Choices of careers in medicine: some theoretical and methodological issues
1996; Wiley; Volume: 30; Issue: 3 Linguagem: Inglês
10.1111/j.1365-2923.1996.tb00736.x
ISSN1365-2923
Autores Tópico(s)Medical Education and Admissions
ResumoMedical EducationVolume 30, Issue 3 p. 157-160 Free Access Choices of careers in medicine: some theoretical and methodological issues H Dohn, Corresponding Author H DohnHelge Dohn, University of Copenhagen, Department of Education, Philosophy and Rhetoric, Centre for Studies in Higher Education, Njalsgade 80, DK-2300 Copenhagen K, DenmarkSearch for more papers by this author H Dohn, Corresponding Author H DohnHelge Dohn, University of Copenhagen, Department of Education, Philosophy and Rhetoric, Centre for Studies in Higher Education, Njalsgade 80, DK-2300 Copenhagen K, DenmarkSearch for more papers by this author First published: May 1996 https://doi.org/10.1111/j.1365-2923.1996.tb00736.xCitations: 16AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Considerable scholarly attention has been devoted to choice of specialty by doctors. Can a coherent and generalized picture of the results so far collected be summarized meaningfully on the basis of theoretical foundations which underlie the research? A recent study (Dohn 1994), limiting itself to 250 references published between 1950 and 1994, highlighted the secular change in the literature on the factors which are supposed to be associated with the choice of specialty: 1950–70: Personality traits, attitudes and values, and socio-economic factors (including gender, age, place of upbringing). 1970–85: The effect of medical education (including the effects of admission policies, medical school characteristics, curriculum content and organization, teachers and the clinical parts of the study programme). 1985–95: The influence of debt and expected earnings, anticipated working conditions (including the characteristics of the future patients and responsibilities in patient care). In line with this tendency is a renewed interest in exploring the association of personality traits with the choice of specialty. In contrast to these trends some areas have attracted continuing attention; among these are the importance of gender and ethnic background. The changing priorities appear to reflect the contemporary predominant educational and psychological orientation. The large and increasing body of studies in this field presents a problem when attempting to summarize the findings. The most common method of establishing a synthesis of the findings is the traditional review, although the means and formats vary. The reviews by Hutt (1976), Mowbray (1989) and Davis et al. (1990) identify and categorize the factors which have been shown to be associated with specialty choice. Under each group the major findings in question are described, compared and evaluated in order to present an overview. Others review the literature with special attention to specific issues, e.g. the methodology of research (Anderson 1975; Zuckerman 1977), or the choice of specialty conceived as a vocational choice (Rezler 1969). An alternative approach taken by Ernest & Yett (1984, 1985) is to formulate a set of hypotheses for each category of factors in question; reported findings are then discussed to decide if they support the hypotheses. Irrespective of the format chosen there seems to be overall agreement between the reviewers as to the range of factors which are relevant for the specialty choice. Consensus does not extend to views on the priority of the factors and the interaction between them, the magnitude by which they contribute to the specialty decision, and the attached theoretical significance. Clarification of these issues will require: (1) a thorough evaluation of the research methodology of each of the studies; (2) a rigorous and standardized definition of the variables and concepts involved; and (3) an examination of the concepts underlying the studies. Mowbray (1989) on the basis of his review proposed that large scale multifactorial investigations should be carried out using multivariate analysis to establish the pattern of relationships between factors. However, on the basis of the findings of the studies already carried out it is questionable whether this approach will lead to coherent and clearcut conclusions. Meta-analysis represents an approach to the synthesis of the results of quantitative research which claims to achieve greater precision and objectivity than a traditional review. The technique used in taking the statistical results of independent studies, converting these results to common statistical metrics, combining and integrating these results is elaborated elsewhere (e.g. Hunter & Schmidt 1990; McGraw 1994). The criteria for including, weighting and integrating studies are a meta-analysis is also dealt with in the literature on this approach (e.g. Cooper 1984). Disregarding the magnitude and the complexitity of the task needed to process the findings according to meta-analytic procedures, there must be doubt about the validity of combining data collected during more than four decades under different conditions. There are also problems of process. Which is the 'definitive' meta-analytic procedure to be used? It has been shown that different meta-analyses of the same studies have yielded different conclusions. It has been questioned whether statistical hypothesis testing, and estimation of effect size, constitute a meaningful context for substantive interpretation. These problems bring to the foreground the theoretical foundation and epistemological orientation of the studies. Usually, medical specialty choice is conceived as an effect of personality and environmental factors or the effect of medical education as independent variables. From a traditional viewpoint the results of the effect can be quantified, statistically processed and presented on a common scale (Zuckerman 1977). The theoretical model for investigations on specialty choice according to this approach may be termed the Single Factor Model. On the one hand this model can be characterized as a meta-theory and, on the other, as a research-design. In the latter capacity the model can include more elaborated approaches, e.g. research designs using multiple discriminant analysis (Watson & Croft 1978), or exploring the relationship between groups of variables (Weil & Schleiter 1981). In contrast to the predominant almost atheoretical approach of most studies, a few studies are based upon assumptions and hypotheses derived from general theories of vocational choice, theories of socialization and role-model functions, psychoanalytic theories, and theories of social and educational selection (e.g. Anderson 1975). Hadley (1977, 1979) described the relationships between independent and dependent variables utilizing an economic–mathematical theory. The underlying assumptions were that specialty choices can be conceived as a labour market allocation process and that a search for utility maximization (the balance between the returns and costs) govern the choice of a medical specialty. The results did not demonstrate convincingly the importance of expected income on decision-making. Later studies (Geertsma & Romano 1986; Silliman et al. 1987; Ebell 1989; Fincher et al. 1992; Rosenthal et al. 1992) indicate that expected income and debt are significant factors, while other studies disagree in both respects (Lieu et al. 1989; Rogers 1990; Kassebaum & Szenas 1992). The Single Factor Model is an efficient way to test and predict relationships between the independent and dependent variables. On the other hand, the model and the studies which are based on it have major limitations: subjective and objective variables regarded as the same, e.g. specialty preferences and actual specialty choice; specialty choice regarded as a single event rather than a process. The model promotes a kind of conservatism in the design of studies because the independent variables chosen tend to be conventional psychological, sociological and educational features. An alternative approach is the Cognitive–Psychological Model proposed by Mitchell (1975). It conceives the making of career choice decisions by medical students and doctors as a process in which they seek optimum matches between the career alternatives open to them and their own preferences and life circumstances. The major elements in this process are envisaged to be the personal characteristics of the doctors and their underlying cognition in selecting relevant information from the environment. The Cognitive-Psychological Model has never been tested empirically; one reason is that it is difficult to deduce testable consequences from a model which is in itself explanatory. However, findings from other studies can be interpreted using the model as a frame of reference. It has been shown (e.g. Otis & Weiss 1973; Gough 1975a, b) that specialty preferences at the beginning of medical education are directed towards broad categories of specialties (except for surgery and psychiatry). The model regards specialty choice as a series of matching processes. Different alternatives are considered which eventually lead to selection of more narrow career 'niches'. This process is reflected in the findings reported in many studies that the consistency of the preference is low when a precise specialty is compared with the actual specialty choice, and much higher when looking upon groups of related specialties (e.g. Rothman 1985; DeForge & Sobal 1991). Another aspect of the model relates to the impact of personal characteristics on the selection process. The model presumes that the choice of specialty is a result of a match between students' and doctors' concepts of a specialty (its ethos) and their image of themselves and their values and attitudes: some studies indicate that kind of relationship (e.g. Bruhn & Parsons 1964, 1965; Linn & Zeppa 1980). In this respect the model may be generalized and used to explain the reported association between personality traits and specialty selection and, additionally, that certain personality traits act as a dynamic factor in speciality choice decisions. As an example, in many studies choice of surgery is associated with an authoritarian trait and with low tolerance for ambiguous situations (e.g. Coker et al 1965; Waton & Last 1969; Mowbray & Davies 1971; Matteson & Smith 1977). Some investigators have used a Sociological Model to examine factors outside the medical school. The theory behind the model was proposed by Funkenstein (1971, 1978) who also tried to verify it empirically. Five societal eras (since 1910) were related to the career orientation and preparation of students. The students and their career-orientation were divided in two main categories termed bio-social and bio-scientific. The hypothesis put forward was that students belonging to each category would choose different career orientations during different eras. Important determinants were postulated to be the admission policy to medical schools and the role-models provided by the clinical teaching staff. The model has been criticized on the grounds of its empirical foundation and the underlying data analysis (e.g. Sherman 1978). Also, it is doubtful that the classification of the students' as bio-social or bio-scientific is independent of the definition of the various societal eras. The magnitude of the fluctuations predicted in career orientation predicted by this model is not substantiated by other studies from the period covered by the five societal eras or by later longitudinal studies (e.g. Weiskotten et al 1961; Babbott et al. 1988, 1989). This does not preclude the possibility that the changing social ideology of society and of medical schools plays a part in specialty preferences and may account for, among other factors, the inconsistency reported in many studies. In spite of the disputed empirical evidence, the importance of the mechanisms which the model pointed out as regulating the students' career orientation gets some support from other studies. As an effect of the admission policy to medical school on the choices of specialty it has been demonstrated that students with high pre-medical grades in science tend to prefer surgery, anaesthetics or pathology whereas students with a strong background in social science prefer general medicine (e.g. Gough 1978; Nieman et al. 1986). Furthermore, the role-model impact of clinical teachers has been shown to have an impact upon the choice of specialty (e.g. Rogers et al. 1989; Mattsson et al. 1991). These two mechanisms seem to be more decisive than other educational factors, such as the institutional characteristics of the medical school, curriculum content and organization. From the literature on the subject of specialty choice an array of individual and interrelated factors have been described. The magnitude of the effect of the factors varies across the studies, implying that the validity of the results may be questioned. One response is to advocate further studies which meet the requirements of biomedical research and to subject previous studies to meta-analysis. In both cases the underlying concept is of stable determinants of choice. The meta-analytical approach in particular disregards the idea that choice in its very nature is contextual, and that specific time, place and mode constitute integral components of choice. In contrast an idiographic approach emphasizes choice as a conscious process in context leading to a decision between career alternatives. This approach seeks to characterize the decision-making process of individuals and to relate it to the resultant career choice. REFERENCES Anderson R B (1975) Choosing a medical specialty: a critique of literature in the light of 'curious findings'. Journal of Health and Social Behaviour 16, 152– 62. 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Google Scholar Citing Literature Volume30, Issue3May 1996Pages 157-160 ReferencesRelatedInformation
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