Attracting Medical Students to Understaffed Fields

A shortage of physicians in any medical specialty or subspecialty represents a threat not only to patients but to the field of medicine. When the supply of physicians in any field is insufficient to meet the demand for their services, patient care ideally provided by specialists is likely to be provided by nonspecialists, or perhaps even by nonphysicians. A workforce shortage also interferes with the ability of physicians in understaffed specialties to develop good working liaisons with physicians in other fields. This may compromise patient care by interfering with the development of effective interdisciplinary collaborations. Finally, a workforce shortage may make the field even less attractive to medical students who might otherwise enter it, because they see practitioners as overworked and stressed out.

The etiologies of workforce shortages are complex. For example, production may be insufficient. Consider the advice given to students during their training. During the early and mid-1990s, students at many US medical schools were discouraged from entering subspecialties, which were seen as oversupplied, and encouraged to enter primary care fields. By the mid to late 1990s, the number of applicants to specialties such as anesthesiology and radiology had fallen markedly. Other factors affect demand. These include population growth (which stimulates demand for all medical specialties), demographics (the demand for geriatricians increases with the number of elderly people), and the introduction of additional services by specialists in the field (such as the effect of the introduction of MRI on the demand for radiologists).

If we are to cope effectively with workforce shortages, we need to gain a clearer understanding of the factors that influence medical student career decision making. We need to understand what factors weigh most heavily in their career choices. What makes one medical specialty more attractive than another? Why do some medical specialties seem so unattractive to so many students? In this sphere, perception is more important than reality. How do medical students appraise the strengths of an understaffed field? What do they see as its weaknesses? What features do they find attractive, and which tend to drive them away?

One factor that may undermine student interest is income. Students may be attracted to relatively highly remunerated specialties, and less attracted to fields that pay relatively poorly. Some may fear that a field is too subspecialized, narrowing their focus to an excessive degree to only a particular organ system and thus drawing them away from the "whole" patient. Others may worry that a specialty is too broad, rendering them "jacks of all trades but masters of none." Some may fear that opting for an understaffed medical specialty would leave them little time or energy to pursue a life outside medicine. Similarly, they may worry that faculty members in the field are too thinly stretched to provide good training. Some medical students may also have doubts about the patient populations characteristically served by the field. Some may find working with sick children emotionally stressful, and others may find a career caring for elderly patients with chronic diseases too depressing.

If we are to address the perceptual factors that contribute to workforce shortages in medicine, we need to get inside the minds of students to understand how they see each specialty. If we gain a clear understanding of those forces, we will be in a much stronger position to develop effective responses. The specific factors will vary from specialty to specialty, but there are also some general factors from which most any specialty could benefit.

Broadly speaking, there are two fundamentally different types of factors that affect student interest in a specialty, with two corresponding strategies for enhancement. These are extrinsic factors and intrinsic factors. Intrinsic factors concern the nature of the work performed by physicians in the specialty. Extrinsic factors lie outside the work itself. These might include compensation, flexibility of scheduling, ease of entry into the field, availability of allied health personnel in support roles, and the availability of new technologies to increase efficiency and decrease the less engaging aspects of clinical practice. Although such extrinsic factors certainly deserve to be addressed, they are not the focus of this discussion. What follows are brief descriptions of a number of the intrinsic factors, as well as strategies for addressing them.

One such factor is confidence. When medical students are exposed to a particular medical specialty during their training, do they develop sufficient confidence in their abilities to begin feeling comfortable at applying such knowledge and skills to the care of patients? In an effort to impress students with how smart we are or demanding our field is, how often do we simply overwhelm students with information, leaving them with the feeling that they could never approach mastery? One effective response to this problem would be to develop a clearly defined curriculum of what students could reasonably be expected to master and then giving them an opportunity to apply that knowledge during their training experience in the field. What specifically are they expected to learn and to be able to do, and what opportunities will they enjoy to contribute to the care of patients? The goal is not to make things unrealistically easy for students, but to give them an opportunity to develop a graduated mastery, or at least competency. No one, even the most accomplished expert in the field, knows everything, and we can do our field a favor by giving students an opportunity to feel they have acquitted themselves well as learners.

A related factor is expertise. Although similar at first glance to confidence, expertise involves a different dimension of mastery: namely, depth of understanding. If expectations for students are set at the right level, they can achieve most mastery and confidence in those learning objectives. They cannot, however, become masters in the field, because there simply isn't time. True expertise would require years, perhaps even decades. They can, however, get a taste of expertise by choosing a particular question or topic in the field and exploring it in depth, and then making a presentation on it at the end of their training experience. For example, a student might choose to investigate a particular disease, test, patient, or clinical presentation. One way of making learning especially rewarding to students is to seek out opportunities to put their new-found expertise to use in the care of patients. For example, if a student has made a particular inpatient her focus of study, she can be called upon to provide information needed for discharge planning and the like. There is a special kind of satisfaction to be found from knowing one thing really well, and we should make an effort to allow students to experience it.

Another factor is the academic side of the field. Student interest in a field may be enhanced by giving them an opportunity to participate in such academic pursuits as education and research. Every student can learn enough about a subject to teach it well to someone else,whether a patient, a more junior student, or a health professional in another field. Likewise, every medical student is intelligent enough to contribute in some way to investigation. The key is to move students out of the role of passive recipients of knowledge and into the active role of sharing or advancing it. The very brightest of our students will not be fully engaged by merely memorizing what someone else tells them they need to know. What they need are opportunities to see what they are capable of and to spread their intellectual wings.

Another factor that can influence student interest in a field is teaching excellence. We need to ensure that we as faculty members care about education out of more than a sense that our jobs may be on the line if we do not do at least a passable job of teaching. Of course, education should be a meaningful factor in career advancement, including promotion and tenure. Yet the best teaching is grounded in something more: a sense that education is one of the highest callings of a physician, and that excelling as an educator is one of the most rewarding aspects of a career in medicine. How can we help faculty find more fulfillment as educators? One way is to help them perform better at it. There is no question that some people seem to be more naturally gifted as teachers than others, but teaching is also a learnable art, and given the right opportunities, all of us can improve. Our career choices are powerfully influenced by the teachers with whom we come in contact, and specialties that boast the best teachers in the medical school will enjoy a competitive advantage in recruiting medical students. We can encourage good teaching by developing and supporting faculty development programs, and by recognizing outstanding teachers appropriately.

A related factor concerns the opportunities faculty members enjoy to teach. If the clinical workday is so overstuffed with patient care responsibilities that there is no time to seize important teaching opportunities, then education will suffer. This is not to say that academic physicians cannot be busy, but only that we cannot be too busy. We need sufficient time for meaningful educational interaction with students, including above all time at the point of patient care. Formal lectures and other didactic learning opportunities are also important, and must be protected if the education is to thrive. To find such time, it may be necessary for departments to add to their support staff, to install new technology to increase clinical efficiency, or even to permit an expanded workday to permit more time for student learning. The amount of time involved need not be great. Just one 30-minute session each day, or only a few days per week, can make a big difference in terms of student perception of a field's educational commitment.

Another often unrecognized factor is the presence of role models. Do students feel that the faculty in the field are good mentors? Do they see in them their future selves? Do they feel welcome and appreciated for their efforts? Do they feel that they can approach faculty members for advice? Above all, do they admire them? It is important that students see in faculty members a sincere dedication to the best interests of patients, and the fulfillment that grows out of it. We cannot afford to neglect the role of inspiration in career choice.

Finally, we need to ensure that medical students enjoy meaningful opportunities to contribute to the care of patients. Many young people enter medical school in hopes of making a difference in the lives of others, and it is primarily through face-to-face contact with patients that such satisfaction is likely to emerge. This is the very motivation that medicine most needs to reward. Hence we need to design the training experience accordingly, so that medical students can experience what it feels like to have a patient call you "my doctor." Likewise, medical students should enjoy meaningful responsibility for interacting with other health professionals in the care of their patients, including writing chart notes, requesting tests and procedures, and representing their patients in case conferences.

0 0

Post a comment