A Survey of Medical Students’ Attitudes Concerning Career Decisions

There is currently a chronic shortage of surgeons, particularly cardiac surgeons, in Japan and worldwide. Additionally, the number of female medical students has been increasing worldwide; half of our university’s medical students are females. We assessed the attitudes of medical students regarding preferred lifestyles and specialties, aiming to identify strategies for increasing the number of surgeons in Japan. We conducted a questionnaire survey among second- and fth-year medical students at Aichi Medical University, to assess their career priorities and ideal lifestyles when choosing specialties. In total, 71 second-year (male:female, 36:35) and 55 fth-year (male:female, 27:28) students were surveyed. Differences were compared between school year and sex.


Conclusions
Most students had decided their ideal career path in the lower grades and desired controlled lifestyle. To increase the number of surgeons, it is necessary to improve surgeons' lifestyles, reduce their workloads, develop medical students' interest in surgery, and ensure development of useful skills.

Background
Perceived poor access to postgraduate training and heavy workload dissuade students worldwide from considering careers in surgery [1]; furthermore, interest in surgery among medical students has declined over the past decade [2]. Incompatibility with lifestyle or family commitments was noted to be the main reason for not wishing to pursue a career in surgery, which was closely followed by poor teaching of anatomy at medical school and perceived strong, competitive, and aggressive surgical culture [3]. The most common causes of attrition were the uncontrolled lifestyle of surgeons and choosing to pursue another specialty [3,4]. Uncontrolled lifestyle results from situations which surgeons must be available all times for emergent surgeries or high demand with a limited number of surgeons. In addition, limited exposure to surgery and the operating room during medical school may deter students from entering surgical careers [2]. Similar problems have also been noted in Japan [5,6].
Nearly half of the medical school graduates are females who are less likely to pursue a career in surgery [7]. Similarly, almost half of the medical students at our university are females, and female residents often discourage female medical students from pursuing a surgical career, speci cally because of the di culties in balancing pregnancy and motherhood with training [7].
Interestingly, however, residents in the United Kingdom reportedly had a strong desire to choose cardiac surgery once they had an experience in the department [8]. Cardiothoracic surgery has been shown to be the least popular subspecialty for core surgical trainees across all surgical elds; however, among those who have had earlier experience in the specialty, it is immensely popular [8]. Some trainees have reported that workshops have a signi cant effect in in uencing undergraduate medical students toward a career in cardiothoracic surgery [9]. The present study aimed to assess the attitudes of medical students regarding preferred lifestyles and medical specialties, with the goal of identifying strategies for increasing the number of surgeons in Japan.

Methods
We conducted a questionnaire survey among second-and fth-year medical students at Aichi Medical University, Japan. A total of 71 second-year (36 males, 35 females) and 55 fth-year students (27 males, 28 females) were included. The differences in outcomes were compared between the school year and sex.
The survey comprised seven sections that included 23 questions ( Figure 1). The questions asked about the age, sex, ideal lifestyles, and specialty preferences of the medical students. Regarding an ideal lifestyle, questions about the students' career path, work-life balance, private life, wishes of having a family, and present vision of their future life were asked. The students were also asked about their priorities for decision-making, that is, if they were interested in a surgical career, in achieving job satisfaction, or in dedicating themselves to their work. They were also asked if they had concerns about heavy workload, working overtime or on nights and weekends, their personal welfare, harassment, salary, lawsuits, and having a good departmental atmosphere. The answers were assigned grades by the students to indicate their level of interest or concern.
The second-year medical students in our university study basic medicine and general liberal arts, and their questionnaire survey was administered in a class about professionalism. The fth-year medical students had started their rst-year clinical internship at Aichi Medical University Hospital, and their questionnaire survey was administered during their training in the Department of Cardiac Surgery.
However, in 2020, some students could not attend the training because of self-isolation due to the coronavirus disease 2019 outbreak.
All procedures were performed in accordance with the protocols of the Ethics Committee of Aichi Medical University Hospital. The identities of the students were protected. All students provided written consent regarding use of the data containing their answers in scienti c presentations or publications.

Data analysis and statistical methods
Continuous variables are expressed as the mean ± SD or median (range), and categorical variables are expressed as the number (%) of patients. Data were analysed by Fisher's exact test for categorical variables. Continuous variables were compared using the Student's t-test, whereas the Mann-Whitney Utest was used for nonparametric variables. All data analyses were performed with JMP 14.1 software (SAS Institute, Cary, NC, USA). P < 0.05 was considered statistically signi cant.

Results
Our study population comprised 126 medical students from one university. The response rate was 76% (71/93) for the second-year students and 42% (55/108) for the fth-year students. The response rate was small because of the abovementioned self-isolation of the fth-year students. Moreover, some students were absent from the class and refused to answer the questionnaire. There were 71 second-year students (33 females, 46%) and 55 fth-year students (27 females, 49%). Overall, 60 (48%) of the respondents were female.
The results for all students are shown in Fig. 2. Regarding the question about ideal lifestyles, few students considered becoming general surgeons (19%) or cardiac surgeons (14%), few were interested in dedication to work (7%) and career advancement (6%), and few were disinterested in having a family (14%). Regarding the question about their priorities for decision-making, most of the students focused on interest in the eld (92%), rewarding work (88%), acquiring useful skills (86%), and a good departmental atmosphere (92%).
Tables 1a and 1b present the results of the comparisons between the second-year and fth-year students. With increasing grade, more students tended to give importance to acquiring useful skills (p = 0.0021, Table 1b) and wanting to train in the neighboring Tokai area (p < 0.0001, Table 1a).

Discussion
Interest in surgery among medical students has declined over the past decade [2]. There has also been a tidal change in recruitment into cardiothoracic surgery careers, with declining applicant numbers in the United Kingdom [9]. In Canada, surgical specialties have also seen a reduction in applications, whereas an increasing proportion of applications for "controlled lifestyle" specialties, such as radiology, emergency medicine, and anesthesiology [2]. The cardiothoracic surgery subspecialty has a poor reputation because of the di cult lifestyle [10]. The shortage of cardiac surgeons is a global problem [11]. The major reasons for the decrease in the number of cardiac surgeons are uncontrolled lifestyle, competitive and aggressive culture, and very long training period [3]. Uncontrolled lifestyle results from situations which surgeons must be available all times for emergent surgeries or high demand with a limited number of surgeons. Here, in Japan, we suffer from the same crisis [5,12]. The present survey showed interesting similarities to previous ones conducted in other countries. Most students regardless of their school year or sex desired having a controlled lifestyle with their family in the future. Consistent with previous reports, the most common cause of attrition was the uncontrollable lifestyle of surgeons [4]. Peel et al. [2] found that most medical students did not see their lives as compatible with surgery, so they considered a career-focused surgical lifestyle as a primary deterrent to specializing in surgery.
Despite the introduction of national regulations on resident duty-hour restrictions in 2003, resident attrition remains a signi cant issue, particularly in general surgery training programs [4]. The same situation will probably occur in Japan when the work-style reformation program by the government will begin in 2024. To increase the number of surgeons, working surgeons should change their work-centered lifestyle into a controlled lifestyle that provides adequate work-life balance. The survey results reveal that appeal to medical students regarding dedication to work or career advancement would not be useful. Instead, we need to highlight good work environment and recognize most students' desire to have a family and be able to spend su cient time with them. Moreover, it goes without saying that prospective students should be interested in surgery and that rewarding work, acquisition of very useful skills, and good departmental atmosphere are important.
The present survey revealed that female students particularly considered a heavy workload to be a signi cant problem and were less likely to consider becoming surgeons compared with male students. One of the major reasons for the decrease in the number of cardiac surgeons is that the number of female medical students has been increasing. Female students are less likely to pursue a career in surgery [1]. According to an American survey of female surgical residents who were pregnant, 29% considered dropping out and nearly 30% would advise female medical students to pursue a different career [13]. The main cause of discouragement and attrition in female residents was the di culty in balancing pregnancy and motherhood with training [7]. The perception of sex discrimination is frequently reported during surgical experiences and has been shown to decrease interest in the pursuit of further surgical training [2]. The lack of female role models has also been reported as a cause of reduced interest in surgery among female students [2]. The present study revealed that female students were more impressed by medical problems than male students, but they were not interested in a career as a surgeon. We need to encourage talented and passionate female candidates to pursue surgical careers. To increase the number of female surgeons, working surgeons should seek to reduce their heavy workloads and change the work-centered lifestyle into a balanced lifestyle. Furthermore, we should eliminate sex discrimination and increase female role models.
Additionally, a national survey in the United Kingdom reported that poor teaching of anatomy to medical students was one of the reasons why residents did not choose to pursue a career in surgery. Some studies have reported that early exposure to surgeries and communication with surgeons was effective for increasing interest among medical students in surgical careers [3,14]. The Surgical Exploration and Discovery Program is a unique combination of (1) internship, (2) informal discussions on surgical careers, and (3) hands-on simulation workshops [14]. Participation in the program also positively in uenced their interest in pursuing a career in surgery [14]. The lack of female students' interest in cardiothoracic surgery may stem from a lack of experience in the eld during medical school [15]. Furthermore, Burnside et al. [8] reported that residents had a strong desire to choose cardiac surgery once they had gained experience in the eld of cardiac surgery. Cardiothoracic surgery has been shown to be the least popular subspecialty for surgical trainees, but it is immensely popular among those who have previously worked in the specialty [8]. In the present study, most students prioritized acquiring useful skills, working in a specialty that interested them, performing rewarding work, and a good departmental atmosphere when deciding their future career path. In accordance with these results, working and teaching surgeons should consider establishing good relationships with medical students in earlier grades before their clinical internship, emphasizing the attractions of cardiac surgery, and giving residents opportunities to acquire useful skills.

Study Limitations
Our study had several limitations. First, we were able to collect data from only one institution, which may undermine the general applicability of our ndings. Second, because our university is private, it may differ in some ways from national and public universities. Third, the results may not be universal because student awareness changes year to year. Nevertheless, our ndings provide some insight into how to overcome the current worldwide shortage of cardiothoracic surgeons.

Conclusion
Most students already decide their future course in the lower grades.
They desire having a controlled lifestyle with their family and were not as interested in strictly dedicating their lives to work or career advancement.
To increase the number of cardiac surgeons, surgeons should change our own lifestyles, decrease heavy workloads, establish good relationships with medical students in earlier grades, emphasize the attractions of cardiac surgery, and provide residents opportunities to acquire useful skills.