Journal of Obstetrics and Gynaecology
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
Graduate medical students’ perception of obstetrics and gynaecology as a future career specialty S. I. M. F. Ismail & E. H. Kevelighan To cite this article: S. I. M. F. Ismail & E. H. Kevelighan (2014) Graduate medical students’ perception of obstetrics and gynaecology as a future career specialty, Journal of Obstetrics and Gynaecology, 34:4, 341-345 To link to this article: http://dx.doi.org/10.3109/01443615.2013.876396
Published online: 31 Jan 2014.
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Date: 13 November 2015, At: 03:36
Journal of Obstetrics and Gynaecology, May 2014; 34: 341–345 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2013.876396
GYNAECOLOGY
Graduate medical students’ perception of obstetrics and gynaecology as a future career specialty S. I. M. F. Ismail & E. H. Kevelighan
Downloaded by [University of Wisconsin Oshkosh] at 03:36 13 November 2015
Department of Obstetrics and Gynaecology, Singleton Hospital, Swansea, Wales, UK
The aim of this study was to explore the perceptions of graduate-entry medical students of obstetrics and gynaecology as a specialty, in order to understand how to increase its appeal to them, and therefore enhance recruitment to the specialty. A total of 90 questionnaires were returned out of 145 questionnaires distributed to years 2 and 4 graduate-entry medical students (62% response rate). Although fewer than 4% of respondents are considering the specialty as their career choice, more than half of the respondents would consider the specialty as a second option, which shows that there is room to persuade them to have a second look. Gender was the only factor that significantly affected views regarding obstetrics and gynaecology. There is a need for more information about the specialty and its training opportunities and exposure to areas of special interest and subspecialisation, as well as role models, rather than focussing on labour ward in timetables. Areas of apprehension about the specialty, such as the risk of litigation, need to be aired and addressed through career days, as well as formal tutorials within teaching programmes.
Method
Keywords: Career, graduate entry, medical students, obstetrics and gynaecology, recruitment, UK
Result
Introduction The specialty of Obstetrics and Gynaecology in the UK is facing a recruitment crisis (RCOG 2004). Less than 1 in 30 of the medical school graduates seek the specialty as their first career choice (Turner et al. 2006). Efforts have been made to increase the appeal of the specialty to applicants for training placements and explore the perceptions of medical students of the specialty and its various aspects (RCOG 2006). Recently, graduate entry has been introduced in the UK, not only to increase the number of doctors (Cullen et al. 2007) but also diversify their mix, in terms of maturity, self-directed learning and career choice (Geffen 1991). Research has shown male graduate entrants to prefer general practice rather than hospital-based specialties (Goldacre et al. 2007). No work has been carried out to look specifically at their perceptions of obstetrics and gynaecology, which may hold the key to understanding their interest in the specialty, and therefore guide increasing its appeal to them. The aim of this study was to explore the perceptions of graduate-entry medical students of obstetrics and gynaecology as a specialty, in order to understand how to increase its appeal to them, and therefore enhance recruitment.
A self-constructed questionnaire was circulated to graduate medical students during their obstetrics and gynaecology attachment at Singleton Hospital, in Swansea in the academic year 2009–2010. These students attended obstetrics and gynaecology for 5 weeks in year 4 and for a week of teaching in year 2. The questionnaires covered background features of graduate-entry medical students, such as gender, nature of first degree and working experience since completion of first degree, career prospects in terms of the views and perception of obstetrics and gynaecology as a specialty and its merits and demerits, and included an area of free comments. Completed questionnaires were collected at the end of attachments. Continuous data were described using the median [inter-quartile range], as they did not fit a normal distribution. Categorical data were outlined in numbers (%). Data were saved on Microsoft Works version 5 database for windows (Microsoft Inc, CA USA) Statistical analysis was carried out on Stata version 6 for windows (StataCorp LP, TX USA).
A total of 90 questionnaires were returned out of 145 questionnaires distributed to years 2 and 4 medical students, which represented a 62% response rate. The background features of these students are shown in Table I. The preference of obstetrics and gynaecology as a career, together with factors likely to affect this, as well as the perception of opportunities to train in the specialty, preference for a split between obstetrics and gynaecology, as well Table I. Background features of participants. Feature Age (years) Time since obtaining primary degree (years) Type of primary degree Health-related Non-health-related Working while medical students Part-time Shift work No Gender Male Female
n
(%) 25 [23–27]∗ 2 [1–3]∗
68 22
75.6 24.4
17 4 69
18.9 4.4 76.7
36 54
40 60
∗These values are presented as median [inter-quartile range].
Correspondence: S. I. M. F. Ismail, Department of Obstetrics and Gynaecology, Royal Sussex County Hospital, Brighton BN2 5BE, East Sussex, England, UK. E-mail: [email protected]
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Table II. Respondents’ career intentions regarding obstetrics and gynaecology as a specialty and factors affecting these intentions.
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Career aspect Career intentions regarding obstetrics and gynaecology First choice Second choice No No answer Factors affecting career intentions∗ Health related primary degree Prior employment Gender Opportunities to train in obstetrics and gynaecology Good Limited Do not know No answer Split of obstetrics and gynaecology Yes No No answer Effect of split on attractiveness of the specialty Yes, as I would like to concentrate on obstetrics Yes, as I would like to concentrate on gynaecology No, as I would like a bit of each No, as I do not like it any way No answer
n
(%)
3 47 36 4
3.5 54.7 41.9 4.4
p ⫽ 0.56 p ⫽ 0.09 p ⫽ 0.0009 15 7 32 36
16.7 7.8 35.6 40
37 44 9
41.1 48.9 10
34 3 35 12 6
37.8 3.3 48.9 13.3 6.7
∗Mann–Whitney test.
as the likely impact of such a split on career intentions are shown in Table II. The perception of suggested merits as well as demerits of a career in obstetrics and gynaecology is shown in Tables III and IV, respectively. Free response comments and suggestions to improve the appeal of the specialty are shown in Table V.
Discussion The aim of this questionnaire study was to explore how graduate-entry medical students perceive obstetrics and gynaecology as a specialty, and perhaps increase its appeal as a career choice. The study has shown ⬍ 1:25 (4%) of respondents to be considering the specialty as their career choice. This matches the reported ⬍ 1:30 (3.3%) of overall medical school graduates seeking the specialty as their first career choice (Turner et al. 2006). However, more than half of the respondents would consider it as a second option, which shows that there is room to persuade students to have a second look at obstetrics and gynaecology as a career. Gaining insight into the factors that influence graduate medical students’ perception of the specialty and correcting any misconceptions is likely to increase the chance of students choosing obstetrics and gynaecology as their first choice.
Our findings show the choice of obstetrics and gynaecology as a specialty was affected by gender, with more female graduate medical students considering it than male graduate medical students (p ⫽ 0.0009, as shown in Table II). This confirms previous research findings that showed graduate medical students (Shelker et al. 2011) and male graduate medical students to prefer general practice rather than hospital-based specialties (Goldacre et al. 2007), as well as the documented fall in interest of male UK graduates in the specialty (RCOG 2004). However, this could simply represent the fact that there are more female than male graduate entrants, as is also the case with undergraduate medical students. Looking at other factors therefore, may provide guidance on to how to improve the appeal of the specialty. The field of graduate medical students’ primary degree had no influence on their preferences towards obstetrics and gynaecology as a specialty. Research has shown that the nature of graduate medical students’ primary degree has no impact on their experience as graduate medical students (Rapport et al. 2009). While this vindicates the open approach adopted by the graduate entry programme in welcoming applicants, regardless of primary degree (Rapport et al. 2009) which is shown by the non-normal distribution of age and time since obtaining first degree, it also highlights the importance of adopting the same approach when trying to promote the specialty of obstetrics and gynaecology to graduate medical students, rather than focussing on those whose primary degree was health-related, on the assumption that their experience will influence their career choices. Work experience since completing the primary degree had no significant influence on the perception of obstetrics and gynaecology and the interest in it as a potential career specialty. Graduate students have been shown to have higher distinction but not graduation rates than standard entry students (Shelker et al. 2011). They have also been shown to be less anxious, less empathetic, less conscientious (James et al. 2009) and less prone to syncope in theatre (Jamjoom et al. 2009) than direct entry students. Graduate medical students may therefore differ from direct entry students in aspects that do not necessarily make them more interested in specific disciplines. This concurs with other reported observations about the career directions of graduate entry medical students. As senior house officers, they pay more attention to hospital accommodation and food and family time than do their direct entry colleagues (Goldacre et al. 2008). Graduate medical students prefer general practice to hospital specialties (Lambert et al. 2001). Therefore, we need to provide graduate entry students with more information and exposure to obstetrics and gynaecology, in an effort to attract them into our specialty. A key finding of this study, and one which may help to increase the appeal of obstetrics and gynaecology to graduate entrants, is their request for information about the specialty. Over one-third of participants explicitly indicated that they were unaware of
Table III. The distribution of respondents according to their perception of suggested merits of obstetrics and gynaecology as a career. 1 (too bad)
2 (bad)
3 (neither bad nor good)
4 (good)
5 (too good)
No answer
Merit
n
(%)
n
(%)
n
(%)
n
(%)
n
(%)
n
(%)
Exciting Interesting Fulfilling Rewarding Challenging
1 1 0 0 0
1.1 1.1 0 0 0
12 8 6 3 8
13.3 8.9 6.7 3.3 8.9
21 11 7 11 9
23.3 12.2 7.8 12.2 10
37 42 37 37 42
41.1 46.7 41.1 41.1 46.7
12 24 35 34 26
13.3 26.7 38.9 37.8 28.9
7 4 5 5 5
7.8 4.4 5.6 5.6 5.6
Graduate medical students’ perception of obstetrics and gynaecology 343 Table IV. The distribution of respondents according to their perception of suggested demerits of obstetrics and gynaecology as a career. 1 (too bad) Demerit
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Demanding Boring Stressful Incompatible with family life Risky
2 (bad)
3 (neither bad nor good)
4 (good)
5 (too good)
No answer
n
(%)
n
(%)
n
(%)
n
(%)
n
(%)
n
(%)
7 4 6 2 18
7.8 4.4 6.7 2.2 20
25 13 19 24 24
27.8 14.4 21.1 26.7 26.7
33 35 29 38 18
36.7 38.9 32.2 42.2 20
13 18 25 14 14
14.4 20 27.8 15.6 15.6
4 12 3 5 9
4.4 13.3 3.3 5.6 10
8 8 8 7 7
8.9 8.9 8.9 7.8 7.8
the opportunities to secure a training post in obstetrics and gynaecology and a further 40% of them did not answer the question about the chances to secure such a placement. In fact, less than one in four respondents answered this question, with less than one in six indicating their perception of good training opportunities. It is known that information about specialisation and training opportunities influences career choices of graduate students (Newton et al. 2011). Training in obstetrics and gynaecology is based on a run-through training programme, which means that trainees do not have to compete for a national training number at ST3–4 level, like many other specialties which are uncoupled. This is a positive attraction for trainees, in that once they secure their training number to enter at ST1, they enter a 7-year programme and, subject to satisfactory progress, will emerge with a Certificate of Completion of Training, which entitles them to apply for a consultant post. The need for information and exposure was also expressed in the free comments made by graduate medical students who took part in the study. One of them recommended ‘earlier exposure before people form uneducated prejudices against it’. Another described ‘stigmatisation of female medical students/doctors pursuing career in the specialty’. Correct and early information about the specialty is vital to improving the appeal of obstetrics and gynaecology as a specialty. This should be kept in mind when planning the curriculum and scheduling exposure to obstetrics and gynaecology. Table V. Free comments made by participants regarding the merits, demerits of obstetrics and gynaecology as a specialty and suggestions to improve its appeal. Comment Merits of a career in obstetrics and gynaecology Rewarding (childbirth) Interesting/challenging/pace Variety Training/career Healthy population Supspecialisation Demerits of a career in obstetrics and gynaecology Risk/litigation Long hours/incompatible with family Narrow Broad Midwives Stigma Suggestions to improve the appeal of the specialty More exposure/information Family friendly/less hours Split obstetrics and gynaecology Litigation protection Better relations between doctors and midwives Increase training opportunity
n
(%)
47 29 28 12 7 1
52.2 32.2 31.1 13.3 7.8 1.1
37 26 15 1 1 1
41.1 28.9 16.7 1.1 1.1 1.1
11 8 4 2 1 1
12.2 8.9 4.4 2.2 1.1 1.1
The request for more exposure and/or information was the most frequent suggestion made by over 10% of the participants. Adequate exposure may help graduate students identify positive role models in the specialty; a factor that has long been shown to help favourable career intentions of medical students towards a particular specialty (Johnson and Michener 1994), and more recently, shown to be significant in the career choices of graduate medical students (Ravindra and Fitzgerald 2011). The range of services and activities included in student timetables has a significant influence on their exposure to, and therefore impression of, the specialty. Childbirth was highlighted by over half of the study participants, a reflection of the prominence of labour ward in their timetable, with little exposure to the wider and more specialised aspects of the specialty. This gives them a rather narrow view of the specialty and misses other aspects that some may find interesting and encounter impressive role models that can stimulate them to look at the specialty as a career. It is encouraging that a large proportion of participants showed their appreciation of the positive aspects of obstetrics and gynaecology. Over half of the participants felt the specialty to be exciting or very exciting; over 70% felt it was interesting or very interesting; and over 75% thought it was fulfilling or very fulfilling, rewarding or very rewarding and challenging or very challenging. More than half respondents re-emphasised the rewarding merit of the specialty, especially in relation to childbirth and almost one-third expressed their positive impression of its working pattern and variety. This positive perception could be nourished further with more information and exposure about the specialty and its training opportunities. The Royal College of Obstetricians and Gynaecologists (RCOG) runs an annual careers fair, which includes lectures about training in the specialty and involves booths for different specialist societies to give medical students a real life flavour of a career in the specialty. This careers fair is at the Royal College of Obstetricians and Gynaecologists, in London, which may not be accessible to all medical students, and certainly less so for those based away from London. Including a lecture, creating A Career in Obstetrics and Gynaecology handbook in all attachments and running career days in local universities are ideas worth exploring. This is an aspect where local deaneries and schools of obstetrics and gynaecology can cooperate with academic departments. The impression of negative features of the specialty also deserves consideration. Almost half of the participants felt the specialty to be risky or very risky and over 40% highlighted this perception of risk attached to a career in obstetrics and gynaecology specifically in their free comments. This needs addressing if the appeal of the specialty is to be improved. Just over one-third of the participants felt the specialty to be demanding or very demanding and less than one-third felt it was boring or very boring and incompatible or very incom-
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S. I. M. F. Ismail & E. H. Kevelighan
patible with family life. The concern about long hours and incompatibility with family life were the second most common issue raised in the free comments made by over a quarter of participants. Since obstetrics and gynaecology was more popular among the female participants and there are now more female than male students, these concerns about family life are very important. While some attributes of obstetrics and gynaecology are not possible to improve, such as the risk of litigation, the long hours, the emergency nature of obstetric cover and working with midwives, the way these features are managed and handled can be discussed with medical students to show them that these are not insurmountable hurdles. All practising obstetricians face the risk of litigation. Appropriate risk management, practising evidence-based medicine, providing adequate patient counselling and communicating effectively with patients and colleagues reduces the risk of litigation. Focussed practical training in dealing with emergencies as well as regular skills and drills increase obstetricians’ confidence and competence in the management of uncommon emergencies, usually with a good outcome. We have found it helpful to acknowledge and discuss with the students the increased risks inherent in obstetrics and gynaecology. Our students receive a session of simulation in obstetric emergencies during their 5-week specialty attachments. Good team skills can help working well and efficiently with midwives. The potential for subspecialisation in O&G provides more career choice options, catering for generalists, who like variety, and specialists and subspecialists, who are keen to master specific areas. Similarly, flexible training and part-time working enable those with families to pursue a career in obstetrics and gynaecology. This aspect is particularly important, since there are now more female medical students, both graduate and non-graduate, as well as the significant effect of gender on career intention shown in this study. It is also the second most frequent suggestion made by participants to improve the specialty. It is important not to confuse student experience with their views on the specialty. For the last 6 years, Swansea students rated their attachment in obstetrics and gynaecology as their most enjoyable student attachment. This however, does not match their career intentions and their views of the specialty, as shown in this study. Improving the appeal of the specialty is more than looking after students while they are on obstetrics and gynaecology attachments. It is also possible that students change their mind having experienced other specialties and potentially more so as they graduate and start foundation years. The findings of this study should be considered within the context of its limitations. It was a questionnaire survey that covered an academic year in a single medical school, with a 60% response rate. While this rate may appear low, in reality, it is average for this form of research (Raszeja et al. 2013) Other research methods, such as interviews and focus groups, may have provided more information, but this study has given a body of information and suggestions to explore further through these more targeted methods. The work could be expanded to cover other medical schools and perhaps include comparison with standard entry students.
Conclusion The aim of this study was to explore the perceptions of graduate-entry medical students to obstetrics and gynaecology as a specialty, so as to understand how to increase its appeal to them, and therefore enhance recruitment to the speciality.
This study showed that 4% of graduate-entry medical students at Swansea Medical School see obstetrics and gynaecology as their first career choice, which is in-keeping with 3.3% of all graduates from medical schools in the UK who choose obstetrics and gynaecology as a career. Gender was the only factor that significantly affected the views of graduate-entry medical students towards the specialty, with more females in favour of obstetrics and gynaecology as a career than their male counterparts, which matches trends in applications for training placements in obstetrics and gynaecology from all graduates from medical schools in the UK. However, more than 50% of these students would consider the specialty as a second choice, which represents a real opportunity to increase recruitment to the specialty. This will depend on providing graduate-entry medical students with information about training opportunities in the specialty and exposing them to its varied range of special interest and subspecialist areas, where they can develop and utilise their skills, and potential role models, who may inspire them to take up the specialty as a career. Recognising and addressing perceived challenges in the specialty, such as working with midwives and the risk of litigation, can be achieved through open discussion, where medical students can voice their apprehensions and hear the actual experience of doctors of various grades within the specialty who benefit from the team skills to work well with midwives and apply risk management principles to deal with litigation. This can be arranged through career days, as well as formal tutorials within the teaching programme. Although not assessed in this study, these ideas may well also be relevant to standard-entry medical students. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Cullen W, Power D, Bury G. 2007. The introduction of graduate entry medical programmes: potential benefits and likely challenges. Irish Medical Journal 100:500–504. Geffen LB. 1991. The case for graduate schools of medicine in Australia. Medical Journal of Australia 155:737–740. Goldacre MJ, Davidson JM, Lambert TW. 2007. Career preferences of graduate and non-graduate entrants to medical schools in the UK. Medical Education 41: 349–361. Goldacre MJ, Davidson JM, Lambert TW. 2008. The first house officer year: views of graduate and non-graduate entrants to medical school. Medical Education 42:286–293. James D, Ferguson E, Powis D, Bore M, Munro D, Symonds I et al. 2009. Graduate entry to medicine: widening psychological diversity. BMC Medical Education 9:67. Jamjoom AA, Nikkar-Esfahani A, Fitzgerald JE. 2009. Operating theatre related syncope in medical students: a cross sectional study. BMC Medical Education 9:14. Johnson VK, Michener JL. 1994. Attitudes, experience, and influence of family medicine predoctoral education directors. Family Medicine 26:309–313. Lambert TW, Goldacre MJ, Davidson JM, Parkhouse J. 2001. Graduate status and age at entry to medical school as predictors of doctors’ choice of long-term career. Medical Education 35:450–454. Newton P, Cabot L, Wilson NH, Gallagher JE. 2011. The graduate entry generation: a qualitative study exploring the factors influencing the career expectations and aspirations of a graduating cohort of graduate entry dental students in one London institution. BMC Oral Health 11:25. Rapport F, Jones GF, Favell S, Bailey J, Gray L, Manning A et al. 2009. What influences student experience of Graduate Entry Medicine? Qualitative findings from Swansea School of Medicine. Medical Teacher 31:e580–e585. Raszeja VM. Jordens CF. Kerridge IH. 2013. Survey of practices and policies relating to the use of complementary and alternative medicines and therapies in New South Wales cancer services. Internal Medicine Journal 43:84–88.
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Ravindra P, Fitzgerald JE. 2011. Defining surgical role models and their influence on career choice. World Journal of Surgery 35:704–709. RCOG. 2004. A career in obstetrics and gynaecology; recruitment and retention in the specialty. London: Royal College of Obstetricians and Gynaecologists. RCOG. 2006. Improving recruitment to obstetrics and gynaecology; report of a joint working party of the RCOG and AAOG. London: Royal College of Obstetricians and Gynaecologists.
Shelker W, Belton A, Glue P. 2011. Academic performance and career choices of older medical students at the University of Otago. New Zealand Medical Journal 124:63–68. Turner G, Lambert TW, Goldacre MJ, Barlow D. 2006. Career choices for obstetrics and gynaecology: national surveys of graduates of 1974–2002 from UK medical school. British Journal of Obstetrics and Gynaecology 113:350–356.
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
Graduate medical students’ perception of obstetrics and gynaecology as a future career specialty S. I. M. F. Ismail & E. H. Kevelighan To cite this article: S. I. M. F. Ismail & E. H. Kevelighan (2014) Graduate medical students’ perception of obstetrics and gynaecology as a future career specialty, Journal of Obstetrics and Gynaecology, 34:4, 341-345 To link to this article: http://dx.doi.org/10.3109/01443615.2013.876396
Published online: 31 Jan 2014.
Submit your article to this journal
Article views: 58
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijog20 Download by: [University of Wisconsin Oshkosh]
Date: 13 November 2015, At: 03:36
Journal of Obstetrics and Gynaecology, May 2014; 34: 341–345 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2013.876396
GYNAECOLOGY
Graduate medical students’ perception of obstetrics and gynaecology as a future career specialty S. I. M. F. Ismail & E. H. Kevelighan
Downloaded by [University of Wisconsin Oshkosh] at 03:36 13 November 2015
Department of Obstetrics and Gynaecology, Singleton Hospital, Swansea, Wales, UK
The aim of this study was to explore the perceptions of graduate-entry medical students of obstetrics and gynaecology as a specialty, in order to understand how to increase its appeal to them, and therefore enhance recruitment to the specialty. A total of 90 questionnaires were returned out of 145 questionnaires distributed to years 2 and 4 graduate-entry medical students (62% response rate). Although fewer than 4% of respondents are considering the specialty as their career choice, more than half of the respondents would consider the specialty as a second option, which shows that there is room to persuade them to have a second look. Gender was the only factor that significantly affected views regarding obstetrics and gynaecology. There is a need for more information about the specialty and its training opportunities and exposure to areas of special interest and subspecialisation, as well as role models, rather than focussing on labour ward in timetables. Areas of apprehension about the specialty, such as the risk of litigation, need to be aired and addressed through career days, as well as formal tutorials within teaching programmes.
Method
Keywords: Career, graduate entry, medical students, obstetrics and gynaecology, recruitment, UK
Result
Introduction The specialty of Obstetrics and Gynaecology in the UK is facing a recruitment crisis (RCOG 2004). Less than 1 in 30 of the medical school graduates seek the specialty as their first career choice (Turner et al. 2006). Efforts have been made to increase the appeal of the specialty to applicants for training placements and explore the perceptions of medical students of the specialty and its various aspects (RCOG 2006). Recently, graduate entry has been introduced in the UK, not only to increase the number of doctors (Cullen et al. 2007) but also diversify their mix, in terms of maturity, self-directed learning and career choice (Geffen 1991). Research has shown male graduate entrants to prefer general practice rather than hospital-based specialties (Goldacre et al. 2007). No work has been carried out to look specifically at their perceptions of obstetrics and gynaecology, which may hold the key to understanding their interest in the specialty, and therefore guide increasing its appeal to them. The aim of this study was to explore the perceptions of graduate-entry medical students of obstetrics and gynaecology as a specialty, in order to understand how to increase its appeal to them, and therefore enhance recruitment.
A self-constructed questionnaire was circulated to graduate medical students during their obstetrics and gynaecology attachment at Singleton Hospital, in Swansea in the academic year 2009–2010. These students attended obstetrics and gynaecology for 5 weeks in year 4 and for a week of teaching in year 2. The questionnaires covered background features of graduate-entry medical students, such as gender, nature of first degree and working experience since completion of first degree, career prospects in terms of the views and perception of obstetrics and gynaecology as a specialty and its merits and demerits, and included an area of free comments. Completed questionnaires were collected at the end of attachments. Continuous data were described using the median [inter-quartile range], as they did not fit a normal distribution. Categorical data were outlined in numbers (%). Data were saved on Microsoft Works version 5 database for windows (Microsoft Inc, CA USA) Statistical analysis was carried out on Stata version 6 for windows (StataCorp LP, TX USA).
A total of 90 questionnaires were returned out of 145 questionnaires distributed to years 2 and 4 medical students, which represented a 62% response rate. The background features of these students are shown in Table I. The preference of obstetrics and gynaecology as a career, together with factors likely to affect this, as well as the perception of opportunities to train in the specialty, preference for a split between obstetrics and gynaecology, as well Table I. Background features of participants. Feature Age (years) Time since obtaining primary degree (years) Type of primary degree Health-related Non-health-related Working while medical students Part-time Shift work No Gender Male Female
n
(%) 25 [23–27]∗ 2 [1–3]∗
68 22
75.6 24.4
17 4 69
18.9 4.4 76.7
36 54
40 60
∗These values are presented as median [inter-quartile range].
Correspondence: S. I. M. F. Ismail, Department of Obstetrics and Gynaecology, Royal Sussex County Hospital, Brighton BN2 5BE, East Sussex, England, UK. E-mail: [email protected]
342
S. I. M. F. Ismail & E. H. Kevelighan
Table II. Respondents’ career intentions regarding obstetrics and gynaecology as a specialty and factors affecting these intentions.
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Career aspect Career intentions regarding obstetrics and gynaecology First choice Second choice No No answer Factors affecting career intentions∗ Health related primary degree Prior employment Gender Opportunities to train in obstetrics and gynaecology Good Limited Do not know No answer Split of obstetrics and gynaecology Yes No No answer Effect of split on attractiveness of the specialty Yes, as I would like to concentrate on obstetrics Yes, as I would like to concentrate on gynaecology No, as I would like a bit of each No, as I do not like it any way No answer
n
(%)
3 47 36 4
3.5 54.7 41.9 4.4
p ⫽ 0.56 p ⫽ 0.09 p ⫽ 0.0009 15 7 32 36
16.7 7.8 35.6 40
37 44 9
41.1 48.9 10
34 3 35 12 6
37.8 3.3 48.9 13.3 6.7
∗Mann–Whitney test.
as the likely impact of such a split on career intentions are shown in Table II. The perception of suggested merits as well as demerits of a career in obstetrics and gynaecology is shown in Tables III and IV, respectively. Free response comments and suggestions to improve the appeal of the specialty are shown in Table V.
Discussion The aim of this questionnaire study was to explore how graduate-entry medical students perceive obstetrics and gynaecology as a specialty, and perhaps increase its appeal as a career choice. The study has shown ⬍ 1:25 (4%) of respondents to be considering the specialty as their career choice. This matches the reported ⬍ 1:30 (3.3%) of overall medical school graduates seeking the specialty as their first career choice (Turner et al. 2006). However, more than half of the respondents would consider it as a second option, which shows that there is room to persuade students to have a second look at obstetrics and gynaecology as a career. Gaining insight into the factors that influence graduate medical students’ perception of the specialty and correcting any misconceptions is likely to increase the chance of students choosing obstetrics and gynaecology as their first choice.
Our findings show the choice of obstetrics and gynaecology as a specialty was affected by gender, with more female graduate medical students considering it than male graduate medical students (p ⫽ 0.0009, as shown in Table II). This confirms previous research findings that showed graduate medical students (Shelker et al. 2011) and male graduate medical students to prefer general practice rather than hospital-based specialties (Goldacre et al. 2007), as well as the documented fall in interest of male UK graduates in the specialty (RCOG 2004). However, this could simply represent the fact that there are more female than male graduate entrants, as is also the case with undergraduate medical students. Looking at other factors therefore, may provide guidance on to how to improve the appeal of the specialty. The field of graduate medical students’ primary degree had no influence on their preferences towards obstetrics and gynaecology as a specialty. Research has shown that the nature of graduate medical students’ primary degree has no impact on their experience as graduate medical students (Rapport et al. 2009). While this vindicates the open approach adopted by the graduate entry programme in welcoming applicants, regardless of primary degree (Rapport et al. 2009) which is shown by the non-normal distribution of age and time since obtaining first degree, it also highlights the importance of adopting the same approach when trying to promote the specialty of obstetrics and gynaecology to graduate medical students, rather than focussing on those whose primary degree was health-related, on the assumption that their experience will influence their career choices. Work experience since completing the primary degree had no significant influence on the perception of obstetrics and gynaecology and the interest in it as a potential career specialty. Graduate students have been shown to have higher distinction but not graduation rates than standard entry students (Shelker et al. 2011). They have also been shown to be less anxious, less empathetic, less conscientious (James et al. 2009) and less prone to syncope in theatre (Jamjoom et al. 2009) than direct entry students. Graduate medical students may therefore differ from direct entry students in aspects that do not necessarily make them more interested in specific disciplines. This concurs with other reported observations about the career directions of graduate entry medical students. As senior house officers, they pay more attention to hospital accommodation and food and family time than do their direct entry colleagues (Goldacre et al. 2008). Graduate medical students prefer general practice to hospital specialties (Lambert et al. 2001). Therefore, we need to provide graduate entry students with more information and exposure to obstetrics and gynaecology, in an effort to attract them into our specialty. A key finding of this study, and one which may help to increase the appeal of obstetrics and gynaecology to graduate entrants, is their request for information about the specialty. Over one-third of participants explicitly indicated that they were unaware of
Table III. The distribution of respondents according to their perception of suggested merits of obstetrics and gynaecology as a career. 1 (too bad)
2 (bad)
3 (neither bad nor good)
4 (good)
5 (too good)
No answer
Merit
n
(%)
n
(%)
n
(%)
n
(%)
n
(%)
n
(%)
Exciting Interesting Fulfilling Rewarding Challenging
1 1 0 0 0
1.1 1.1 0 0 0
12 8 6 3 8
13.3 8.9 6.7 3.3 8.9
21 11 7 11 9
23.3 12.2 7.8 12.2 10
37 42 37 37 42
41.1 46.7 41.1 41.1 46.7
12 24 35 34 26
13.3 26.7 38.9 37.8 28.9
7 4 5 5 5
7.8 4.4 5.6 5.6 5.6
Graduate medical students’ perception of obstetrics and gynaecology 343 Table IV. The distribution of respondents according to their perception of suggested demerits of obstetrics and gynaecology as a career. 1 (too bad) Demerit
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Demanding Boring Stressful Incompatible with family life Risky
2 (bad)
3 (neither bad nor good)
4 (good)
5 (too good)
No answer
n
(%)
n
(%)
n
(%)
n
(%)
n
(%)
n
(%)
7 4 6 2 18
7.8 4.4 6.7 2.2 20
25 13 19 24 24
27.8 14.4 21.1 26.7 26.7
33 35 29 38 18
36.7 38.9 32.2 42.2 20
13 18 25 14 14
14.4 20 27.8 15.6 15.6
4 12 3 5 9
4.4 13.3 3.3 5.6 10
8 8 8 7 7
8.9 8.9 8.9 7.8 7.8
the opportunities to secure a training post in obstetrics and gynaecology and a further 40% of them did not answer the question about the chances to secure such a placement. In fact, less than one in four respondents answered this question, with less than one in six indicating their perception of good training opportunities. It is known that information about specialisation and training opportunities influences career choices of graduate students (Newton et al. 2011). Training in obstetrics and gynaecology is based on a run-through training programme, which means that trainees do not have to compete for a national training number at ST3–4 level, like many other specialties which are uncoupled. This is a positive attraction for trainees, in that once they secure their training number to enter at ST1, they enter a 7-year programme and, subject to satisfactory progress, will emerge with a Certificate of Completion of Training, which entitles them to apply for a consultant post. The need for information and exposure was also expressed in the free comments made by graduate medical students who took part in the study. One of them recommended ‘earlier exposure before people form uneducated prejudices against it’. Another described ‘stigmatisation of female medical students/doctors pursuing career in the specialty’. Correct and early information about the specialty is vital to improving the appeal of obstetrics and gynaecology as a specialty. This should be kept in mind when planning the curriculum and scheduling exposure to obstetrics and gynaecology. Table V. Free comments made by participants regarding the merits, demerits of obstetrics and gynaecology as a specialty and suggestions to improve its appeal. Comment Merits of a career in obstetrics and gynaecology Rewarding (childbirth) Interesting/challenging/pace Variety Training/career Healthy population Supspecialisation Demerits of a career in obstetrics and gynaecology Risk/litigation Long hours/incompatible with family Narrow Broad Midwives Stigma Suggestions to improve the appeal of the specialty More exposure/information Family friendly/less hours Split obstetrics and gynaecology Litigation protection Better relations between doctors and midwives Increase training opportunity
n
(%)
47 29 28 12 7 1
52.2 32.2 31.1 13.3 7.8 1.1
37 26 15 1 1 1
41.1 28.9 16.7 1.1 1.1 1.1
11 8 4 2 1 1
12.2 8.9 4.4 2.2 1.1 1.1
The request for more exposure and/or information was the most frequent suggestion made by over 10% of the participants. Adequate exposure may help graduate students identify positive role models in the specialty; a factor that has long been shown to help favourable career intentions of medical students towards a particular specialty (Johnson and Michener 1994), and more recently, shown to be significant in the career choices of graduate medical students (Ravindra and Fitzgerald 2011). The range of services and activities included in student timetables has a significant influence on their exposure to, and therefore impression of, the specialty. Childbirth was highlighted by over half of the study participants, a reflection of the prominence of labour ward in their timetable, with little exposure to the wider and more specialised aspects of the specialty. This gives them a rather narrow view of the specialty and misses other aspects that some may find interesting and encounter impressive role models that can stimulate them to look at the specialty as a career. It is encouraging that a large proportion of participants showed their appreciation of the positive aspects of obstetrics and gynaecology. Over half of the participants felt the specialty to be exciting or very exciting; over 70% felt it was interesting or very interesting; and over 75% thought it was fulfilling or very fulfilling, rewarding or very rewarding and challenging or very challenging. More than half respondents re-emphasised the rewarding merit of the specialty, especially in relation to childbirth and almost one-third expressed their positive impression of its working pattern and variety. This positive perception could be nourished further with more information and exposure about the specialty and its training opportunities. The Royal College of Obstetricians and Gynaecologists (RCOG) runs an annual careers fair, which includes lectures about training in the specialty and involves booths for different specialist societies to give medical students a real life flavour of a career in the specialty. This careers fair is at the Royal College of Obstetricians and Gynaecologists, in London, which may not be accessible to all medical students, and certainly less so for those based away from London. Including a lecture, creating A Career in Obstetrics and Gynaecology handbook in all attachments and running career days in local universities are ideas worth exploring. This is an aspect where local deaneries and schools of obstetrics and gynaecology can cooperate with academic departments. The impression of negative features of the specialty also deserves consideration. Almost half of the participants felt the specialty to be risky or very risky and over 40% highlighted this perception of risk attached to a career in obstetrics and gynaecology specifically in their free comments. This needs addressing if the appeal of the specialty is to be improved. Just over one-third of the participants felt the specialty to be demanding or very demanding and less than one-third felt it was boring or very boring and incompatible or very incom-
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344
S. I. M. F. Ismail & E. H. Kevelighan
patible with family life. The concern about long hours and incompatibility with family life were the second most common issue raised in the free comments made by over a quarter of participants. Since obstetrics and gynaecology was more popular among the female participants and there are now more female than male students, these concerns about family life are very important. While some attributes of obstetrics and gynaecology are not possible to improve, such as the risk of litigation, the long hours, the emergency nature of obstetric cover and working with midwives, the way these features are managed and handled can be discussed with medical students to show them that these are not insurmountable hurdles. All practising obstetricians face the risk of litigation. Appropriate risk management, practising evidence-based medicine, providing adequate patient counselling and communicating effectively with patients and colleagues reduces the risk of litigation. Focussed practical training in dealing with emergencies as well as regular skills and drills increase obstetricians’ confidence and competence in the management of uncommon emergencies, usually with a good outcome. We have found it helpful to acknowledge and discuss with the students the increased risks inherent in obstetrics and gynaecology. Our students receive a session of simulation in obstetric emergencies during their 5-week specialty attachments. Good team skills can help working well and efficiently with midwives. The potential for subspecialisation in O&G provides more career choice options, catering for generalists, who like variety, and specialists and subspecialists, who are keen to master specific areas. Similarly, flexible training and part-time working enable those with families to pursue a career in obstetrics and gynaecology. This aspect is particularly important, since there are now more female medical students, both graduate and non-graduate, as well as the significant effect of gender on career intention shown in this study. It is also the second most frequent suggestion made by participants to improve the specialty. It is important not to confuse student experience with their views on the specialty. For the last 6 years, Swansea students rated their attachment in obstetrics and gynaecology as their most enjoyable student attachment. This however, does not match their career intentions and their views of the specialty, as shown in this study. Improving the appeal of the specialty is more than looking after students while they are on obstetrics and gynaecology attachments. It is also possible that students change their mind having experienced other specialties and potentially more so as they graduate and start foundation years. The findings of this study should be considered within the context of its limitations. It was a questionnaire survey that covered an academic year in a single medical school, with a 60% response rate. While this rate may appear low, in reality, it is average for this form of research (Raszeja et al. 2013) Other research methods, such as interviews and focus groups, may have provided more information, but this study has given a body of information and suggestions to explore further through these more targeted methods. The work could be expanded to cover other medical schools and perhaps include comparison with standard entry students.
Conclusion The aim of this study was to explore the perceptions of graduate-entry medical students to obstetrics and gynaecology as a specialty, so as to understand how to increase its appeal to them, and therefore enhance recruitment to the speciality.
This study showed that 4% of graduate-entry medical students at Swansea Medical School see obstetrics and gynaecology as their first career choice, which is in-keeping with 3.3% of all graduates from medical schools in the UK who choose obstetrics and gynaecology as a career. Gender was the only factor that significantly affected the views of graduate-entry medical students towards the specialty, with more females in favour of obstetrics and gynaecology as a career than their male counterparts, which matches trends in applications for training placements in obstetrics and gynaecology from all graduates from medical schools in the UK. However, more than 50% of these students would consider the specialty as a second choice, which represents a real opportunity to increase recruitment to the specialty. This will depend on providing graduate-entry medical students with information about training opportunities in the specialty and exposing them to its varied range of special interest and subspecialist areas, where they can develop and utilise their skills, and potential role models, who may inspire them to take up the specialty as a career. Recognising and addressing perceived challenges in the specialty, such as working with midwives and the risk of litigation, can be achieved through open discussion, where medical students can voice their apprehensions and hear the actual experience of doctors of various grades within the specialty who benefit from the team skills to work well with midwives and apply risk management principles to deal with litigation. This can be arranged through career days, as well as formal tutorials within the teaching programme. Although not assessed in this study, these ideas may well also be relevant to standard-entry medical students. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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