Specialty Preferences of Medical Students: Gender and Work-Life Balance

Research output: PhD ThesisPhd-Thesis - Research and graduation external


Chapter 1 Introduction
On an international level the feminization of medicine did not result in a proportional intake of female physicians into all medical specialties. In this a gendered socialization, culturally as well as professionally, may be of influence. More specifically, the values related to the division of work and care may differ from the full-time employment expectations of physicians. In order to determine the implications of this feminization for the professional field, it is important to know how future male and female physicians develop their specialty choice-making. To date, profound knowledge on how and when male and female medical students proceed to shape their career considerations and the way gender influences specialty selection during medical education, is lacking.
In this thesis we aim to describe how specialty preferences and related reasons for career considerations of male and female medical students commence and develop over time. We describe how related factors such as motivations, preferred working hours, considerations on work-life issues and cultural differences, influence specialty preferences. Most of all we wish to specify the influence of gender and work-life balance on specialty choice-making. The research conducted consists of six studies.

Chapter 2 New students’ motivations
Work motivational factors play a pivotal role when choosing a specialty and a career in medicine and these differ among female or male physicians. If medical students have gender-related expectations for their future specialty, this might shed a light on the future division of labour between physicians. In the first research we explored what early specialty preferences male and female students at the Radboudumc in Nijmegen the Netherlands had, what was the influence of motivational factors on specialty preferences and whether gender differences existed.
We found that six out of 10 students already had a specialty preference at the start of medical education. Most male students opted for surgery, whereas female students preferred pediatrics more often. At the outset women were also interested in surgery and men in pediatrics. None of the male students opted for gynaecology. The specialty of internal medicine was chosen by both genders in equal measure. Taken together, women valued a good combination of work and care and attractive working hours, whereas men attached more importance to career opportunities, a good salary and technology. The most important motivations namely an interesting content and lots of patient contact, did not relate to gender differences. Women who valued attractive working hours and high levels of patient contact more often opted for general practice. Men with similar values more often opted for internal medicine. When students preferred surgery, both genders had a greater preference for technology and a lower preference for patient contact.

At the outset of medical education male and female students’ specialty preferences differ and relate to motivational factors, especially to work-life issues.

Chapter 3 New students’ work-life balance; a cultural compare
The way that female and male future physicians are socialized in a society, forecasts that women and men enter the labour force with choices that are early learned in life, also from role models. This may be different in a welfare-state with a part-time working culture like the Netherlands than in Sweden, a country with high gender equality. In addition, our objective therefore also was to specify cultural differences in specialty preferences, especially with regard to how students anticipated their future work-life balance. A comparison study with Sweden was used to examine the influence of a different working culture. In this research new medical students at the Radboudumc in Nijmegen the Netherlands as well as new students of Umea University in Sweden were surveyed. We explored how female and male students vary in their preferences for working hours and work-life issues and specialty preferences.
Our comparative study showed that in Sweden no other gender-related specialty preferences existed except for gynaecology which was only mentioned by women as their stated preference. However in the Netherlands a large gender-gap existed in surgery, especially preferred by Dutch male students preferred and paediatrics, preferred by Dutch female students. Both male and female students in Sweden opted for full-time employment in equal measure, whereas in the Netherlands approximately 80 percent of the male students versus 50 percent of the female students wanted to be in full-time employment. Women in both countries expected equality in career-opportunities and care-tasks more than men, and agreed more often that their career would influence their family life. Women with a preference for surgery most often emphasized equality in career opportunities and care tasks. In most preferred specialties female gender related to a lower degree to full-time work. A gender gap in preferred working hours was larger for Dutch students preferring surgery or pediatrics than for Swedish students.
Thus our study shows that from entrance of medical education not only gender but as well culture affects new students’ specialty preferences through considerations on work-life issues.

Chapter 4 International Review
Gender differences in specialty preferences throughout medical education may occur at an international level. Therefore, by means of an international literature review, we inventoried gender differences in specialty preferences among first- to final-year male and female undergraduate students, to acquire solid background information of our survey results. We explored the extent of differences between male and female medical students’ specialty preferences during the curriculum and how men and women develop in modifying or holding on to specialty preferences.

We determined that, throughout medical education in different cultures, men more often opted for surgery and women for gynecology, pediatrics, and general practice. Internal medicine was pursued by both genders. The extent of gender-specific specialty preferences seemed related to the male-to-female ratio in the study population. When a population contained more male students gynecology seemed even more preferred by women, while in a more feminine population, men more highly preferred surgery. We conclude that gender differences in specialty preferences during medical education can be placed in an international setting.

Chapter 5 First three years of studies and work-life balance
In the first half of training female and male medical students follow the same education that will give them an insight in the theoretical background of the specialties, with teachers that may be seen as “role models” in a peer group of fellow students. We wished to gain more clarity at which point during their studies medical undergraduates begin to seriously consider specialty choice, how preferences develop, whether gender differences in specialty preferences converge or diverge over the years and what factors are of importance. Therefore we conducted a two-wave longitudinal study. At entrance and after three years of theoretical medical education, we collected students’ career considerations, namely specialty preferences, working hour preferences and considerations on motivational factors and work-life issues. We compared changes in specialty preferences and factors influencing this preference, taking into account the influence of gender or that of initial considerations.
After the first three years of medical education, 80 percent of the students had a preference. The interest of women in surgery and men in paediatrics at the outset, were slackening. Male students remained highly interested in surgery, and female students increasingly preferred gynecology. It appeared that an early preference for surgery, gynaecology, or general practice increased the likelihood of having the same preference at the end of the theoretical education phase. Foremost, a gender-gap in preferences for full-time employment increased: 90 percent of men versus 30 percent of women wanted to be in full-time employment. Moreover men tended to retain their initial preference for full-time employment, while one out of four women changed their initial full-time preference to a part-time one. Halfway through their medical education, men as well as women expected that having a family would impact the career of the women, which men did not think at the outset of their education. Women, who emphasized equal career opportunities only at the outset, halfway studies increasingly favoured possibilities for reconciliation of work and care. The interesting content of the specialty remained a major motivation for both genders, as well as the level of patient contact, but the latter more so for women. A good salary remained more important to male students. Although one might have expected to see a change in favour of their career as students interest in their profession will grow after the first three years of theoretical training, there proved to be no turning-point. Gendered career considerations consolidate from the start of medical education, specifically that women prefer to work fewer hours and anticipate care tasks more often.

Chapter 6 End of sixth year and all influencing factors
Working part-time is sometimes difficult to realize in hospital specialties, and the majority of all physicians across specialties work full-time in their present job. Family responsibilities and work and time-related aspects have been suggested to be the most important cause of changing a full-time workload into a part-time one. From the previous studies we learned that female medical students make different specialty choices compared to their male counterparts. In this a cross-cultural aspect might play a role in the extent of the gender-differences. Just before graduation a more reliable endpoint for the final choice for a specialty can be given. It is therefore that we wished to find out how large the influence of preferred future work-life balance was on gender-related specialty preferences at the completion of the practical part of medical education in year six. Graduating students completed our survey on gender issues in specialty preferences. We aimed to describe the interplay of specialty preferences and influential factors involved. We wished to find out whether final year medical students’ specialty choices are influenced by gender or a full-time or part-time work preference, if work-life issues mediate the relationship between gender and specialty choices and what was the relationship between full-time or part-time work preference and specialty choice.
It appeared that at the end of medical education, when 90 percent of the students had a preference, eighty percent of the male students and fifty percent of the female students wanted to be in full-time employment. These figures were the same as upon enrolment. A preference for full-time employment more often led students to opt for surgery, internal medicine, or neurology; a preference for part-time employment led students to opt for general practice or psychiatry. Men and women had a greater preference for full-time employment if they valued equal career opportunities. They also opted more often for full-time employment if they expected their partner to be less ambitious. Though surgery was related to full-time employment throughout their entire medical education, fewer women than men amongst these students wanted to work in full-time employment. Female students who preferred surgery tended to value equal career opportunities more and attractive working hours less. When they expected their partner to be less ambitious, women had a greater preference for surgery. Having an ambitious partner increased the likelihood for women to choose general practice. Anticipated care tasks in men and women negatively influence the career of Dutch female graduates.

Chapter 7 End of sixth year students reasons in a focus group study
Previous studies mostly are quantitative with predetermined motivational factors. Ultimately, we wanted to establish themes in medical graduates’ career considerations and whether assumptions of male and female medical graduates differed. In a qualitative study we conducted focus group interviews amongst male and female medical graduates to determine what reasons they gave for their specialty choice. We were especially interested in the role of gender in specialty choices.
It seemed that most students in their final year, when asked, said they felt they only made their specialty choice at the end of the second phase of medical education, that is, after three years of practical training during their clerkships. A theme in choice-making was work-life balance. Women focused more on their private life and men on their career. All students felt that the best conditions for reconciling work and care responsibilities were available in non-hospital specialties. Men also felt that, for the time being, part-time employment was not really an acceptable option for them. The workplace culture experienced during clerkships strongly enhanced or discouraged students’ choice-making. Workplace culture was particularly important to female participants and the least to men with a hospital preference. Strict admission requirements appeared to be a reason for graduates not to enter a vocation. Our participants noticed that male students were positive discriminated when entering the specialty of their choice. The most important reason for a specialty choice was an appealing content and both genders attributed the same specific characteristics to a given specialty: in surgery, this was hustle and bustle, technology, and lower degrees of patient contact; in general practice, it was higher degrees of patient contact, greater professional diversity, and a less competitive atmosphere.
Medical graduates feel that they choose their specialty at the end of their clerkships and foremost because of the appealing and interesting content. Gender did play a role in the influence of specialty choice by the workplace culture, restrictions of admission requirements and work- life balance.

Chapter 8 Discussion
Finally, the main findings of all studies in this thesis were summarized. The lessons were discussed and the limitations of our study described. The chapter closes with recommendations for practice, education and future research. We concluded that the expectations female students have from the outset till completion of medical education on the distribution of career and care responsibilities between partners weaken their focus on full-time employment, which is highly influential on their specialty preferences. Same times, throughout their entire medical education, men valued high wages and career opportunities more than women. This behaviour seems to be predetermined by the Dutch cultural role pattern. Though both men and women mention the specialty’s content as being the guiding factor in their decision-making, our study shows that the choice to work full-time or not guides the students’ specialty preference. Medical students, medical education, and the medical profession appear to be conforming themselves to prevailing work and care role patterns. Gender differences in career preferences are present from the very start of medical education and consolidate halfway through medical training. Career decision-making, therefore, does not take place at the end but at the beginning of medical education. Guidance in a content-driven career choice earlier in medical education can create opportunities. With a large influx of female employees, all the above implicates that it is important for hospitals to adopt a clear policy towards their doctors. Choosing a specialty is an active process that requires the students’ conscious decision-making and consultation with their instructors. Feedback from the specialties is desired to make sure that students, as potential future employees, are aware of the required profile. It would be interesting to conduct a follow-up study on the relation between the personal competencies of male and female students and their choice for a particular professional domain. Students might participate in a study in education exploring how they may be made aware of culturally determined patterns by way of discussion.
As such the combination of work and care as an inequitable career choice determiner with a negative influence on women’s careers, will be exposed and changed proactively.
Original languageEnglish
Publication statusPublished - 2015

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