitz LR, Miller BW, Henderson MC. Redesigning residency education in internal medicine: a position paper from the Association of Program Directors in Internal Medicine. Ann Intern Med. 2006;144(12):920-926. DOI: 10.7326/0003-4819-144-12-200606200-00010 External link
7.
Weinberger SE, Smith LG, Colliere VU; Education Committee of the American College of Physicians. Redesigning training for internal medicine. Ann Intern Med. 2006;144(12):927-932. DOI: 10.7326/0003-4819-144-12-200606200-00124 External link
8.
Meyers FJ, Weinberger SE, Fitzgibbons JP, Glassroth J, Duffy FD, Clayton CP. Redesigning residency training in internal medicine: the consensus report of the Alliance for Academic Internal Medicine Education Redesign Task Force. Acad Med. 2007;82(12):1211-1219. DOI: 10.1097/ACM.0b013e318159d010 External link
9.
Huddle TS, Heudebert GR. Internal medicine training in the 21st century. Acad Med. 2008;83(10):910-915. DOI: 10.1097/ACM.0b013e3181850a92 External link
10.
Märker-Hermann E. Science, medical education and promotion of young scholars in internal medicine. Dtsch Med Wochenschr. 2011;136(48):2453. DOI: 10.1055/s-0031-1297264 External link
11.
Dominiczak MH. Teaching and training laboratory professionals for the 21st century. Clin Chem Lab Med. 1998;36(3):133-136. DOI: 10.1515/CCLM.1998.025 External link
12.
Federici G, Bernardini S. The new Italian course of post-graduate education in laboratory medicine. Clin Chim Acta. 2008;393(1):31-32. DOI: 10.1016/j.cca.2008.03.023 External link
13.
Newton D, Grayson M, Thompson L. The variable influence of lifestyle and income on medical students' career specialty choices: data from two U.S. medical schools, 1998-2004. Acad Med. 2005;80(9):809-814. DOI: 10.1097/00001888-200509000-00005 External link
14.
Buddeberg-Fischer B, Klaghofer R, Abel T, Buddeberg C. The influence of gender and personality traits on the career planning of Swiss medical students. Swiss Med Wkly. 2003;133(39-40):535-540.
15.
Kiolbasse K, Miksch A, Hermann K, Loh A, Szecsenyi J, Joos S, Goetz K. Becoming a general practitioner – which factors have most impact on career choice of medical students? BMC Fam Pract. 2011;12:25. DOI: 10.1186/1471-2296-12-25 External link
16.
Murinson B, Klick B, Haythornthwaite J, Shochet R, Levine R, Wright S. Formative experiences of emerging physicians: gauging the impact of events that occur during medical school. Acad Med. 2010;85(8):1331-1337. DOI: 10.1097/ACM.0b013e3181e5d52a External link
17.
Maiorova T, Stevens F, Scherpbier A, van der Zee J. The impact of clerkships on students' specialty preferences: what do undergraduates learn for their profession? Med Educ. 2008;42(6):554-562. DOI: 10.1111/j.1365-2923.2008.03008.x External link
18.
Goldacre MJ, Goldacre R, Lambert TW. Doctors who considered but did not pursue specific specialties as careers: questionnaire surveys. J R Soc Med. 2012;105(4):166-176. DOI: 10.1258/jrsm.2012.110173 External link
19.
Daniels VJ, Kassam N. Determinants of internal medicine residents' choice in the Canadian R4 fellowship match: a qualitative study. BMC Med Educ. 2011;11:44. DOI: 10.1186/1472-6920-11-44 External link
20.
Kolasinski SJ, Bass AR, Kane-Wanger GF, Libman BS, Sandorfi N, Utset T. Subspecialty choice: why did you become a rheumatologist? Arthritis Rheum. 2007;57(8):1546-1551. DOI: 10.1002/art.23100 External link
21.
Steiner JF, Curtis P, Lanphear BP, Vu KO, Main DS. Assessing the role of influential mentors in the research development of primary care fellows. Acad Med. 2004;79(9):865-872. DOI: 10.1097/00001888-200409000-00012 External link
22.
Crabtree BF, Miller WL. Using codes and code manuals: a template organizing style of interpretation. In: Crabtree BF, Miller WL (Hrsg). Doing Qualitative Research. 2nd Edition. Thousand Oaks: Sage Publications; 1999. p.163-178.
23.
Glaser B, Strauss A. The Discovery of Grounded Theory. Chicago: Aldine; 1967.
24.
Basco WTJr, Reigart RJ. When do medical students identify career-influencing physician role models? Acad Med. 2001;76(4):380-382. DOI: 10.1097/00001888-200104000-00017 External link
25.
Paice E, Heard S, Moss F. How important are role models in making good doctors? BMJ. 2002;325(7366):707-710. DOI: 10.1136/bmj.325.7366.707 External link
26.
Goldstein EA, Maestas RR, Fryer-Edwards K, Wenrich MD, Oelschlager AM, Baernstein A, Kimball HR. Professionalism in medical education: an institutional challenge. Acad Med. 2006:81(10):871-876. DOI: 10.1097/01.ACM.0000238199.37217.68 External link
27.
Adkoli BV, Al-Umran KU, Al-Sheikh M, Deepak KK, Al-Rubaish AM. Medical students' perception of professionalism: a qualitative study from Saudi Arabia. Med Teach. 2011;33(10):840-845. DOI: 10.3109/0142159X.2010.541535 External link
28.
Ho Ping Kong H, Robb K, Cleave-Hogg D, Evans K. Achievement of objectives: internal medicine fourth year clinical clerkship. Med Teach. 1991;13(1):29-37. DOI: 10.3109/01421599109036754 External link
29.
Kuhnigk O, Reissner V, Böthern AM, Biegler A, Jüptner M, Schäfer I, Harendza S. Criteria for the successful completion of medical dissertations – A multicenter study. GMS Z Med Ausbild. 2010;27(3):Doc45. DOI: 10.3205/zma000682 External link
30.
Pruskil S, Burgwinkel P, Georg W, Keil T, Kiessling C. Medical students' attitudes towards science and involvement in research activities: a comparative study with students from a reformed and a traditional curriculum. Med Teach. 2009;31(6):e254-e259. DOI: 10.1080/01421590802637925 External link
31.
Phillips SP, Clarke M. More than an education: the hidden curriculum, professional attitudes and career choice. Med Educ. 2012;46(9):887-893. DOI: 10.1111/j.1365-2923.2012.04316.x External link
32.
Sutkin G, Wagner E, Harris I, Schiffer R. What makes a good clinical teacher in medicine? A review of the literature. Acad Med. 2008;83(5):452-466. DOI: 10.1097/ACM.0b013e31816bee61 External link