Attracting physicians into academic medicine is important for the continued advancement of medicine.3,63
Several studies have shown waning interest in this career path worldwide.3,12,63
In order to revitalize academic medicine, we need to consider what factors are influencing career choice. This study represents the first attempt to review systematically the available evidence and found that several factors may influence the decision to enter academic medicine.
Completion of an MD with a graduate degree or fellowship is associated with a career in academic medicine. Of the articles identified for this review, this finding is supported by the highest quality of evidence. Similarly, the completion and publication of research in medical school and residency are associated with a career in academic medicine. However, it is not clear what factors stimulate people to complete a PhD or research program. Residents were found to lose interest in academic medicine as their training progressed, which is of concern and should be explored in other studies to determine whether this is valid and if so, what factors contribute. For example, does the length of training, the lack of exposure to mentors or research opportunities, or a combination of these factors result in loss of interest? And, given the reduction in resident work hours over the last 5 years and studies showing that less time is spent in training,97
has this issue been addressed?
None of these data are sufficient to suggest causality but it may help administrators and educators consider strategies to enhance the attractiveness of this career. For example, initiatives to encourage medical students to complete research projects during their training could be developed and evaluated. Program directors and deans of medical schools could initiate programs (with input from students and residents) to introduce students to research at an early stage in training. Research electives (in basic and clinical research) could be offered throughout training. And, similar opportunities could be offered to provide experience in education and administration so that over the course of their training, students would complete at least 1 elective in each area. Moreover, exchanges between developed and developing countries should be mandated. For example, students in developed countries should complete at least 1 elective in a developing country. These efforts should be continued throughout residency in the hope that interest in academic medicine can be maintained. And, interdisciplinary collaborations should be encouraged in all of these activities as the successful career of the physician relies on these relationships.
The influence of a role model or mentor may also impact decision making. This influence was seen in training and in practice. Lack of mentorship was felt to impact negatively on research productivity and few formal mentorship programs have been implemented and evaluated. In an effort to improve academia, faculty development initiatives to enhance mentoring skills should be developed.98
Mentorship is underrecognized by administrators and appropriate academic compensation should be considered for excellent mentors.
Finally, administrators should develop strategies to address the disincentives to academic medicine such as enhancing the level of autonomy and career flexibility for academics and reducing the financial disparities. By working in academia, physicians accept lower financial rewards than their colleagues in private practice and until the value of their activities is recognized by society and the relevant funders, this will not change. However, administrators can work toward making the career more attractive by enhancing autonomy and career flexibility. Allowing clinicians to choose what duties they want to assume rather than mandating that all participate in teaching, research, and clinical care, and placing equivalent academic value on each of these areas may influence career choice. Certainly, the desire to teach, conduct research, and the intellectual stimulation and challenge provided in academia influence people to choose this career path while the pressure to be a “triple threat,” requiring productivity in clinical work, research, and education, was seen to be a disincentive.
There are several limitations to this study. The quality of a systematic review is limited by the quality of the individual studies that are available. Many of these studies have small sample sizes and provide little detail on how the surveys were constructed. Similarly, details on methodology were often absent, including information about the sampling frame. And, most of the studies in this review are surveys, reflecting self-report. Neither this evidence nor that from the other studies identified is sufficiently valid to suggest causation.69
For example, people who enroll in PhD programs are self-selected and thus it is not the PhD that influences career choice but rather some other individual characteristic.
Despite these limitations, this article does reflect the current state of our understanding about what factors influence career choice in academic medicine. It underscores the need for additional studies of higher quality and more robust study design to better understand the decision-making process. It also highlights a significant gap in our understanding about the impact of factors such as race and gender on career choice. This study is strengthened by the triangulation of study design that is available. For example, the impact of the desire to carry out research was reported in both quantitative and qualitative studies.
It is hoped that this review can stimulate innovative and collaborative work by encouraging administrators at academic institutions to enhance the factors that appear to increase interest in academic medicine, to address some of the disincentives to this career choice, and to evaluate these strategies rigorously. Some of the potential initiatives, as described above, are straightforward and could be implemented and evaluated simply. Other efforts to stimulate interest in academic medicine are more complex and require complete transformation of the current model. For example, 5 scenarios for the future of academic medicine were developed by the International Campaign to Revitalise Academic Medicine (ICRAM) after consultations with stakeholders worldwide (Appendix 3).99
These scenarios were developed to reinvigorate academic medicine and to make it more appealing to medical students and residents. For trainees, one of the most appealing of these scenarios is the “Fully Engaged” model in which all stakeholders (including patients, policymakers, health care professionals, students, and the public) are engaged with each other to advance academic medicine. In this model, medical education is community based and students and the public help drive the medical education and research agendas. Research is collaborative, conducted by diversely skilled individuals (including students and residents at various levels of training). Education, research, and governance of academic medicine are shared responsibilities involving all stakeholders. Using this approach, academic medicine could be energized and by implementing these transformative relationships, medical students and residents would become immediately and fully engaged with all aspects of academic medicine. This interest could be sustained throughout their training, enhancing their interest in a career in academic medicine.
While it may not be possible to implement the transformation of academic medicine as envisioned in the ICRAM scenarios, there are several research initiatives that could be implemented in the current model of academic medicine to facilitate engagement of trainees and academics. First, prospective studies of medical students should be conducted to explore what factors influence career choice. Surveys and qualitative assessment of participants could be completed yearly throughout their undergraduate and postgraduate training to determine interest in academic medicine. Second, this material should be used to develop strategies to enhance recruitment to academic medicine. Some of these strategies would be amenable to study in a randomized trial. For example, mentorship programs could be developed and evaluated using a randomized study design, measuring impact on selection of academic medicine, career satisfaction, and productivity. While it may not be feasible to randomize participants to an MD-PhD program or alternative, a prospective cohort study could be completed including a cohort of people who have enrolled in a fellowship or graduate training program in research or education and comparing them with a cohort who have not participated in such a program and following them to determine impact on career choice. Third, all of the studies described above could be performed at single sites but rigor would be enhanced if they were completed across multiple sites. This endeavor would require collaboration at the highest levels, under leadership of the deans of medicine and organizations such as the Association of Professors of Medicine who are interested in preserving academic medicine. Given that medical schools and training programs are charged with training health care professionals for the future and with advancing clinical care, research, and education, they should feel compelled to participate in endeavors to stimulate interest in academic medicine and to mandate evaluation of these efforts. Indeed, why should educational interventions be considered different from other interventions such as drugs or care coordination strategies and not be subjected to the same valid evaluation in a randomized trial?
The future of academic medicine requires that we attract bright, enthusiastic candidates. This review provides an initial step to help guide this process. In addition to identifying some of the factors that may be relevant to career decision making, it highlights that more rigorous research, using higher quality study designs, must be completed to further understand what influences career choice in academic medicine. It is hoped that this review will lead to further efforts to revitalize academic medicine.