The factors contributing to career indecision in doctors - A research project
Written by Dr Ashe Coxon
As part of my Masters of Clinical Education I did a small research project on Career indecision in doctors. This project was done in 2016 and although it was a few years ago now (I can't believe how time flies!), the themes that I found are still commonly experienced by the doctor I coach.
My study found that there were six main themes identified with the most common factors contributing to career indecision being;
- A lack of exposure to a variety of specialties, and
- Lifestyle and family considerations.
The remaining factors were;
- Negative previous experiences
- Advice from other people creating indecision
- Obstacles of hospitals and training programs, and
- Long-term uncertainty about medicine in general as a career choice.
The full findings are outlined below. Please note this article has not been published in a journal, but was part of a Masters by research qualification.
Abstract
Objective: To explore the factors contributing to specialty pathway choice indecision in Australian doctors.
Methods: This was a qualitative study utilising semi-structured, in-depth interviews with seven Australian doctors who were undecided on their career pathway within medicine. Interview questions addressed their personal experience on what contributed to their indecision on what specialty career to pursue. Interviews were audiotaped, transcribed, and thematically analysed after informed consent.
Results: Six themes were identified with the most common factors contributing to career indecision being;
- A lack of exposure to a variety of specialties, and
- Lifestyle and family considerations.
The remaining factors were;
- Negative previous experiences
- Advice from other people creating indecision
- Obstacles of hospitals and training programs, and
- Long-term uncertainty about medicine in general as a career choice.
Conclusions: Indecision around specialty career choice can be a daunting and isolating experience for a doctor. Many doctors have dedicated significant time and made many sacrifices to qualify as a doctor. Not all doctors are certain of their career pathway and not all doctors will manage to discover their specialty of choice without external assistance. Having knowledge of what factors contribute to a doctors’ indecision may assist those giving career advice and pastoral care to doctors to have a better understanding of the factors contributing to indecision and how to best assist.
Introduction
On graduation from university, doctors are left with the potentially difficult decision of choosing a specialty postgraduate area. The Medical Board of Australia currently recognises over 80 medical specialty areas1, not including non clinical medical careers. With such a large number and diversity of specialties it is predictable that some doctors have difficulty making their decision on which pathway to pursue. Specialty choice career indecision is commonly experienced by doctors with many reporting a lack of support during their decision making and a desire for more accessible career guidance2,3. Research has shown that 20% of fourth year postgraduate (PGY) doctors were still undecided on a career pathway 4 with less than 50% of PGY 3 doctors regarding their career choice as definite5. Doctors also report wanting better career advice throughout their training to assist in specialty choice, with 95% of PGY1 doctors wanting career advice at this stage of their training.6
Research has been published on the factors that contribute to a doctor choosing a particular specialty pathway, findings suggesting that the personal attributes of the doctor were the largest influencer of specialty choice, followed by work factors4. The most important work factors were
- Work culture in the specialty
- Work experience since graduation
- Opportunity to work flexible hours
- Influence of consultants and mentors
- Hours of work within the specialty and
- Career information and support (4, 7).
A hypothesis is that the factors contributing to why a doctor chooses a specialty may potentially be similar to the factors leading to career indecision, but there is currently no published research on the latter.
A considerable proportion of doctors’ report experiencing career indecision (4, 5, 6) yet the reasons behind this are currently unknown. The aim of this study was to identify the factors contributing to career indecision in Australian doctors.
Methodology
Ethical considerations
Ethical approval was granted from the Flinders University Social and Behavioural Research Ethics Committee (Project Number 7329).
Research design
This project utilised qualitative research methods that collected data through semi-structured, confidential telephone interviews with informed consent.
Study Participants
Participants were recruited using purposive sampling techniques targeting doctors who are working in Australia and yet to complete a specialty training program. Recruitment occurred through a private social media forum which has over 4,000 members who are all doctors, and all members were invited to participate in the study if they were experiencing career indecision. The social media page is a support page for parents who are doctors, so all participants are parents. The inclusion criteria for the study was being a doctor and being undecided on a career pathway.
Data collection method
The data was collected by telephone and Skype interviews. All participants provided informed consent and interviews were recorded using a digital voice recorder. Interview questions aimed at establishing the individual factors that led indecision. Each interview lasted between 30 – 45 minutes.
Data analysis
All of the interviews were transcribed verbatim by the Principal Researcher and re-checked for accuracy to enable data immersion. The transcripts were then reviewed and thematically coded. Saturation of the major themes was reached by the 4th interview and no additional themes were uncovered in the remainder of the interview transcripts.
Results
There were seven participating doctors with postgraduate experience varying from second to tenth year postgraduate. There was a range of experiences with some participants yet to start any specialty training and some participants were on a training pathway but still undecided if this was the correct pathway for them. All participants were parents and the participants were all female.
There were open-ended questions asked of each participant (Table 1), with additional questions asked depending on the answer to the previous question to further examine the previous answer. The questions were formulated in response to the literature All participants were asked initially “Have you decided on a career pathway within medicine?” to confirm eligibility.
Table 1 - Interview questions
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Have you decided on a career pathway within medicine? |
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Why do you think you are yet to decide on a career pathway? |
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Have you previously felt like you knew which path to pursue? |
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Do you feel like there have been any experiences that have impacted on your current indecision? |
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Do you feel any pressure to decide on a career pathway? |
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Have you sought any specialty pathway career choice advice? |
Saturation of the major themes was reached by the 4th interview and no additional themes were uncovered in the remainder of the interview transcripts.
There were six major themes identified and they are as follows:
- Lack of exposure to a variety of careers
- Lifestyle and family consideration
- Long term uncertainty about medicine in general as a career choice
- Negative previous experiences
- Advice from other people, and
- Obstacles of hospitals and training programs.
Lack of exposure
The most frequently cited factor contributing to indecision regarding a specialist career pathway was a lack of practical experience in different medical areas. Several of the participants spoke about having repetitive exposure to traditional medical careers throughout medical school and in their resident medical years, particularly Emergency Medicine, Paediatrics, Obstetrics and Gynaecology, General Medicine terms and General Surgical terms. Some of the participants had chosen to pursue these careers that they were exposed to early, and were now considering alternative careers and reported wishing for more early exposure to less common medical specialty choices. The majority of participants felt that they were not making a truly informed decision on their medical career, as their exposure to other medical disciplines had been minimal.
“I think just not being able to sample everything makes it difficult to make a decision”
(Interviewee 1)
“I didn’t realise it was an available career path, that was part of why I was indecisive about what I wanted to do, because it’s not something that is commonly talked about as it’s not one of your typical training career pathways, which is basically what you get taught in medical school is all traditional training pathways” (Interviewee 2)
“Medicine is such a rigid box, so when you get put into hospital medicine you get exposed to hospital medicine. Our actual exposure to community medicine, and anything outside of hospital medicine, is quite limited” (Interviewee 2)
“’Having more experience at a junior level would help” (Interviewee 3)
“It would be nice to be able to have a go at it before you commit yourself to these careers” (Interviewee 3)
“I don’t know that I want to commit to something that I haven’t really had a good look at to know whether I’m going to like it or not” (Interviewee 6)
“I would like the opportunity to try different things” (Interviewee 7)
Many participants also described being unable to sample a career they were interested in pursuing, but yet to have any clinical experience in. Speaking to Registrars in the field, or attending careers exhibitions were not considered to be enough information to commit to a specialty pathway in these circumstances. Many interviewees spoke of the difficulty in getting advice about the training program from specialists in the field and how they felt the only way of getting advice often was organising an official meeting with a Consultant. Participants were hesitant to do this as they felt that if they just had a slight interest and wanted to know a bit more about the field, they didn’t want to bother the Consultant particularly if they weren’t certain they were intending on working in that field.
“I don’t know even if I would like it as I haven’t had much experience in it and the effort that I would have to do to get into the college for an area that I am not that passionate about may be a bit too much as well” (Interviewee 3)
“Something that would help would be a rotation as a junior in GP, or public health, or pathology or radiology and then you have the options. I think there is one option to do radiology but it is very competitive between Resident Medical Officers and the ones that know that they want to do radiology will go for it, and if you want to just have a go at it if you’re not sure then you’re not really going to get a chance” (Interviewee 3)
“I need more experience in that area to decide to commit myself to them and the only way of getting more experience where I am is to become a registrar and that’s just too hard basket if I ended up not going into it, with the process of going through exams and that kind of thing, because you need to do exams to get into pathology and if I don’t know if it’s exactly what I want to do then that’s a pretty big step to try and get some experience in that area” (Interviewee 3)
Lifestyle and family considerations
Lifestyle and family considerations were one of the most commonly cited reasons why participants were undecided on their career pathway. Many participants described having an interest in pursuing a particular specialty, but faltering in committing to the pathway due to the impact on their family and lifestyle. The majority of participants expressed that they experienced significant confusion, guilt and occasionally a feeling of betrayal to the medical profession for considering choosing a career which is more suitable for their lifestyle.
All participants had children and all participants reported that placing their families as a priority often contributed to indecision in future careers. Participants spoke of the struggle they experienced in deciding whether to leave a training program that was not family friendly (E.g. Expectation to do night shifts, on call, after hours and un-flexible work) and how the non-medical factors played a significant role in their eventual decision making.
“If you’re going to be miserable in your job and your family is going to be unhappy, is this really what you want to be doing?” (Interviewee 2)
“The hours that I work makes me wonder if, like on call shift work and working weekends and especially now that I have a family and doing nightshift… they’re things I take into account when thinking about what jobs I want to do”
(Interviewee 3)
“The work is quite demanding, including the on call roster, which is only about 1 in 5 but you do get called in all the time, which is something that I am not sure that I want to do for the rest of my life as my husband is participating in an on-call roster too” (Interviewee 4)
“But at the time I did feel like I was enjoying it, but not enough that I wanted to be full-time and on-call forever” (Interviewee 5)
“There is very limited options for part time if I did decide I want to do that in the future” (Interviewee 6)
Long term uncertainty about medicine in general as a career choice
Many participants that were uncertain on their specialty career choice also reported that they had never felt certain that pursuing medicine initially was a correct career choice for them. The decision whether to continue working as a doctor or not was often mentioned, and their career indecision and self-perceived lack of commitment and passion for medicine were largely the reasons behind this.
“It’s been really difficult for me because a lot of people who I went to university with went into medicine knowing what they wanted to do from the very beginning they had an area of interest but I have never had a “I want to be a so and so” – that’s been something that I have to figure out along the way” (Interviewee 3)
“I often I do think about leaving medicine all together because I don’t think I’m really cut out for it, but at the same time I think what else I would do” (Interviewee 3)
“Even through medicine, as a university student, I never was 100% sure that medicine was what I wanted to do. I sort of went into med as it just happened, I did well on the GAMSAT, I didn’t know what else to do and I’m just quite good at finishing things that I start, even if I’m not particularly passionate about it. That’s probably the core issue I would say, because I think if you have a passion for something you work out the logistics around it whereas I’m just not 100% sure it’s the right thing” (Interviewee 4)
“I often I do think about leaving medicine all together because I don’t think I’m really cut out for it, but at the same time I think what else I would do” (Interviewee 3)
“At the heart of all this is actually whether I definitely want to continue in medicine full stop” (Interviewee 4)
Negative previous experiences
Negative experiences in their previously desired career choice was also contributing to participants’ indecision. The negative experiences that were reported all related to work hours, working in an understaffed and unsupported environment and low department morale. No participants reported that the actual clinical work, or patient encounters contributed to their negative experiences.
“Certain bad experiences that I have had within the hospital have stopped me from going into some careers” (Interviewee 3)
“I found that job also really understaffed and I had a really horrible experience on that rotation actually so I avoided anything surgical from that point onwards”
(Interviewee 3)
“The department that I worked in for the last 2 years in rotations wasn’t a particularly pleasant place to work and I don’t know whether my thoughts on emergency are based on that particular emergency department or based on my experience with emergency medicine as such” (Interviewee 6)
“They were very short staffed and what I thought was a very low morale in the department and I found it very difficult to go to work everyday. So did I just not like that particular department or do I not actual like emergency medicine?”
(Interviewee 6)
Advice from other clinicians
Some participants reported that a cause of their indecision was related to advice from other clinicians that either encouraged them to pursue an unexpected and unconsidered career, or to deviate from their intended career pathway. Some participants felt that getting advice from senior doctors resulted in the doctors advising them away from a certain career they were considering, thus contributing to their indecision. Although this advice was found to be useful for some of the doctors, some felt that the advice was biased and given without any consideration into whether the career would be good for the individual doctor, but instead was focused on the senior doctors’ own career pathway and experiences.
“I know the times I have sought out people for advice it is all based on their experiences so it’s a bit hard to get a broader idea of all the different pathways”
(Interviewee 2)
“People are very biased towards their own specialties. All the paediatricians I know are like ‘Well you have to do paediatrics, why would you even consider GP training’ and the GPs I know are like ‘Come and do GP training’, there’s no one who has an open mind to all of the scenarios” (Interviewee 5)
“I find it hard to have conversations with people and get an unbiased opinion and advice on what road to take, to try, where to go. Everybody always has an agenda when they talk to you and I’m not sure if their agendas are the same as mine”
(Interviewee 6)
None of the participants had been offered any formal, independent career advice, or mentorship programs through the hospital. Some participants had informally found a mentor but many also described not having a mentor or formal advice, and all participants felt this advice would have been beneficial.
“I have never had a mentor, or someone that has ever been available for career questions and stuff and I think that probably, well definitely would be something that would be a benefit and I know people that have had someone like that have found it a little bit easier” (Interviewee 1)
“I find it quite unclear about how you get into some training programs. I have made a few mistakes in the past about assuming how you get in or not finding the information properly or the information on the website is too hard to decipher and getting it wrong” (Interviewee 3)
“I did go to the careers expo…. I didn’t even find that really helpful as they just handed out the slides that they had which was information from the college website which I could have looked up…. I didn’t get the information I wanted really but having the opportunity to approach people and ask them what the job is about would be very helpful” (Interviewee 3)
Obstacles of hospitals and training programs
Certain obstacles and barriers of specialty training led the participants to question whether the specialty was a correct choice for them, therefore impacting on their indecision. Many participants expressed frustration at the inflexible training pathway structure for their specialty college, including no part time training options, no dual training options and the lack of control over their own training pathway. Some participants reported indecision on their previous planned specialty due to their local hospital being unable to support the training position, and therefore to undertake any training they would need to move locations, which impacts their family and partners work.
“Not having access to the subspecialties I wanted. I kind of thought that they were available over here and I got here and they were like ‘no you have got to do general training’. And again that is not something that I wanted to do….. It’s not the colleges because on paper the colleges are very supportive of flexible training and taking time out but it’s the hospitals are the ones who are giving us the jobs and they’re not flexible and I think part of it not just the colleges, it is the employers… Every place has a new set of rules and expectations as well and trying to negotiate that is very difficult….. yeah like saying this is my plans for what I want to do and the hospitals say ‘oh sorry, that doesn’t fit in with our plan” (Interviewee 5)
“Is it worth it? And do I want to play their games and the politics and all of that”
(Interviewee 6)
Discussion
Career pathway indecision is a common and expected phase for many doctors 4,5. Factors contributing to why a doctor would choose a particular career pathway are well documented 4 but currently there is no published literature on what factors contribute to career indecision in doctors. This study aimed to identify factors contributing to career indecision by interviewing doctors who were undecided on their career pathway.
The results of this research may benefit many parties – hospital administration, medical education units, universities and the individual doctor. The majority of Australian hospitals currently have mentoring programs, compulsory junior doctor education, medical education staff and Directors of Clinical Training who provide support to doctors. Based on the research findings, modifications could be made to informing the career decision making process for doctors.
The most common reason for career indecision was based on individual circumstances and personal factors (E.g. Lifestyle and family considerations) which hospitals and training programs have limited external influence over. However by having a greater understanding and awareness of such a significant factor in decision making the individual doctor may be able to pre-empt the difficulty in choosing a pathway and make a considered approach to their future careers.
Those involved in education, training and pastoral care of doctors do have the ability to improve the career making process for doctors based on contributing factors to career decisions identified in this research.
Lack of exposure to a variety of specialties was mentioned by all participants with many suggesting that gaining some better experience in areas such as pathology, public health and radiology would assist with their decision making process. Participants had a variety of suggestions including offering these terms as rotations, allowing clinical observerships for a short period of time and having an approachable contact person that participants didn’t feel intimidated by to enquire about the specifics of training.
Improving access to career advice and mentors would also likely improve career decision making pathways. Participants reported receiving advice from colleagues and senior doctors, but this advice was often unrequested and perceived as being bias towards their specialty and not impartial. Participants reported wanting to speak to completely independent people regarding career advice that could provide unbiased, impartial information.
Interestingly many participants reported never knowing if medicine was the ‘right choice’ for them since the beginning of medical school. Identifying those doctors who are uncertain from the beginning of medical school and providing them with career advice during their early postgraduate years may improve their career decision making process.
Some of the factors identified are difficult for any individual to influence and change, but an awareness of them is still important. For instance, there is often little that can be done about preventing individual negative experiences, however it is important to recognise that negative experiences specifically related to workload and department morale plays a role in discouraging doctors from pursuing that field. Making doctors aware of this potential reaction could assist them in acknowledging that their uncertainty on a specialty they thought may have been a potential career is related to work stressors, as opposed to their enjoyment of the clinical work.
Training program and hospital rules are often quite specific to the individual circumstances making it difficult for any interventions to assist in the career decision making process. Support for those doctors who are grappling with the training programs and hospital rules would be beneficial however.
The major limitation to this study was that all participants were female with families and the factors that impact on career indecision may potentially be different depending on gender, relationship status or family status. Additionally, participants varied significantly in their years working as a doctor and career indecision factors may potentially vary depending on what level of training the doctor is at. Although the study sampled a small amount of doctors, a strength of this study was that saturation was achieved after four interviews providing relative confidence that the themes were accurate.
Future research considerations
This research has provided a thorough insight into career indecision for seven doctors ranging in postgraduate experience. There is the potential for further research into this field, particularly considering the current limited research in this area. Future research could investigate the factors contributing to indecision in recent graduates compared to older graduates, and also indecision in doctors not yet on a specialty program compared to those who are on a specialty program. Hospital site specific research on indecision would also be beneficial to individual hospitals. Research into indecision about medicine from an undergraduate level would also be a potential further research area.
Although saturation was achieved in the above research, specifically including male doctors would contribute further to understanding career indecision in doctors.
Conclusions
Career indecision in doctors is common with the majority of doctors experiencing indecision at some stage. Some may view career indecision as a positive situation, providing them with an opportunity to sample differing careers. Others find career indecision challenging, frustrating and many feel guilty for not ‘finding’ their specialty area and having a fellowship. All participants reported wanting more support in this area. Although many hospitals have adequate pastoral care and support, further interventions and programs to assist doctors who are undecided can be implemented into medical education units and hospitals to guide those doctors who need assistance. Being aware of the factors contributing to indecision can assist those involved in pastoral care and educational guidance to guide their doctors through the potentially difficult decision of choosing a medical specialty career.
References
- Medical Board of Australia 2016, Medical Specialties and Specialty Fields, Australia, viewed 18 March 2016, http://www.medicalboard.gov.au/Registration/Types/Specialist-Registration/Medical-Specialties-and-Specialty-Fields.aspx
- Blades D Ferguson G, Richardson H & Redfern N. A study of junior doctors to investigate the factors that influence career decisions, British Journal of General Practice. 2000; 50: 483-485.
- Lambert TW & Goldacre MJ, Views of doctors in training on the importance and availability of career advice in UK medicine, Medical Education. 2007; 41: 460–466
- Harris MG, Gavel PH & Young JR, Factors influencing the choice of specialty of Australian medical graduates, Medical Journal of Australia. 2005; 183, no. 6, 295 – 300.
- Goldacre MJ, Lambert TW, Stability and change in career choices of junior doctors: postal questionnaire surveys of the United Kingdom qualifiers of 1993, Medical Education. 2000; 34: 700 - 707
- Lambert TW & Goldacre MJ 2007, Views of doctors in training on the importance and availability of career advice in UK medicine, Medical Education. vol. 41, pp. 460–466
- Scott A, Joyce C, Cheng T & Wang W, Medical career path decision making: a rapid review, 2013, NSW Health. https://www.saxinstitute.org.au/wp-content/uploads/REPORT_Medical-career-path.pdf
- Saunders D, Peterson G, Sampson Jn J, Reardon RC, 2000, Relation of Depression and Dysfunctional Career Thinking to Career Indecision, vol 56 (2); 288 - 298
- Walker J, Peterson G, 2012, Career Thoughts, Indecision, and Depression. Implications for Mental Health Assessment in Career Counseling, Journal of Career Assessment, vol, 20 (4), 497 – 506
- Lambert TW & Goldacre MJ 2007, ‘Views of doctors in training on the importance and availability of career advice in UK medicine’, Medical Education, vol. 41, pp. 460–466
