Factors affecting physicians’ specialty selection: A demographic and socioeconomic perspective

INTRODUCTION

The medical field is expanding rapidly in the direction of meticulous specialization and fine fragmentation of knowledge, research, technology, methods, diagnosis, and treatment. Medical specialization options have diversified and expanded since the gradual development of the modern specialty system in the 19^th century,^[1] which in some cases reached staggering numbers, as in the case of the United States medical training system, where more than 150 specialties are accredited by the American Board of Medical Specialties.

Global and regional statistics indicate that most medical graduates go on to pursue specialist training rather than practice general medicine after obtaining their license.^[2,3] According to the latest data, the Republic of Sudan has more than 66 medical schools, with around 5000 doctors graduating every year,^[4] while the Sudan Medical Specialization Board currently enrolls over 4000 residents in more than 33 different specialties.^[5]

The progressing nature of the field necessitates a well-adjusted, practical distribution of physicians among specialties to achieve quality healthcare. Certain specialties face persistent workforce shortages, and some are highly competitive and oversaturated. Understaffed specialties will inevitably encounter difficulties in health-care provision and scientific progress, and overstaffed specialties will lead to financial implications and suffer health-care provision obstacles such as increased competition for jobs and reduced opportunities for professional development.

Each specialty offers a diverse spectrum of trade-offs that befits the variable preferences of physicians. While some specialties are considered to be high demanding and stringent, like in the case of orthopedic surgery and emergency medicine,^[6,7] they still endure significantly high enrollment competition rate.^[8] On account of this, it is evident that individual factors play a key role in the process of specialty selection.

The decision to undergo a particular specialty training is fundamentally unstable and depends on many influencing factors. This decision reshapes the lives of physicians and impacts the performance of the medical specialties. Ultimately, the impact can be far-reaching and affect society as a whole. To achieve optimal health care across all specialties, we must look for the factors that influence this decision and seek to optimize accordingly.

Less is known about the role of socioeconomic factors in shaping the career choices of medical graduates, particularly in terms of their choice of medical specialty. In this study, we investigate the potential role of socioeconomic factors in influencing the career trajectories of future physicians, health system in general. Ultimately, this research has the potential to inform efforts to promote greater diversity, equity, and practicality within the medical specialty domain.

MATERIAL AND METHODS

This is a cross-sectional and descriptive study.

RESULTS

The associations between the demographic and socioeconomic status indicators and specialty preferences

Female physicians exhibited a significant tendency toward choosing obstetrics and gynecology, and pediatrics as their main line future career preference, while male physicians were more abundant among those who are willing to specialize in surgical specialties, as illustrated in Figures 1 and 2 (P=.000579, P ≤ 0.01 respectively). There was no significant relationship between age nor ethnicity and chosen specialties. The majority of the married and divorced physicians chose family medicine and/or its’ branches as their specialty of interest (P ≤ 0.01).

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Figure 1:

The distribution of genders among surgical and non-surgical specialties.

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Figure 2:

The distribution of genders among obstetrics and gynecology and pediatrics as main specialty path.

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Family income was found to be associated with the rationale of the physicians behind their specialization path decision, where we found that those with family income below mean have salary as their main reason behind their decision while the ones whom reported family income above mean had clinical interest/stimulation and work/life balance as their main reason along with other reasons (P ≤ 0.01). The majority of the physicians who were able identify their subspecialty choices had higher family income.

The associations between Kuppuswamy scale findings and specialty preferences

Obstetrics and gynecology and family medicine were found to be significantly associated with below mean Kuppuswamy score (P = 0.010359) and surgical specialties were associated with relatively high score (P ≤ 0.01). Most of the physicians whom were able to identify their future subspecialty and further choices had above mean scores (P = 0.022179). Salary and work/life balance as reasons behind the physicians’ specialization decision were associated with physicians with blew mean scores (P = 0.015037). Figure 3 illustrates the significant associations between mean Kuppuswamy scores and different main line specialization choices.

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Figure 3:

Specialties with significant associations with mean Kuppuswamy scores.

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DISCUSSION

Specialization in the practice of medicine became an essential obligation to compensate and manage the great expansion of medical knowledge and technologies. Since the unification of medicine with surgery, the medical field, like other scientific fields, is heading toward the direction of increasing specialization of labor, knowledge, and expertise.

Specialization conveys fundamental advantages to the medical practice, including higher quality care and focused, thus more efficient medical research. However, some scholars find the rapid increase in specialization to have potential serious drawbacks, challenges and limitations like the fragmentation and discontinuity of care, higher healthcare costs, coordination difficulties between specialties, and increased length and cost of training.^[3] As our study illustrated, almost all of the physicians are willing to undergo specialty training instead of practicing general medicine or providing primary health care in general, which coincide with a lot of recent regional and national studies that discovered a significant decline in the number of general practitioners despite the rising number of physicians.^[15,16]

The diversity and variance of specialization options inevitably result in differing degrees of favorability and preference among physicians along with their individual circumstances. Specialization preferences influence workforce staffing and consequentially, the quality and development of particular specialties. Specialization trends vary from one country to another, and sometimes from region to another within the same country. Obstetricians and gynecologists are in limited supply in Ireland, whereas anesthesiologists and psychiatrists are in low supply in Bulgaria and Turkey,^[17] and the United States of America is facing severe shortages in critical care medicine and endocrinology among other specialties that are overstaffed in other countries.^[18]

Undertaking a certain specialty as an ultimate career development path is governed by numerous variables that scholars are still trying to identify and find methods to control. One study found that a potential specialization preference was expressed by less than half of the students 40.2%, while, in our study, only 0.5% of physicians did not express any preference, which can be attributed to factor of seniority, which the aforementioned study found that senior students and having background about specialties were the significant factors for career choices.^[19]

Gender appears to be a major factor in specialties’ workforce distribution as we found in our study that female physicians exhibited a significant association with choosing obstetrics and gynecology, and pediatrics as their main line future career preference while majorly male physicians prefer surgical specialties. This coincides with the findings of a study concerning gender segregation in medical specialization in the United States of America, where they found that the fields of pediatrics and obstetrics and gynecology are female dominant, while surgical specialties are male dominant. They also found a strong negative correlation between the presence of female physicians in a specialty and its salary, which concur with our findings.^[20]

In this study, we found that salary, work/life balance, and clinical interest were the most common reasons the physicians’ specialty decision. Another study found that medical students tend to consider lifestyle factors more than other factors when choosing a specialty and the majority of which usually choose specialties that allow the physician to control the number of hours devoted to practicing the specialty.^[21] Salary being the most prominent influencer in specialization raises many questions about the possibility of a major role of countries economic status and salaries system in physicians’ specialty selection decision. One study found that the number of working hours, the duration of training, observed covariates, and unobserved skill differences do not explain the difference in average annual income between specialists and general practitioners.^[22]

Some studies sought novel approaches to identify the factors behind the specialty selection decision, with some of them succeeding in discovering significant associations. Carol Elam applied Holland’s theory of vocational personalities and work environments to find patterns of vocational personalities in various specialty decisions among medical students. Elam found that Investigative and Realistic students tend to choose surgical specialties as future careers and fewer Artistic and Social students tend to do so, while Realistic and Enterprising personalities tend to select radiology, among other findings.^[23] Another study utilized marketing research models to examine the specialty selection process to find that male medical students considered surgical specialties to be interesting and challenging while deeming pediatrics and family medicine to be “boring.” They also found that 70% of female students responded that the ability to have a manageable lifestyle was the most important selection criterion, and the majority of which chose obstetrics and gynecology to be their specialty if choice.^[24]

Internal medicine was the most frequently chosen specialty as a possible main line career path. This could be explained by the fact that internal medicine is a generalized specialty that provides training in multiple specialty departments and represents a base ground for further particular specialization later on.

We found in this study that both subjective and objective SESes have significant associations with the physicians’ specialty preferences. The physicians who chose surgical specialties had higher scores in both Kuppuswamy and subjective SES scales, while physicians who chose family medicine and obstetrics and gynecology had below mean scores in both scales. We attribute those findings to the cost of training, the adjustability to modifiable lifestyle factors and the potentiality of practicing privately in family medicine and obstetrics and gynecology, which might also explain the load of the married and divorced physicians choosing family medicine as their main specialty choice as shown in our study.

CONCLUSION

As the results of this study shows, the demographic and socioeconomic factors have a potent impact on physicians’ decisions on their future specialization paths. Identifying the significance and magnitude of such factors will facilitate an impartial and practical distribution of physicians on different specialties through the adjustment of specialties’ characteristics to match to variables that affect the physicians’ specialty selection decision.