Why choose paediatrics? A systematic review of factors affecting choice of paediatrics as a career

Despite being at the undergraduate level, paediatrics lags behind most other medical and surgical specialties for postgraduate recruitment. As many individuals decide on their future career choice while still in medical school, it is important to identify the factors that attract individuals to a career in paediatrics. A systematic review of primary research articles was conducted searching Medline, Embase, ERIC and Google Scholar, in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses recommendations. Studies exploring medical student, junior doctor and current paediatricians’ perceptions of paediatrics were included. Factors affecting career choice were identied. Eight studies out of a possible 705 met the inclusion and were included in this review. Five key inuencing themes were identied. These were: early undergraduate and clinical exposure to paediatrics; the presence of role models and mentors; an enjoyable working atmosphere and varied clinical work; a personal commitment to paediatrics; and working with children. question/hypothesis; (b) appropriateness of data collection methods; (c) clear research methodology with reliable and valid data collection methods and analysis; (d) an acceptable response rate; (e) addressing confounding factors and biases; and (f) clear conclusions. For each criterion, any item rated 'yes' received +1 point, while any item rated 'no' or 'information not available' received +0 points. A cut-off mark of 7 was deemed to represent a 'high-quality' study.


Introduction
Paediatrics is a popular subject among medical students in the United Kingdom (UK). However, this enthusiasm does not translate to an equally high number of specialty training applications (1). Since 2016, paediatrics has had one of the lowest 'competition ratios' at ST1 level entry (2) with ' ll rates' below those for general medical and surgical training, and in decline (3).
There remain signi cant training rota vacancies across the UK(4), with concerns that these di culties in recruitment threaten child health (1). The Royal College of Paediatrics and Child Health (RCPCH) reported signi cant increases in service demand of 60-80% over the past decade, with forecasts of further increases of up to 145% in disease burden up to the year 2040 (5). Given this ongoing strain on the health service, recruitment of paediatricians must keep up with growing service demand.
Published literature suggests most students will choose their future career during medical school and that these early choices highly correlate with actual specialty destinations(6, 7). Policymakers must therefore understand the factors in uencing career choice and how to attract students to undersubscribed specialties.
Efforts have been made to identify factors in uencing choice of specialty, with broad explorations(8) or focus on general practice (9)(10)(11)(12), surgical specialities (13)(14)(15)(16) and internal medicine (17). To date, no such review exists for paediatrics. Therefore, this study aims to identify factors in uencing choice of paediatrics as a career through a systematic review of available literature, speci cally from the UK. Findings from this study can help inform strategies to best engage medical students and enhance the paediatric workforce.

Search strategy
A literature search of Medline, Embase, ERIC and Google Scholar was performed using the terms: 'career choice', 'career', 'paediatrics*' and 'paediatrician*'. References of selected articles were also searched.
Articles were screened by title and abstract to identify relevant literature and full-text articles then reviewed against inclusion and exclusion criteria. There was no date range limit.

Inclusion criteria
Eligible participants were de ned as individuals in medical school or doctors who had not already begun specialty training. Consideration was given to studies including currently practising paediatricians. Studies were limited to those performed in the UK due to differences in medical school course content and structure of medical training. Studies investigating career choice in general but not including information speci c to paediatrics were excluded. No restrictions were applied to study methodology.

Data extraction
This review followed the 2020 guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)(18). The PRISMA ow diagram is displayed in Figure 1.
Data was collated using a standardised form including information on the author, date of publication, study design, study population, methodology and key ndings ( Table 1). The vast heterogeneity of studies precluded a quantitative analysis of the data. Results 705 papers were identi ed of which eight met inclusion criteria and were relevant to the research question. Two were conference abstracts and one a conference poster. All papers were reviewed, and several themes identi ed.

Exposure to paediatrics
Undergraduate exposure was the most commonly stated reason for choosing paediatrics (20)(21)(22)(23). In a national survey of nearly 25,000 UK medical graduates from 1974-2002, undergraduate experience affected long-term career choice for paediatrics more so than for any other specialty (23). In an additional study, following clinical exposure, an additional 19% of students considered a career in paediatrics compared to prior undertaking the clinical attachment (22), while a separate study found involvement in a summer school increased self-reported likelihood of selecting paediatrics (24).
Furthermore, a dedicated careers workshop positively impacted medical student perceptions, with interest increasing from 70-77% (25). Additionally, experience of paediatrics in foundation years was found to be a positive contributing factor. Interestingly, in one study, working in the specialty as a junior doctor was found to be more in uential for career choice than experience as a student (23).

Role models
The importance of positive role models was identi ed in several papers. One study comprising eight semi-structured interviews with female consultant paediatricians found that role models or mentors were a signi cant in uence in choosing paediatrics(26).
For current medical students, the presence of role models, particularly those who were enthusiastic about their work and keen to teach, was vital. In one study, the mean Likert scores for paediatrician enthusiasm and being keen on teaching were the highest of all available motivating statements (22).

Working life
The holistic approach employed by paediatricians was identi ed as one factor encouraging individuals to pursue the specialty (27). An enjoyable working atmosphere and feeling a part of the team were further in uential factors (21,22). In addition, opportunities for multi-disciplinary and general team working were highlighted as other in uencers(26, 27).
A perceived informal and exible way of working on paediatric wards was identi ed as a positive factor(26), in addition to a clinically varied and rewarding workload (25). However, it cannot be ignored that paediatrics is viewed as a challenging speciality, particularly regarding work-life balance and out-ofhours working commitments. A signi cant proportion of medical students participating in a summer school identi ed long working hours as the most signi cant factor discouraging them from a career in paediatrics (24). Similarly, 60% of medical graduates surveyed identi ed poor quality of life, mainly due to long hours and arduous training, as a reason to 'reject' paediatrics(28).

Personal attributes
The concept of paediatrics being 'what I want to do' featured in several papers. In a survey of 127 nal year medical students investigating factors in uencing choice of paediatrics as a career, a personal desire to work in paediatrics was the most highly rated reason (22).
In a separate study of rst-year paediatric trainees, the most cited reason for choosing paediatrics was having personal attributes suitable to the speciality (20). Similarly, a survey of UK graduates found that paediatricians were strongly in uenced by their perceived enthusiasm and desire to do the speciality(23).

Working with children
Finally, enjoyment of working with children was a key in uencing factor (21,22). Semi-structured interviews performed by Moorkamp identi ed working with children as one of the main themes for why participants choose paediatrics(26).

Negative perceptions of paediatrics
Several studies also explored possible negative perceptions of paediatrics. The most frequently cited were the perceived long working hours with frequent on-call commitments(21, 24) and a poor work-life balance (20,21,27). A separate study exploring reasons for junior doctor rejection of specialities found the most commonly given reason for not pursuing paediatrics was the poor quality of life, which is not alleviated with seniority(28).

Discussion
This review has identi ed several factors positively in uencing paediatrics as a career choice (Table 2). In particular, enjoyable clinical attachments and role models were positively associated with medical student and junior doctor motivation to consider the speciality as their future career. However, there are several limitations to this review. The primary aim of this review was to investigate reasons why individuals choose to enter the speciality. The literature search has highlighted a lack of focussed studies addressing the relatively poor paediatric recruitment among medical students, with only three studies focussing on this cohort (22,24,25). Three of these studies were presented as conference abstracts or posters, making it di cult to fully appraise the methodology. One study investigated the effect of a paediatric summer school while the remaining two focussed on medical student perceptions of paediatrics before and after their paediatric clinical placement through surveys. While they were all able to identify positive indicators, drawing any rm conclusions is di cult. By the nature of the interventions employed, those studied are likely to already hold a positive view of paediatrics and an underlying motivation to pursue the speciality. In addition, surveying students immediately after their clinical placement is likely to result in more positive views of the specialty. Longitudinal studies exploring if those students who were positively in uenced by a clinical placement actually went on to apply for a training post would be very informative and provide much valued information aiding policy planning.
Given the lack of large-scale peer-reviewed studies exploring medical student perceptions of paediatrics, consideration was given to studies of working paediatricians. All the remaining ve studies explored current paediatricians' views of their speciality and reasons for their choice. One study employed semistructured interviews with eight female paediatric consultants in Yorkshire(26). While there was a range of seniority and primary place of work, all had quali ed before the introduction of Modernising Medical Careers and were currently working in one geographical area, thereby limiting generalisability to today's undergraduates. In addition, as well as being a retrospective study and so prone to recall bias, there was little exploration of how their medical school experiences may have in uenced their nal career choice. All the remaining four studies employed questionnaires to explore their research aims, limiting the information or opinions respondents can give.
Furthermore, none of the questionnaire-based studies provided information on pilot trials or validated survey tools and did not provide copies of the questionnaires used, making it di cult to appraise their reliability and validity. In particular, there is a risk of introducing acquiescence bias depending on question phrasing. While many of the questionnaire-based studies employed Likert scales, there was a difference in scales used making comparisons di cult. In addition, some studies did not provide information on the exact rating scale used, making it di cult to determine whether central tendency bias was avoided.
There was wide heterogeneity in the eight identi ed studies. None of the eight identi ed studies reviewed against a quality assessment tool were given a mark >7, the determined cut-off for a 'high-quality' study (19). Finally, many were single-centre trials and performed at a single point in time with no follow-up of participants.

Relevance to clinical practice
The RCPCH has recognised the di culty of recruitment into paediatrics, in particular the challenge of translating early medical school interest to speciality training applications (29). What is clear from this systematic review is that early and positive experiences of paediatrics are essential in forming medical student perceptions and interest. This was most evident in a national survey of graduates, which revealed that undergraduate exposure to paediatrics was more important for future career choice than in any other specialty (23).
A study in the United States explored the impact of a pilot project, 'Education in Pediatrics Across the Continuum (EPAC)' (30). Students were allowed to engage with a supplemental paediatric curriculum before clinical exposure to other medical or surgical specialities. As a result, all students in the intervention group described the bene t of increased exposure to paediatrics early in medical school to help shape their perceptions of the speciality.
This aligns with the results of several studies included in this review, highlighting the importance of early exposure to paediatrics. Most medical school curricula teach paediatrics towards the end of undergraduate training. Efforts therefore need to be made to incentivise medical student involvement in paediatrics much earlier (1). Medical student societies, such as 'Teddy Bear Hospital', are examples of such strategies (31). Local paediatric departmental engagement with medical schools and a variety of 'special study modules' can increase student engagement early on (29), while paediatric-focussed simulation-based courses have also been shown to increase foundation doctor interest in the specialty (32).
Several studies have also highlighted role models or mentors as critical determining factors for speciality choice (22,26). Both are essential in helping guide students through their professional development and career choices (33,34). While there are examples of established mentorship programmes for paediatric trainees (35), there is a lack of such programmes for medical students. Mallet et al. have proposed a paediatric training mentorship model aimed at building meaningful relationships throughout training (1).
Similarly, local departments should be encouraged to 'showcase' the variety of clinical work available, emphasising the rewarding multi-disciplinary team working and enjoyable clinical atmosphere on offer.
In addition to highlighting the many attractive aspects of paediatrics, it is also essential to be aware of and address any reservations students may have. One noteworthy observation from this review was that many individuals commented on the supposed di cult work-life balance and heavy out-of-hours commitment. Paediatrics has the highest proportion of trainees working less-than-full-time (LTFT), with the specialty being one of the rst to make LTFT applications easier for trainees (29). More should be done to highlight changes to postgraduate paediatric curriculums, providing more exible and ful lling training(1).
Career decision making is a complex and dynamic process, with many different factors in uencing individual choice resulting in matching of personal career needs to student perceptions of specialty characteristics(8). Experiences during medical school, in particular extra-curricular experiences, can powerfully shape student perceptions and subsequent career choices, as evidenced by studies exploring differences in career choices for students from different medical schools (7,36). This suggests that creating and implementing a uniform undergraduate paediatric curriculum is required to ensure students are offered equal exposure and opportunities to experience paediatrics. The RCPCH has created an undergraduate curriculum for child health (37), but it is unclear how medical schools have adopted this nationwide.

Implications for research
This systematic review has identi ed the need for more detailed research into medical student perceptions of paediatrics. Further exploration of the views of those not considering a career in paediatrics is warranted. Longitudinal studies would provide crucial information on why individuals are deterred from pursuing the speciality and better inform student and junior doctor engagement policies nationwide. Furthermore, this should be coupled with further research into the appropriate evidence-based strategies to employ to best achieve these goals, given the paucity of appropriate data currently available(38).

Conclusion
Paediatrics is a popular speciality among undergraduates, though this has not translated to a correspondingly high application rate for postgraduate training (1). Medical students are drawn by the enjoyable working atmosphere and wide clinical variety available, with clinical placements and extracurricular activities being meaningful in attracting and solidifying a student's desire to pursue the specialty. Given the importance of early clinical exposure in determining student motivation, paediatrics needs to do more to advertise this wide variety of clinical and research work available, starting early in medical school and continuing through to foundation training. Medical students need to be offered more opportunities to experience the specialty through student selected components, summer schools, or workshops. This requires coordination between medical schools and regional paediatric departments.
The creation of local mentorship programmes can guide students through their medical school journey and application for postgraduate training, ensuring early enthusiasm is not lost. As suggested by Fromme and Fagan, the paediatric workforce needs to promote the profession and brand paediatrics as a specialty where the 'most innovative, intellectually rigorous, and altruistic leaders practice' (39). More, high-quality and large-scale studies using standardised assessment tools are needed to fully appreciate medical student perceptions of paediatrics and thus aid policy planning at an undergraduate and postgraduate level.

Declarations
Funding: The authors have not declared a speci c grant for this research from any funding agency in the public, commercial or not-for-pro t sectors.
Competing interests: None declared.
Availability of data: Articles as referenced.
Code availability: Not applicable.
Ethic approval: Not applicable.
Consent to participate: Not applicable.

Consent for publication: Not applicable
Contributors: Conception and design of the study was carried out by MK and PV. Design of the data collection instrument, selection and analysis of papers and draft of the initial manuscript was performed by MK. Both authors contributed to the discussion and edited the manuscript.