This review has identified several factors positively influencing 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.
- Early preclinical exposure
- Early clinical exposure
- Role models and mentors
- Enjoyable working atmosphere
- Personal commitment
- Working with children
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 difficult 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 firm conclusions is difficult. 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 influenced 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 five studies explored current paediatricians’ views of their speciality and reasons for their choice. One study employed semi-structured interviews with eight female paediatric consultants in Yorkshire(26). While there was a range of seniority and primary place of work, all had qualified 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 influenced their final 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 difficult 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 difficult. In addition, some studies did not provide information on the exact rating scale used, making it difficult to determine whether central tendency bias was avoided.
There was wide heterogeneity in the eight identified studies. None of the eight identified 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 difficulty 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 benefit 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 difficult 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 first to make LTFT applications easier for trainees(29). More should be done to highlight changes to postgraduate paediatric curriculums, providing more flexible and fulfilling training(1).
Career decision making is a complex and dynamic process, with many different factors influencing 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 identified 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).