Becoming a practicing physician requires the completion of an intensive and demanding residency program. In the final years of medical school, students must choose which of the 30 direct entry specialties they wish to specialize in as a career. Many factors can influence a student’s choice in career paths including lifestyle, location, and “fit”(1,2). The final years of medical school, also known as the clerkship years, are typically comprised of medical students getting first-hand experience in various medical fields. This serves a two-fold purpose: to create a comprehensive foundation of medical knowledge and to expose them to possible specialization career choices.
Each specialty can vary in the degree of patient information available to practitioners. Patients can present with vague, non-specific symptoms, such as diffuse abdominal pain, or exhibit clear presentations such as a fracture of the humerus due to a fall—or anywhere in between that spectrum. Different presentations are associated with different degrees of ambiguity in diagnoss, treatments, and prognosis. As such, different medical specializations and contexts may potentially be better suited to certain personality traits. Both tolerance of ambiguity and perfectionism are personality traits that vary across all persons, but not frequently researched in the context of medical education and thus are the focus of this study(3–5).
Tolerance of ambiguity (TOA) refers to how we perceive, respond to, and tolerate information that may lack credibility, and is uncertain (6–9). While interest in TOA in the medical field can be traced back to the early 1990s, studies have often led to conflicting results, with some showing a larger, but non-statistically significant, TOA in 3rd-year medical students (first year of clerkship experience in North American schools) (6) and others showing no difference (10). However, a recent review of 11 studies (Hancock and Mattick, 2020) concluded there was an association between a lower level of tolerance of ambiguity and lower psychological well-being amongst medical students and practicing doctors (3). Residents have been reported to have higher TOA compared to medical students (11). When examining baseline data of 13867 matriculating first-year medical students in the United States in 2013, higher TOA was seen in men and older individuals (12). Interestingly, there was a statistically significant relation between TOA and declared specialty of interest; those students pursuing specializations in Dermatology, Physical medicine, and rehabilitation, and otolaryngology have the lowest mean TOA scores in contrast to those selecting Psychiatry, Radiation Oncology, Emergency medicine, and Neurosurgery the highest TOA(13). However, this was an incidental finding and no further analyses were done. Other studies have shown that surgeons have a lower TOA than other physicians(14). However, we are not aware of research investigating how TOA changes with clinical exposure.
Perfectionism is a personality trait of interest in the medical field as it has been implicated in anxiety(15,16), depression(17), and burnout(18–20). While perfectionism may appear to have an intuitive definition, it is emerging to be a multi-dimensional construct. Although there are several models describing the composition of perfectionism, recent research has identified three measurable dimensions: rigid perfectionism, self-critical perfectionism, and narcissistic perfectionism(21). Rigid perfectionism is defined as requiring “flawless performance from the self”(22), self-critical perfectionism is defined as negative responses to flawed performances(23), and narcissistic perfectionism refers to expecting perfectionism from others in a grandiose, hypercritical, and entitled way (24). Medical students have been shown to have higher perfectionism scores than arts students, with maladaptive perfectionism being predictive of depression and academic distress(25), a result that has been replicated in other studies(18,26,27).
More recently, Leung et al (2019) described a personality profile of medical students linking TOA and high levels of maladaptive perfectionism, which in turn may underlie vulnerability to stress and ineffective coping(4). However, we are not aware of any studies investing how perfectionism may change with clinical training and experience and its relationship with TOA. Given that clerkship is the first time medical students are exposed to a clinical setting in a full time setting we sought to study medical students in this phase of their training. This study was guided by three research questions: 1) To what extent does relationship exist between TOA and perfectionism for medical students in their first year of clerkship? 2)How does clerkship modify these factors and/or their relationship? 3) Are perfectionism and TOA related to a student’s specialty choice?