Part 1: Survey Data
10 of 12 eligible Universities agreed to participate in this study. 110 PGY3 residents across Canada responded to the survey (54% response rate).
Gender was a significant determinant of specialty choice with 78% of positions in procedure based specialties occupied by men compared with only 39% of positions in non-procedure based specialties with declining interest X2 (2, N = 110) = 10, p = 0.006. Residents choosing procedure based specialties and popular non-procedure based specialties were more likely to have applied to multiple programs (p < 0.0001) and to have been involved in research within their specialty during their training. Regardless of the specialty chosen, a significant number of residents developed an interest in their future specialty during medical school (38% – 41%), but their final decision to apply occurred during residency training (73 – 89%) (Table ).
Demographics of survey group participants
The residents' level of debt, hometown population, percentage of specialists and generalists exposed to during medical school and residency, and prior degrees were not found to be significant factors in career choices. The current university and specialties availability at the university did not affect career choice nor were there differences in the reasons for selecting a particular specialty between training programs.
Residents were asked to rank the importance of factors for choosing their specialty on a likert scale (1–5, low – high). There were 2 variables among the 5 most important factors that were common to all three resident groups regardless of future specialty: intellectual stimulation and diversity of clinical spectrum. Residents choosing procedure and non-procedure based specialties ranked satisfaction among staff physicians and challenge of diagnostic problems as important, while their fifth most important variable differed in that consistent with personality was important to residents choosing non-procedure based specialties and ability to do procedures was important to residents choosing procedure based specialties. Residents choosing non-procedure based specialties with declining interest cited consistent with personality, lifestyle and predictable working hours as a staff to complete their top 5 (Table ).
The five most important factors to residents in making career decisions
The opportunity to do procedures (P < 0.001) and the residents perceived reputation of the specialty among the general population (P < 0.001) were significantly more important to residents choosing procedure based specialties. Factors that trended towards significance related to lifestyle included stress among staff physicians, time for leisure as a staff and work hours during training. These factors were most important to residents choosing non-procedure based specialties with declining interest. Work hours as a staff were also important to residents choosing non-procedure based specialties. Anticipated salary as a staff and the opportunity to provide acute/inpatient care was most important to procedure based specialty residents. The opportunity to provide continuity of care and to deal with chronic illnesses were cited as important to residents choosing non-procedure based specialties and non-procedure based specialties with declining interest. Residents selecting non-procedure-based specialties were also more concerned with the patient population treated and a need to contribute towards society.
Part 2: Focus Groups
Twenty-two residents participated in our focus group discussions (5–6 residents per focus group). The demographics of the focus groups are presented in Table . Four major themes were identified; 1) mentorship, role models and experience on a rotation, 2) patients, practice type and personal fit 3) lifestyle and family 4) future job opportunities and finances.
Demographics of focus group participants
Mentorship, role models and experience on a rotation
Residents identified instances where they encountered both positive and negative role models that may have influenced their career decisions. Lack of exposure to fellows may have negatively impacted a residents' decision to apply to a specialty. This was highlighted in a statement by a participant:
"I wonder whether a factor was the amount of exposure you get to fellows. Like in geriatrics I've never seen a fellow and on general medicine you barely saw a fellow. It's mostly staff."
Effective mentorship relationships were more likely to develop informally with either staff or fellows. At one institution where a formal, assigned mentorship program was available to residents, the residents did not perceive this as a helpful initiative and suggested more guidance was needed around the development of a mentoring relationship as outlined by the following statement:
"I don't know how good those forced [mentorship] programs really are.. it's a personal process.
Female residents were more likely to look to female mentors that they could emulate both at work and home. One participant stated:
"A lot of the mentors that I think about are the ones that were actual females with kids that had them during their residency that I've met along the way and they were a great resource."
Patients, practice type and personal fit
Residents were dissuaded from specialties where they felt fatigued, overworked and not confident. They chose specialties where they were stimulated and enjoyed the type of work they were doing as highlighted by the response from one resident:
"you're just very happy to be at work every day and wonderful things with lungs, outpatients, older patients, really sick patients, ICU procedures, bronching .... I haven't been on any other rotation that I thought like I could do this every day and get excited every day."
Participants reported positive experiences on general medicine in non-university affiliated centers where staff appeared to enjoy their jobs more than in the academic environment. The residents noted that subspecialty staff in university-affiliated centers also appeared to enjoy their jobs more than general internists as suggested by one participant:
"I had mentors in GIM but I didn't choose it because I don't think they are as happy in general. Like their satisfaction isn't as good as the ones that are in specialties."
Lifestyle and Family
Lifestyle was an important factor to most participants. Residents were looking for flexibility in their careers and opportunities to do things outside of the hospital and clinic with one resident supporting their career choice by stating:
"It means not having to spend all of my time at the hospital. Opportunities to do other things besides medicine."
Participants realized that in choosing certain specialties, such as cardiology, they would have to make sacrifices in lifestyle, as noted by one resident who said:
"Lifestyle played a big role and that was one of the reasons I eliminated ICU and cardiology. I didn't like the prospect of doing in-house call during fellowship..."
Financial and Job Opportunities
Although residents do not have specific salary expectations, finances seemed to be an important consideration. As stated by one resident entering a procedure based specialty,
"I went through all this school and I'm not going to choose a specialty where I make$150-$200 000. I want a higher earning than that."
In contrast, residents choosing non-procedure based specialties with declining interests believed that salary is less important than job satisfaction as supported by the following statement from a resident:
"In choosing rheumatology money was very, very low down on the list as a defining characteristic."
Residents perceived that an academic career would result in less earning potential than a community career and they believed that this is particularly true in geriatric and general internal medicine with one resident stating:
"I don't want to work a lot harder [in an academic institution] to generate the same salary [as a community cardiologist]."
Finally, participants recognized that it is easier to get a job in specialties with declining interest such as geriatrics. In choosing their subspecialty, residents attempt to assess future job opportunities and the ability to combine research with clinical work. This was highlighted in the statement from a participant:
"The chances of being able to walk into a position [as an academic cardiologist] is actually quite low and so that's very negative."