Choosing a career pathway in medicine is a high stakes decision for both medical students and the field of medicine as a whole. For medical students, selecting a residency has long term consequences impacting their future opportunities, income and lifestyle. In medicine, the career choices made by medical students impacts the composition of the physician workforce and access to care for the general population (Clinite et al., 2014; West & Dupras, 2012). As such, scholars have investigated numerous factors influencing this important decision, ranging from characteristics of medical students such as: admission scores (Ward et al., 2004), gender (Newton et al., 1998; van der Horst et al., 2010; Ward et al., 2004), marital status (Newton et al., 1998), debt (Bland et al., 1995; Grayson et al., 2012), interests and values (Newton et al., 1998), parents’ careers (Griffin & Hu, 2019; Ward et al., 2004), personality traits (Lepièce et al., 2016; Ward et al., 2004); characteristics of specialties such as: training requirements (Dorsey et al., 2003; van der Horst et al., 2010), income (Dorsey et al., 2003; Grayson et al., 2012), work hours (Dorsey et al., 2003), lifestyle (Clinite et al., 2014; Dorsey et al., 2003; Lefevre et al., 2010; Schwartz et al., 1995), patient problems (Lefevre et al., 2010; van der Horst et al., 2010), prestige (Newton et al., 1998); and characteristics of students’ experience in a specialty such as: mere exposure (Bland et al., 1995; Dobie et al., 1997; Maiorova et al., 2008; Mihalynuk et al., 2006), satisfaction (Schwartz et al., 1995), quality of patient relations (Ellsbury et al., 1998), and quality of teachers (Griffith et al., 2000; van der Horst et al., 2010).
Absent from this body of work is the role of temporal elements over which students may have no to limited control, such as timing and duration of access to career related information. Specifically, medical students’ clinical rotation schedules, exogenously determines the timing in which residency information is accessed and the duration of exposure to such information (Shah et al., 2013). However, the influence of these temporal factors on medical students’ career selection decisions has yet to be considered.
Given the importance of residency selection decisions, this body of work typically focuses on a rational purposeful decision-making process where students weigh the various factors to obtain the best match between their attributes and that of the specialty (Bland et al., 1995; Pfarrwaller et al., 2017) also known as subjective utility theory (Gorenflo et al., 1994; Reed et al., 2001). Indeed, the aforementioned temporal elements would be unlikely to influence decisions of this magnitude where all options are known, information of each is abundant and the decision is highly consequential. However, we draw from the decision bias literature to illustrate that both these temporal factors can influence even decisions of this magnitude.
The role of timing of first exposure on career selection decisions
While not typically investigated in medical career decision making, timing is an important factor in socialization, preference formation and decision making research. Socialization research finds that there is an early window of time when individuals are more susceptible to influence. Individuals transitioning into a new career are adjusting to new role demands resulting in heightened uncertainty, greater awareness of their external environment and reduced sense of self (Ibarra & Andrews, 1993; Pratt et al., 2006). Taken together, this experience results in greater receptivity and susceptibility to external influence. In the decision making domain, primacy research finds that we focus upon early information and discount that which comes later, resulting in a disproportionate influence of the former on our preferences and decisions, even in the context of medical decisions (Curley et al., 1988). Based on the belief-updating model, early information anchors our judgements and helps shape our preferences, while later information fails to get noticed or encoded as it lacks novelty or is assimilated based on preceding information (Hogarth & Einhorn, 1992; Tversky & Kahneman, 1974). Given these dual drivers, recent research on career selection decision of residents finds that subspecialty decisions are significantly influenced by rotations first experienced early in a resident’s schedule (Shah et al., 2013). In effect, rotations first experienced early in a medical student’s schedule are apt to be particularly influential especially as students are more susceptible to external information in the early stages of their career (Smith et al., 1997). More formally, we predict that the timing of first exposure to a residency option during medical students’ clinical rotations will influence their career selection decisions such that medical students are more likely to select residency options they experience earlier in their clinical rotations, even when controlling for relevant attributes of the options.
The role of duration of exposure on career selection decisions
In addition to the timing of first exposure, we also investigate how the duration of exposure to residency options influences residency selection decisions. Duration of exposure is defined as the amount of time medical students experience a rotation. Past research on medical career decisions does suggest that exposure to a profession plays a role in generating interest in and even selecting an area (Berman et al., 2012; Maiorova et al., 2008; Parlier et al., 2018; Shah et al., 2013; Yamane et al., 2020). Much of the earlier work provides a systematic review of the literature, case analysis or focuses on exposure to one or just a handful of specific residency options (Bland et al., 1995; Dobie et al., 1997; Maiorova et al., 2008; Mihalynuk et al., 2006); however, our study is the first to investigate the influence of exposure across all residency options available to medical students, while simultaneously controlling for both idiosyncratic characteristics of the residency options and students. We argue that greater exposure with a residency option provides an opportunity to reduce uncertainty as more knowledge is gained, more skills are learned and there is greater opportunity to assess fit with an option.
Decision making research finds that when access to information is not consistent across options, people often favor options in which they have greater experience or knowledge (Le Mens & Denrell, 2011). Career selection decisions in medicine are often plagued with uncertainty as residents feel uncomfortable settling on a choice and 62% of residents change their career plans at least once prior to the application deadline (Smith et al., 1997; West & Dupras, 2012). Uncertainty in career selection decisions can be based on inadequate understanding, incomplete information, conflicting information and undifferentiated alternatives (Lipshitz & Strauss, 1997). Greater exposure to a residency option results in greater awareness of and certainty about the merits and demerits associated with a residency option and the consequences of selecting the residency (Shah et al., 2013). In sum, we predict that the duration of a residency option during medical students’ clinical rotations will influence their career selection decisions such that medical students are more likely to select residency options they experience more often in their clinical rotations, even when controlling for relevant attributes of the options.
The interactive effect of timing of first exposure and duration of exposure on career selection decisions
While it is likely that medical students will select residency options that first appear early and more often over those that first appear later and less often, what happens when a residency option first appears later but for a greater period of time or early but for a shorter period of time? The initial anchor may be established when a residency option appears early in a medical student’s rotation schedule; however, if the experience is limited, the anchor may be less durable and susceptible to adjustment given the limited information (Shah et al., 2013). In contrast, greater duration of experience with a residency option appearing later provides more abundant information that is apt to mitigate the initial anchor of earlier appearing residency options. As such we predict that the duration of and timing of first exposure to a residency option during medical students’ clinical rotations will interact to influence their career selection decisions such that medical students are more likely to select residency options they experience later and more often in their clinical rotations, even when controlling for relevant attributes of the options.