Behavioral exploration of career and specialty choice in medical students.

Understanding the process by which students naturally construct and internalize their educational experiences relating to career development is important to career counseling. The author investigated how exploratory behaviors during a community-based field experience course contributed to the vocational development of 1st-year medical students. Behavioral exploration data regarding medical career development and specialty decision making were collected from 91 first-year medical students before and after they engaged in an exploratory behavioral activity, the Ambulatory Care Experience course. Findings suggest that students had not progressed in their medical career development and that more uncertainty existed among students after completing the course.

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For years, researchers have studied factors believed to influence medical specialty choice (Calkins, Willoughby, & Arnold, 1987; Deckert, Beckham, Hall, & Holmes, 1991; Dorsey, Jajoura, & Rutecki, 2005; Kassebaum & Szenas, 1994; Lambert & Holmboe, 2005). Despite the abundance of literature on this topic, results are inconsistent and inconclusive, and there is still little known about the process by which medical students choose a specialty and how certain aspects of medical education and training (e.g., courses, clerkships, rotations) directly influence specialty decision making. Although voids regarding these topics exist in the medical education literature, other disciplines provide an understanding of the career decision-making process in general. For example, as reflected in vocational psychology literature, historically, indecision regarding vocational choice has been traditionally perceived as unfortunate, problematic, and even bordering on pathologic (Grites, 1981; Krumboltz, 1992). Medical school environments have been viewed as contributing to the pressure students feel to decide on a specialty (Zimny & Senturia, 1973).

Although not directly linked to physician career development, the complexity of the career decision-making process in general has been well documented in the literature by career psychologists. Alternative perspectives on career decision making have been presented with ideas that can be applied to the career of medicine. For example, Germeijs and De Boeck (2003) studied sources of career indecision and identified three factors. One of the factors, the information factor, pertains to feeling informed about alternatives during the decision-making process. In medicine, given that there are more than 100 specialties from which students can choose, there are many options and alternatives for specialty choices. One way in which medical students gain information about specialty options is through their exposure to clinical environments and to physicians they encounter in their medical training. Little is known, however, about how these exploratory experiences relate to medical career development.

Career decision making has been conceptualized as occurring continuously during the life span and not necessarily limited to early adulthood. Individuals may not make only one career decision but, when faced with different life events, may revise their career decisions over time. Career indecision can occur during these transitions (Osipow, 1999). For individuals who pursue careers in medicine, there are many transition points at which indecision can occur. First, the individual has to decide to choose medicine as a career, but not long after they begin their education at medical school, questions begin to arise about what medical specialty to enter. The decision about specialty choice is revisited as medical students progress through the curriculum and are exposed to different areas of medicine. For some students, additional transition points for medical specialty choice include whether to enter a subspecialty of medicine, and if so, which one. Although models for career decision making exist, aspects of identity development related to indecision have not been addressed (Kelly & Lee, 2002).

Vocational psychology provides background information helpful to exploring interests and the vocational identity of physicians. Historically, vocational counselors have relied on interest inventories to determine an individual's vocational interests (Kitson, 1942). These interests are then matched to occupations. Kitson purported that this approach is inadequate because interests are not detectable if interests are not there, and he recommended a shift from detecting interests to creating interests. Based on this idea, this study investigates a relational approach regarding the making of vocational interests as opposed to the traditional method of uncovering or finding interests, as applied to medical students. Vocational identity, coined by Holland, Gottfredson, and Power (1980), is another important construct for physician career development. A review of the literature shows that physician vocational development has been visualized as encompassing three tasks (crystallization, specification, and implementation) pertaining to career choice and to specialty choice (Savickas, 1984). The process of vocational development for physicians begins with the decision to enter medical school and continues to be influenced by vocational decisions pertaining to specialty choice and practice type. This study is concerned with how behavioral activities designed to help students develop their specialty interests influence the vocational development of medical students.

Participants for this study were 1st-year medical students who took part in a new course called the Ambulatory Care Experience (ACE). The course provides the opportunity for students to observe firsthand some of the realities of medical practice (Hartung & Magoon, 2000). During the ACE course, students develop their specialty interests through (a) early clinical exposure to medical environments, such as hospitals, clinics, and office practices, and (b) interpersonal exposure through interactions with physicians in various specialties. Mentoring relationships are formed and role modeling occurs during these experiences. The experiences of shadowing physicians and participating in clinical clerkships can be considered vehicles for carrying out behavioral exploration of medical specialties.

The current study used ACE as an intervention to investigate exploratory processes as central constructs for vocational identity development and medical specialty choice. The current study sought to investigate how exploratory behaviors contributed to the formation of the vocational identity and the career plans of medical students. Results of this study may provide information for designing intervention models and course materials, using behavioral exploratory experiences, to help medical students with identity development and medical specialty exploration.

The current study is concerned with understanding the process by which medical students naturally construct and internalize their exploratory experiences relating to physician career development and how this process influences medical specialty choice. Specifically, this study investigated the way that exploratory behaviors contributed to the vocational development of 1st-year medical students in the context of a practical, community-based field experience course. The current study tested the hypothesis that there would be a change in students' medical career development and their decision making regarding a medical specialty after completing the ACE course.

Method

Participants

A total of 91 first-year students (39 men and 52 women) at one medical school provided consent to participate in this study. Data were collected during two consecutive academic years (2000-2001 and 2001-2002), with 50% of the total number of 1st-year students enrolled at the medial school participating from each year. Participants' age ranged from 19 to 37 years (M= 21.4, SD = 3.18). Regarding ethnicity, 56 (61.5%) of the participants were Caucasian, 29 (31.9%) were Asian or Pacific Islander, 2 were African American (2.2%), 2 were Hispanic (2.2%), and 1 was Native American (1.1%). One individual reported ethnicity as "other."

Measures

Behavioral exploration data were collected at the beginning and end of the 1st year of medical school, using two instruments: The Medical Career Development Inventory (MCDI; Savickas, 1984), which provides information about decisional difficulties, and the Specialty Indecision Scale (adapted from the Career Decision Scale; Osipow, Carney, Winer, Yanico, & Koschier, 1987), which provides information about career indecision.

The MCDI was constructed by Savickas, Super, and Thompson (Savickas, 1984) to measure vocational development during the early stages of a career as a physician. It has been used previously with premedical students to evaluate career development programs (Henry, Bardo, & Henry, 1992). The MCDI assesses career maturity of medical students and physicians. These individuals are considered to be a homogeneous population to which the construct of career maturity applies (Savickas, 1984). Medical students and physicians must cope with a host of vocational choice possibilities and problems as they select a medical specialty, and possibly a subspecialty, as well as having to decide on a practice type and locale (Savickas, 1984).

The MCDI measures two cycles of tasks, career and occupational, involved in physician vocational development. The MCDI consists of seven vocational development tasks: career crystallization, career specification, career implementation, occupational crystallization, occupational specification, occupational implementation, and stabilization (Savickas, 1984). Career crystallization refers to formulating a general preference for a career in medicine and is concerned with forming a vocational identity (Savickas, 1984), whereas career specification refers to converting a generalized preference into a specific preference for a career as a physician and involves the coping behavior of self-evaluation. The third task of career implementation, as well as occupationally related tasks and stabilization, was not included in this study because these tasks pertain more to physicians than to medical students.

The MCDI has five items representing each of the seven developmental tasks, for a total of 35 items. Responses to each item are in Likert-type format. Items are rated using a 5-point, Likert-type scale (5 = I have already done this, 4 = I am now doing what needs to be done, 3 = I know what to do about it, 2 = I have thought about it, but do not yet know what to do about it, and 1 = I have not yet thought much about it). Criterion-related validity with career planfulness as the criterion variable has been reported to be r= .41 for the total MCDI scores. As a measure of reliability, Cronbach's alpha internal consistency coefficients ranged from .73 to .91 for the seven scales and was .93 for the inventory (Savickas, 1984). Cronbach's alphas for the seven developmental tasks for participants of the current study were .65 for career crystallization, .69 for career specification, .77 for career implementation, .66 for occupational crystallization, .70 for occupational specification, .66 for occupational implementation, and .45 for stabilization.

The Specialty Indecision Scale provides information about career indecision and was developed to measure specialty decision making within a chosen field. The Specialty Indecision Scale was originally adapted from the Career Decision Scale (see Savickas, Alexander, Osipow, & Wolf, 1985). It has been used previously to study the difficulties associated with specialty choice (Savickas, Alexander, Jonas, & Wolf, 1986). The questionnaire contains statements regarding the educational and occupational plans of students. The items on the Specialty Indecision Scale pertain to indecision and address areas such as career certainty, specialty certainty, and degree of indecision. Students respond to 18 statements indicating how closely each item describes their thinking about a medical career or specialty choice, using a Likert-type scale with responses ranging from exactly like me (4) to not at all like me (1). Criterion-related validity with degree of vocational development as the criterion variable has been reported to be r = -.58. A Cronbach's alpha coefficient of .82 has been reported for the Specialty Indecision Scale total score (Savickas, Alexander, Osipow, & Wolf, 1985).

Procedure

Data for this study were collected from 1st-year medical students before and after they engaged in an exploratory behavioral activity, the ACE course. Data were collected at the beginning of the year prior to students' first ACE session (pretest) and at the end of the academic year after their last ACE session (posttest). Prior to their first ACE session, students were informed of this study during an orientation session for the course and were invited to participate. ACE served as the intervention for the current study and was a new, yearlong program that provided the opportunity for medical students to conduct self-exploration and to develop their interest in a particular medical specialty through interactive experiences with medical specialists. ACE was a practical, community-based, field experience component of the 1st-year medical school curriculum. The ACE sessions offered medical students diverse, experientially focused activities designed to foster their self-awareness, knowledge, and skill development (Hartung & Magoon, 2000). Seven daylong experiences averaging 6 hours in length provided learning opportunities for 1st-year medical students. Health and human service providers and community-based physicians were preceptors for the course. ACE sessions focused on achieving four fundamental goals: entering the human side of medicine, experiencing diverse dimensions and contexts of human development, enriching the links between basic science courses and clinical medicine, and exploring career opportunities in medicine and the personal meaning of a life-career as a physician (Hartung & Magoon, 2000). Through ACE, the medical students experience the realities of medical practice by interacting with an array of health care providers and medical specialists. ACE provided the opportunity for medical students to conduct self-exploration and to explore their interpersonal relationships and relate this information to choosing a medical specialty. ACE was a required course for all 1st-year medical students. In keeping with the experiential nature of this course, there were no lectures, and a competency-based, pass/fail grading method was used. Students rated the overall quality of the course at the end of each academic year, using a Likert-type scale (1 = valuable overall, 2 = good, 3 = adequate at best, and 4 = needs major improvement). For academic year 2000-2001, the mean rating for the course was 1.80 (SD = .60). For academic year 2001-2002, the mean rating for the course was 2.10 (SD = .74).

Results

Regarding medical career development, a t test was performed using the MCDI to assess whether there was a change in medical students' vocational development. Significant differences were noted between pre- and posttest scores on the MCDI for career crystallization, t(90) = 6.31, p = .000, and career implementation, t(90) = 3.10, p = .003. Because multiple comparisons were made, the significance level was adjusted to p < .006, using the Bonferroni procedure to control for family-wise error. Regarding career crystallization (as measured by the MCDI scale), the mean scores before participating in ACE were higher than the mean scores after the course (pretest, M= 19.13, SD= 3.34; posttest, M = 16.71, SD= 3.47) indicating that, at the end of the course, 1st-year medical students were less likely to have formulated a general preference for a career in medicine and had not yet begun to form a vocational identity. Regarding career implementation (as measured by the MCDI scale), mean scores were also lower after taking the ACE course (pretest, M= 18.03, SD= 3.40; posttest, M= 16.77, SD = 3.63). This suggests that the medical students were less likely to have implemented their preference and to have demonstrated a commitment to medicine after completing the ACE course.

Results of the t test for the Specialty Indecision Scale, which assessed students' thoughts about a medical career or a medical specialty, revealed that the study participants' pretest responses were significantly different from the posttest responses for 1 of the 18 items. Students indicated less comfort about knowing how to implement their choice of a medical career and also indicated that they felt more undecided on a medical career after participating in ACE, t(89) = 4.36, p = .000. The mean scores before participating in ACE were higher than the mean scores after the course (pretest, M = 3.32, SD = .74; posttest, M = 2.83, SD = .89). Because multiple comparisons were made, the significance level was adjusted to p < .002, using the Bonferroni procedure to control for family-wise error.

Discussion

The purpose of the current study was to investigate how medical students construct and internalize their exploratory experiences of medical specialties during their time in medical school. First-year medical students' medical career development and medical specialty decisions were studied prior to and after the students engaged in a field-based course that provided experiential and exploratory opportunities relating to physician career development and medical specialty choice. The current study sought to determine whether there would be a change in students' medical career development and their specialty decision making after completing the ACE course. Findings suggest that the students had not progressed in their medical career development and that more uncertainty existed among students regarding how to go about choosing a specialty, and specialty choice in general, after completing the course.

Given that early in their training medical students may not always have a clear understanding of what it means to be a physician, the ACE course may have served as a reality test for them in terms of career exploration. This reality test may have had a profound and measurable effect on their career concerns and their decision-making process. The forced exploration that resulted from the ACE course may have provoked uncertainty and challenged their vocational self-concepts. Moreover, their first systematic exposure to clinical medicine may have prompted students to realize that they soon needed to make decisions and choices for which they were not prepared. It is possible that confrontation with reality and reduced clarity of their vocational self-concepts, on the average, led to an increase in students' concerns about their career plans.

The results of the current study may lead medical educators to consider reevaluating the structure of an ACE course for 1st-year medical students in terms of how helpful this course is in assisting students with progress in their medical career development and decision making regarding a medical specialty. Although studies have shown that clinical or clerkship experiences during medical school influence medical specialty choice, exposure to medical specialties too early in the medical school curriculum may possibly lead to greater indecision and confusion regarding career plans among 1st-year medical students. Although the students did not progress in their medical career development and specialty choice decision making from a linear perspective, it is possible that the ACE course may have enabled career development in the sense that students were able to gather information that was helpful in reevaluating their choices. In restructuring the course, the course directors could consider adding opportunities for students to openly discuss their ACE sessions. This would allow students to process their uncertainty about choosing a medical specialty and their indecision about specialty choice in general. This could be done in small-group format and could possibly shed light on how gathering information through the ACE course contributed to students reevaluating their choices. Furthermore, qualitative analyses could be included in future studies to better understand the process that medical students undergo when deciding on a medical specialty and how the ACE course affects the process of vocational identity development. Qualitative studies of this nature should be conducted before sweeping changes are made to the ACE curriculum.

It is important to consider the limitations of the current study when interpreting the results. This study took place at only one medical school and, therefore, the results may not be generalizable. In addition, although students completed the MCDI and Specialty Indecision Scale as part of the ACE course, only 50% of the students provided consent for their information to be used for this study. Therefore, it is possible that a selection bias occurred. Future studies seeking to explore medical career development and medical specialty decision making could benefit from using a larger, more representative sample of medical students from various schools across the country.

Although the current study provides an initial foundation for the development of a theoretical framework for understanding the structural aspects of vocational exploration, it is recommended that studies seeking to explore physician career development and medical-specialty decision making continue to be conducted. The second phase of this study could be conducted using 3rd-year medical students. The same pre- and posttest questionnaires used with 1st-year medical students could be readministered prior to and after these 3rd-year students have completed their clinical clerkships, which consist of clinical rotations through various medical specialties. Similar to ACE, clinical clerkships also involve exploratory activity related to medical specialty choice but provide a more in-depth and lengthy opportunity for tracking the nature of vocational exploration in the development of specific interests and the ways in which medical students will construct and internalize their exploratory experiences. A study of this nature would provide a better understanding of the suitability of exploratory, experientially based courses in the development of medical specialty choice and how students progress through the medical career development and decision-making process.

Conclusion

The medical students' career concerns and lack of preparedness regarding specialty decision making revealed by the current study have implications for career counseling. There seems to be a need for career counseling and guidance for medical students regarding decisions concerning medical specialty choice. Medical schools have been slow to recognize this need but are beginning to offer structured programming to help students with career decision making. For example, the Association of American Medical Colleges (2005) Careers in Medicine program is being implemented in some medical schools across the country. This career planning program helps students to choose a medical specialty. Possibly, over time, the theoretical and scientific contributions of scholars in career development and vocational psychology can be realized in the medical school arena. Medical students should receive the support and guidance necessary to make informed decisions about their career as a physician, a task for which career counselors seem well suited.

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Nicole J. Borges, Department of Behavioral Sciences, Northeastern Ohio Universities College of Medicine. Nicole J. Borges is now at Boonshoft School of Medicine, Wright State University. Correspondence concerning this article should be addressed to Nicole J. Borges, Wright State University, Boonshoft School of Medicine, 3640 Colonel Glenn Highway, 232 Frederick A. White Health Center, Dayton, OH 45435-0001 (e-mail: [e-mail]).