key: cord-0774551-kiss83nd authors: Tameez-ud-din, A.; Malik, I. J.; Tameez Ud Din, A.; Mohyud Din, F. title: Factors affecting the choice of a future medical specialty of the junior doctors in a third world country date: 2021-10-07 journal: nan DOI: 10.1101/2021.10.04.21264501 sha: 81d59072e59e0eb2f84dc850fd8df695da3c5656 doc_id: 774551 cord_uid: kiss83nd Background and Objective Pakistan is facing a major brain drain and as long as there is not a better understanding of the needs and desires of the junior doctors this exodus towards the greener pastures shall continue. This study is an effort to recognize the factors which influence the choice of a future specialty of young Pakistani doctors in order to help identify the areas which need improvement. Study design This descriptive cross-sectional study was conducted from 12th May 2021 to 2nd August 2021. Young doctors who had completed their one-year internship in hospitals of Punjab were invited to fill the questionnaire via social media platforms. Data were entered and analyzed using the Statistical Package for Social Sciences (SPSS) version 23.0. Chi-square tests were applied for qualitative variables. A p-value of less than 0.05 was considered significant. Results Out of 105 participants 60 (57.1%) were females. More females as compared to males decided the future specialty based on work-life balance (20/27 p= 0.039). Internal medicine and general surgery were the most sought-after fields both before and after the internship. Forty-three (41%) participants wished to change their choice of specialty after their house job experiences. Fifty-eight (55.2%) participants considered the future prospects of the field while deciding their specialty while sixty-three (60%) reported the attitude of the senior doctors as an important deciding factor. The Covid-19 pandemic had an effect on 12 (11.4%) participants' decision regarding their choice of future specialty. Conclusion Many elements such as internship play a pivotal role in helping young doctors to narrow their choices. It is important to understand the factors considered by young doctors during their choice of a medical specialty to ensure that a significant proportion of the medical workforce does not slip through the cracks in our health infrastructure. Many elements such as internship play a pivotal role in helping the young doctors to narrow their choices. It is important to understand the factors considered by young doctors during their choice of a medical specialty to ensure that a significant proportion of medical work force does not slip through the cracks in our health infrastructure. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 7, 2021. British colonizers are largely credited with the introduction of Western medicine in the Indian subcontinent through the arrival of medical officers onboard the first fleets of East India Company ships [1] . Over the next couple of centuries, the health infrastructure in the subcontinent grew substantially but this growth was not uniform which is evident by the fact that that at the time of independence from the British raj, Pakistan (a part of Indian subcontinent before 1947) had just two medical colleges and the services they provided were grossly insufficient to cater to the burgeoning health needs of a new country [2] . College of Physicians and Surgeons of Pakistan (CPSP) was established in 1962 in order to provide a structured approach to Pakistani physicians' training. Unsurprisingly, the training infrastructure was largely fashioned according to the British health care framework. Over the decades, the Western medical world has undergone many reforms but there have been no major improvements in the Pakistani health sector and the health professionals (including resident doctors in different medical specialties) face a lot of challenges due to a lack of resources and poor utilization of primary health care system [2] [3] [4] . The choice of specialty for post graduate medical training is arguably the most important decision of a doctor's professional life and there are many factors which affect this selection process [5, 6] . In a resource-limited country like Pakistan, the choice of specialty may be influenced by additional sociocultural considerations like family pressure and lack of training facilities. The role of house job (a one-year mandatory hospital internship before medical graduates can apply for residency) in the growth of health professionals has often been discussed in health conferences and international publications, but there is a scarcity of literature describing its part in a young physician's selection of medical field [7] . The policy makers and senior health executives need to have a better understanding of the factors that influence the choice of medical specialties in order to help the young doctors navigate this turbulent and uncertain period of their lives in a stress-free manner. Pakistan is facing a major brain drain as many medical graduates are leaving the country for better job opportunities abroad [8] . The arduous path to acquiring a residency spot in their favorite specialty, difficult working conditions and disappointing prospects of the medical fields in the country are some common complaints and as long as there is not a better understanding of the needs and desires of the young doctors, this exodus towards the greener pastures shall continue. This study is an effort to recognize the factors which influence the choice of a future specialty of young Pakistani doctors in order to help provide a framework for the policy makers to identify the areas which need improvement and make impactful decisions in this regard. Our study also uniquely describes the impact of the mandatory hospital internship over the decisionmaking process and explores whether the pandemic has had any influence over the selection of a specialty. Figure 1 shows a simplified comparison of the likely professional journey of a medical graduate in Pakistan, United Kingdom and United States of America. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 7, 2021. ; https://doi.org/10.1101/2021.10.04.21264501 doi: medRxiv preprint This descriptive cross-sectional study was conducted from 12 th May,2021 to 2 nd August,2021. Ethical approval was obtained from the ethical review board (ERB) of Rawalpindi Medical University. Young doctors who had completed their internship in private and public sector tertiary care hospitals of the Punjab province of Pakistan were invited to fill the questionnaire in person or via social media platforms. The data was collected by convenience sampling technique. The doctors who agreed to take part in the study were provided with a link to the questionnaire. Those who had completed their house job within the last 6 months were included in the study while the doctors who had started their residency were excluded. The questionnaire consisted of two parts. The first part comprised of questions regarding the demographic details of the doctors while the second part had queries concerning the different factors impacting their decision of a future specialty. Towards the end of the questionnaire, a couple of optional questions regarding the impact of the COVID-19 pandemic were asked. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 7, 2021. ; https://doi.org/10.1101/2021.10.04.21264501 doi: medRxiv preprint Data were entered and analyzed using the Statistical Package for Social Sciences (SPSS) version 23.0 (IBM Corp, Armonk, US). The results were reported as frequencies, percentages, and figures. Chi-square tests were applied for qualitative variables. A p-value of less than 0.05 was considered significant. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Thirty-seven (35.2%) participants reported that their choice of specialty was influenced by factors such as family pressure. Fifty-eight (55.2%) participants said that the future prospects of specialty in their country affected their choice. Seventy-seven (73.3%) participants did their . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 7, 2021. ; https://doi.org/10.1101/2021.10.04.21264501 doi: medRxiv preprint rotation (during house job) in the specialty they wanted to pursue while 28 (26.7%) did not. Sixty-eight (64.8%) had a specific center in mind where they wanted to complete their residency and 65 (61.9%) considered the available facilities while selecting their center for residency. Sixty-three (60%) participants reported that the attitude of their seniors and 35 (33.3%) reported that the attitude of paramedic staff affected their decision about selecting their specialty of choice. Ninety-eight (93.3%) held the opinion that different personality types are suited for different medical specialties. Twenty-five (23.8%) participants reported that their decision of choosing a particular specialty was influenced by a family member already working in a specific field. This is shown in Table 2 . Response Frequency (%) Did the future prospects of this field in your country made you consider it? . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 7, 2021. ; https://doi.org/10.1101/2021.10.04.21264501 doi: medRxiv preprint Forty-one (39%) participants reported that they had chosen internal medicine as their future specialty before their house job while 29 (27.6%) said that they had an interest in surgery before the internship. Ten Most of the participants (101, 96.2%) were of the opinion that house job is mandatory for growth of medical professionals, while only 4 (3.8%) said otherwise. The role of this internship period in the professional growth is further elucidated in Table 4 . . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 7, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 7, 2021. graduates later contributing towards the overall work force of the hospitals due to social issues such as arranged marriage and cultural taboos related to the working women [14, 15] . A change . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 7, 2021. ; https://doi.org/10.1101/2021.10.04.21264501 doi: medRxiv preprint in the overall patriarchal mindset of the society and the deeply entrenched gender roles is the need of hour in order to stop this valuable proportion of the medical work force from going to waste. Most of the junior doctors had considered internal medicine as their future specialty before house job followed by general surgery (39% and 27.6% respectively) and these fields were also the most popular choice after their one-year mandatory internship (31.4% and 27.6% respectively). This was similar to the findings of other studies from the country [6, 16] . However, more than [17] [18] [19] . In short, although the importance of mandatory internship before residency (known as foundation years in UK and house job in Pakistan) in the choice of future specialty and the growth of health professionals cannot be overstated, further work needs to be done in order to maximize the learning possibilities this phase has to offer, in order to help nurture a generation of safe, confident and skilled doctors [20] [21] [22] . Sixty percent of the participants in our study considered that the attitude and professionalism of the senior doctors and faculty members was important in their choice of a certain medical . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 7, 2021. Specialty choice in medicine has often been associated with the type of personality of the individuals and a vast majority of the junior doctors in our study (93.3%) agreed with this assumption [25] . Covid-19 pandemic is an unparalleled health disaster of the modern times and has caused seismic shifts in the delivery of health-care facilities [26, 27] . Junior doctors have been at the forefront in the fight against this novel disease and it is important to assess the impact of the pandemic over their future decisions. Eighty percent of our study participants had performed duties in Covid-19 wards during their house job. A majority of the participants (56.2%) reported that they had suffered from the disease during their hospital duties which . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 7, 2021. ; https://doi.org/10.1101/2021.10.04.21264501 doi: medRxiv preprint underlines the risk faced by the frontline health workers during this pandemic and it has been corroborated by many international studies [28, 29] . Despite the profound effects of Covid-19 on the delivery of global health-care services, only 11.4% of the junior doctors in our study agreed that the pandemic had an effect on their choice of a future specialty. The long-term impact of this disease remains to be seen and there is a deficiency of literature regarding this topic [30] . Further studies will be required in the future in order to map the effect of such a global disaster over the choices of the future generation of doctors. The main limitation of our study was that the data from the junior doctors working in other provinces of Pakistan could not be gathered. Although, Punjab is the largest province (by population) of Pakistan, the data from other provinces may have revealed some significant differences owing to the certain geographic and cultural peculiarities specific to every province. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 7, 2021. ; https://doi.org/10.1101/2021.10.04.21264501 doi: medRxiv preprint This study provides insight into the budding minds of junior doctors of Pakistan and indicates the factors they consider important while deciding a medical specialty. Most medical graduates have a pervasive sense of uncertainty regarding their future career in medicine and internship has a pivotal role to play in helping them narrow their choices. Empathetic and kind supervision and a stress-free environment can make it easier to pick a probable path that suits their temperament. There is also a need to make the medical profession more gender inclusive in order to help ease most of the female doctors into the specialties of their choice. It is the need of the hour to understand the factors considered by young doctors during their choice of a medical specialty to ensure that a significant proportion of medical work force does not slip through the cracks in our health infrastructure and everyone can play their part in the improvement of the health sector of this country as well as contributing towards global health efforts. https://www.dawn.com/news/803667/pakistans-medicalschools-where-the-women-rule . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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