Abstract
Background:
The primary influence on medical students’ career choice is their third-year clerkship. However, orthopaedics is not a required rotation in the curriculum of most medical schools. Our goals were to identify factors that motivate students to choose an orthopaedic career and to compare these with the factors that influence students to choose nonorthopaedic disciplines.
Methods:
Fourth-year medical students and orthopaedic residents at the postgraduate year (PGY)-1 level at eight orthopaedic training programs in the United States were surveyed to determine the reasons that they chose orthopaedics instead of other medical or surgical fields.
Results:
Of the 622 individuals who responded to our survey, 125 were entering orthopaedics and 497 were not. Although career choice in both groups was most heavily influenced by third and fourth-year clinical rotations and faculty contacts, orthopaedics-bound respondents were more likely than non-orthopaedics-bound respondents to be strongly influenced by experiences and people prior to medical school. Orthopaedics-bound respondents were less likely to report a faculty member as the most important person influencing career choice. Fifty-one percent (sixty-three) of 124 students who selected orthopaedics had already decided to pursue this field prior to their third-year rotation. Patient care was chosen by 71% (347) of 490 non-orthopaedics-bound respondents and 75% (ninety-four) of 125 orthopaedics-bound respondents as the most important factor for pursuing a particular field. Income was not selected as the deciding factor by respondents in either group.
Conclusions:
Although faculty contacts and third-year clinical rotations played an important role in student selection of specialty training, they were less influential for those choosing an orthopaedic career than for those choosing other disciplines. Many students choosing orthopaedics made this decision prior to medical school. We believe that increased exposure to positive clinical role models and experiences during medical school would enhance medical students’ options for choosing orthopaedic surgery as a career. Anticipated income did not play a deciding role in career selection.
Orthopaedic surgery is a desirable and sought-after profession for graduating medical students. The “match” is highly competitive, with the number of applicants being greater than the number of positions offered annually1. However, current literature shows that the primary influence on medical students’ choice of a career is their third-year clerkship2. This has concerning implications for the orthopaedic profession since it has been reported that 45% of medical schools do not require education in any form of musculoskeletal medicine3, including orthopaedic surgery. Given such a lack of exposure to orthopaedics in medical school, we sought to examine what was attracting students to apply to orthopaedic residency programs.
Prior studies have emphasized the importance of role models and clerkship experiences on medical students’ career choice4-9. To the best of our knowledge, there have been no investigations that looked specifically at the factors that influence medical students to pursue orthopaedics. Our goal was to identify factors that motivated students to choose an orthopaedic career and to compare these with factors that motivated students entering nonorthopaedic disciplines. We hypothesized that medical students who choose orthopaedics as a career were doing so on the basis of a substantially different set of motivating factors compared with their peers who did not choose orthopaedics.
We conducted a multicenter study of fourth-year medical students and orthopaedic residents at the postgraduate year (PGY)-1 level at eight programs in the United States; these students were surveyed to determine the reasons that they chose orthopaedic surgery or other medical careers. We also included students from additional schools who interviewed with us for an orthopaedic residency position.
Study Subjects
Data were collected from fourth-year medical students entering orthopaedics and nonorthopaedic fields as well as from PGY-1 orthopaedic residents. The PGY-1 orthopaedic residents were asked to participate because we recognized that the number of fourth-year students entering orthopaedics was relatively low, and we thought that the first-year orthopaedic residents could still accurately recall the factors that had motivated them to pursue an orthopaedic career. Fourth-year medical students and PGY-1 residents were identified through coinvestigators at eight United States medical schools. Coinvestigators at these schools were individually contacted by the principal investigator based solely on previous professional working relationships and without knowledge of the individual school curricula. Institutional review board approval for the study was obtained individually from each institution. The study information was sent from each school’s coinvestigator to the school’s Dean of Student Affairs, who electronically forwarded it to all fourth-year medical students. PGY-1 orthopaedic residents were contacted by the coinvestigator at each training program and received the study information similarly. Fourth-year medical students who interviewed for an orthopaedic residency position at the principal investigator’s institution were also identified as potential subjects and were sent the study information and a link to the survey via email.
We used a research design involving a web-based computer survey, which was formatted with use of the website http://www.surveymonkey.com. We divided our subjects into two groups: Group 1, consisting of fourth-year medical students who were pursuing nonorthopaedic specialties; and Group 2, consisting of PGY-1 residents in orthopaedics and fourth-year medical students who were pursuing orthopaedics. Figure 1-A represents the questions asked in the survey. We included all students who completed survey question number one, which asked what medical field the student was going into, as this was the only criterion used for placing the respondent into Group 1 or Group 2. We did not exclude surveys that omitted any of the other questions; no students were excluded on the grounds of an incomplete submission if they responded to the career choice question. All of the residents (both orthopaedic residents and PGY-1 candidates applying for an orthopaedic position) were included as they were by definition in Group 2.
In addition to the students’ responses to the questionnaire, we also evaluated the corresponding medical school curriculum at each of the eight participating schools. Each school’s contact was asked to complete the questions listed in Figure 1-B. The information from the schools was correlated with the responses on the surveys.
Statistical Methods
We initially performed a chi-square analysis to compare the two groups, and our initial sample size was determined to provide 80% statistical power to detect a difference between the two groups (0.45 compared with 0.60) at a significance level of p = 0.05 (two-sided). The sample size was estimated to be 400 respondents in Group 1 and 148 in Group 2. This analysis was based, in part, on data previously collected during a pilot study at one of the participating institutions10. However, on further discussion with an independent statistician, we determined that this original analysis was not valid because of the small number of medical schools included, and we chose to present the data as a percentage and thus perform a descriptive study.
Source of Funding
There was no external source of funding for this study.
Of the 622 medical students and residents who responded to the survey, 497 were not orthopaedics-bound (Group 1) and 125 were (Group 2). Our overall response rate was 46% (618 of 1354). Four additional students from schools not listed on the survey could not be included in the response rate calculation but were included in the study because they answered the career choice question. Group 1 had a response rate of 41% (493 of 1197) plus the four additional students from unlisted schools. Group 2 had a response rate of 80% (125 of 157). No respondents were excluded on the grounds of an incomplete survey as long as they answered the question regarding the field of medicine they were going into; therefore, there was some variability in the number of respondents to each question.
Influences on Career Choice (Figure 2)
Respondents were asked when, by whom, and by what they were most influenced regarding their career choice. In Group 1, 15% (seventy-six of 495) were most influenced to pursue their field of choice by experiences prior to medical school compared with 27% (thirty-four of 125) in Group 2. In Group 1, 26% (127 of 493) stated that “they pretty much knew what field they wanted to go into prior to medical school,” compared with 32% (forty of 124) in Group 2.
The person who had the most influence on the student’s residency choice was reported to be someone they had met prior to medical school by 6% of the non-orthopaedics-bound respondents (thirty-two of 495) and 18% of the orthopaedics-bound respondents (twenty-one of 120). Both groups’ decisions regarding the type of residency program they chose were most influenced by medical school years three and four (73% [361 of 495] in Group 1 and 60% [seventy-five of 125] in Group 2), with Group 1 being more influenced by medical school years three and four compared with Group 2. Faculty in medical school had the largest personal influence on respondents in both groups, as stated by 57% (282 of 495) in Group 1 and 41% (forty-nine of 120) in Group 2. Residents were stated to be the most influential by fewer non-orthopaedics-bound respondents (21% [106 of 495]) than orthopaedics-bound respondents (36% [forty-three of 120]).
Demographics (Figure 3)
The non-orthopaedics-bound respondents were 45% male (222 of 494) and 55% female (272 of 494), whereas the orthopaedics-bound respondents were 84% male (105 of 125) and 16% female (twenty of 125). An orthopaedic surgery residency was chosen by 7% of all female medical student respondents (twenty of 292). Twenty-nine percent of respondents in Group 1 (145 of 492) were married compared with 42% in Group 2 (fifty-three of 125). In Group 1, 25% of the women (sixty-nine of 272) were married compared with 34% of the men (seventy-six of 222). In Group 2, 25% of the women (five of twenty) were married compared with 45% of the men (forty-seven of 105). However, the data for Group 2 were underpowered with regard to female orthopaedic students (n = 20) and should be interpreted with caution. We would have needed sixty female orthopaedics-bound students to reach a statistical power of 80%. Respondents with children represented 10% of Group 1 (fifty of 492) and 16% of Group 2 (twenty of 124). The majority of respondents in both groups were White (80% [386 of 480] in Group 1 and 79% [ninety-five of 120] in Group 2). Students pursuing combined MD and PhD degrees were nearly equally distributed between groups (3% [seventeen of 497] in Group 1 compared with 2% [three of 124] in Group 2).
Effects of Medical School Curriculum (Figure 4)
Questions regarding the impact of required and/or elective orthopaedic rotations on career choice were also asked in the survey. One-third to one-fourth of respondents had a required rotation in orthopaedics during their third year of medical school education (33% in Group 1 [165 of 495] and 28% [thirty-five of 124] in Group 2). In the orthopaedics-bound respondents (Fig. 4), 51% (sixty-three of 124) had already decided before their rotation that they were going into orthopaedics, and 41% (fifty-one of 124) made the decision to go into orthopaedics after rotating through the specialty. An orthopaedics rotation (required or elective) was completed by 50% of the respondents in Group 1 (249 of 497) compared with 99% in Group 2 (123 of 124). Many respondents in Group 1 decided against orthopaedics after having taken the rotation (44% [199 of 453]); however, 7% (thirty of 453) were interested in orthopaedics but did not think that they could match into the residency.
We obtained data directly from each school’s administration regarding their students’ orthopaedic rotations using the questions listed in Figure 1-B, and we analyzed these data to evaluate the school’s required and elective orthopaedic curriculum as well as the percentage of students at the school who applied to orthopaedics. The percentage of students at the eight schools who applied for an orthopaedic residency ranged from 0% (0 of 100) to 8% (eighteen of 225). There was no significant difference between schools that had a required orthopaedic rotation (of any duration) and schools that did not. Additionally, there was no difference between schools that had required musculoskeletal education in the first and second years compared with those that did not.
Factors in Career Choice (Figures 5 and 6)
All respondents were asked to rate the importance of income on their career choice on a five-point scale, with 1 being the least important and 5 being the most important (Fig. 5). The mean for non-orthopaedics-bound respondents was 2.36 compared with 2.85 for orthopaedics-bound respondents. We also asked students how much debt they had accumulated, with the choices being zero debt, up to $50,000, between $50,000 and $100,000, between $100,000 and $200,000, and greater than $200,000. The two groups had a similar amount of debt. Only 15% of the respondents in Group 1 (seventy-six of 491) and 12% in Group 2 (fifteen of 125) had less than $50,000 of debt from medical school. However, when asked what influence this debt had on their career choice, more than one-half of each group (56% [277 of 494] in Group 1 and 52% [sixty-five of 125] in Group 2) stated that it did not influence their decision to pursue a particular field. Patient care was stated by 71% of the respondents in Group 1 (347 of 490) and 75% in Group 2 (ninety-four of 125) to be the most important factor for pursuing a particular field (Fig. 6). Income was not chosen by any respondent in either group as the deciding factor.
Sex Differences (Figure 7)
A subgroup analysis compared the 105 men and the twenty women who were going into orthopaedics. Fifteen percent of the female applicants to orthopaedic surgery programs (three of twenty) had known that they wanted to pursue this field prior to medical school compared with 35% of the male applicants (thirty-seven of 105). Eighty percent of the female applicants to orthopaedics (sixteen of twenty) had their most important influence during years three and four compared with 56% of the male applicants (fifty-nine of 105). Fifty-five percent of the female applicants (eleven of twenty) stated that the individual who influenced them the most to pursue orthopaedics was a faculty member compared with 37% of the male applicants (thirty-nine of 105).
Most medical students have little to no formal exposure to orthopaedics as a career opportunity during medical school. Bernstein et al.3 demonstrated that only 55% of graduating medical students had any form of mandatory instruction in musculoskeletal medicine, including orthopaedics, rheumatology, and physiatry. Of the students and residents in our study, only 32% had a required rotation in orthopaedics. Given that previous literature reported the importance of third-year clinical rotations in medical student career choice, orthopaedics would appear to be at a competitive disadvantage in recruiting students to the profession. We sought to better understand those factors that resulted in students electing to pursue an orthopaedic career.
Our data indicated that a substantial proportion of medical students who pursued orthopaedics made their career choice prior to medical school. Almost twice as many orthopaedic respondents (27%) as non-orthopaedic respondents (15%) were most influenced prior to medical school. Additionally, 51% of students who applied to orthopaedics had made this decision before their orthopaedic clerkship. Those who did make their decision during medical school were similarly influenced by faculty and by residents during their orthopaedic clerkship, findings that are similar to those of other investigators who have evaluated the influence that residents can have on students’ career selection9. In contrast, the majority of students pursuing all other fields were most influenced by faculty during the third and fourth-year clerkships.
The results of this study were consistent with a common perception among orthopaedic faculty, based on the personal statements of residency applicants, that students’ interest in orthopaedics is often based on their previous personal interaction as a patient with an orthopaedist. For 27% of the respondents in Group 2, their major influence was prior to medical school. We believe that this reflects positively on our profession and that it demonstrates the potential for orthopaedists to serve as role models and to inspire others to follow in our footsteps. However, we do not know whether orthopaedic residents decide on a career prior to medical school because they are positively influenced at that time or whether it only appears that way because there is no opportunity to obtain orthopaedic exposure in medical school.
Orthopaedic students rated the importance of income more highly than nonorthopaedic students did, as reflected largely by the distribution of scores of 1 and 3, which reflected low to average importance of income on career choice (Fig. 5). There was not a large difference in the number of respondents choosing scores of 4 and 5, which indicated a strong influence of income potential on the choice of career. When respondents were asked to identify the most important factor in selecting their field of interest, patient care was chosen by the majority of both groups, with no significant difference between the groups. Although a recent report indicated that financial considerations were more likely to be rated as the most important factor in the group with the most debt (>$150,000)11, the results of our investigation did not correspond with this. Cumulative debt exceeded $100,000 in the large majority of both groups. However, debt did not play a meaningful role in either group’s career selection.
It is well known that women are a small minority in orthopaedic surgery4. Many women are not exposed to orthopaedics, and they have preconceived notions about the role of women in the field4. Of the 292 female respondents to our survey, only 7% chose orthopaedics. The proportion of women choosing orthopaedic surgery as a career has not changed much over the past twenty years. From 1970 to 2001, the number of female medical students increased 36.7%, whereas there was only an 8.4% increase in the percentage of women in orthopaedics. The field has not had as much success as other surgical specialties in recruiting women, as the numbers have seemingly leveled off over this time period12.
We were surprised to find differences between men and women regarding their reasons for going into orthopaedics. More than twice as many men as women knew that they were going into orthopaedics before medical school. Additionally, 80% of female applicants to orthopaedics compared with 56% of male applicants had their most important influence during years three and four in medical school. Female applicants were also much more likely to be influenced by faculty members compared with male applicants. We were pleased to see the positive effect of clinical rotations in years three and four and the influence of faculty members, suggesting that the clinical environment and orthopaedic educators in this study were supportive of women entering the profession. This would suggest, therefore, that a strategy to increase the representation of women in orthopaedics would include providing early exposure to orthopaedics in medical school and encouraging women to consider an orthopaedic career.
We found no significant difference between MD/PhD students who entered orthopaedics compared with other fields of medicine. It appears that recruiting more MD/PhD students into orthopaedics would require that more students in the general medical school population pursue this type of study3. Additionally, we found no difference in ethnic diversity between the two groups, leading us to conclude that an important step in increasing ethnic diversity in orthopaedics will be to increase the diversity in the medical school population at large.
There are several limitations to this study. Women are unfortunately such a minority in orthopaedics that, despite surveying 622 people, we were only able to evaluate twenty female orthopaedic applicants, and this must be taken into account when evaluating the data from the women respondents. We also surveyed and evaluated only a small proportion of the orthopaedic residency programs in the United States. Performing a similar study with a broader base of medical schools, medical students, and PGY-1 orthopaedic residents along with more in-depth statistical analysis could possibly provide a larger sample of female applicants and also information that would be more generalizable to the field as a whole. Because of this limitation involving the number of schools surveyed, we chose to focus on describing the trends that we obtained during our data analysis instead of stressing statistical significance. Additionally, this study was based on a survey asking students to recall the reasons for their residency choices. This would have been based on subjective data and memory recall. We did take this into consideration when designing our study, which is why we only included fourth-year medical students and orthopaedic PGY-1 residents. We believed that they would have been more likely to accurately recall why they chose their given field than upper-level residents who were further away from the time when they had made that decision. We also realize that such decisions tend to be multifactorial. Although we attempted to address several such factors in our study, identifying all such factors was not possible. Additionally, the orthopaedic group contained residents but the nonorthopaedic group did not, which may be a source of bias. The response rate was also much higher in the orthopaedic group than in the nonorthopaedic group, which could also be a source of bias.
For many years, orthopaedics has been one of the most competitive residencies in the match. Our study demonstrated that the factors that influenced students to pursue orthopaedics were substantially different from those that influenced the remaining group of students, and that motivating factors were different for the female orthopaedic students than for the male students. We find nothing wrong with students becoming interested in orthopaedics on the basis of experiences prior to medical school. However, we believe that it is in the best interests of both the students and the profession to provide every student with an opportunity to consider orthopaedics as a career. We recognize that required orthopaedic rotations do not exist in many medical schools, and we recommend that orthopaedic departments actively meet with students as often as possible to provide them with an understanding of orthopaedic career opportunities and to allow them to make the most informed decision. This may occur in a variety of formats, including orthopaedic interest groups, teaching of first-year anatomy, and establishment of shadowing programs. Finally, we believe that improvements in the diversity of the orthopaedic work force will be dependent in part on improved exposure to orthopaedics for all students during medical school. In the absence of such an approach, many talented students may never consider orthopaedics as a career option.
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.