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ReprintSurgery,Thomauoa.gr.

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� 2010

doi:10.1

510 S

Medical students’ perceptions onfactors influencing a surgical career:The fate of general surgery in GreeceEmmanouil Pikoulis, MD,a Efthimios D. Avgerinos, MD,a Xanthi Pedeli, PhD,b Ioannis Karavokyros,MD,a Neofitos Bassios, MD,a and Sofia Anagnostopoulou, MD,c Athens, Greece

Background. A decline of medical students’ interest in a general surgery career is occurring in theWestern medical world. We sought data on the mentality of Greek students toward specialty selection,and we determined whether trends indicated a decline in interest for general surgery in Greece.Methods. A structured questionnaire was distributed to 3 groups of medical students: to pre-4th-year(group 1) surgical clerkship, post-4th-year (group 2) surgical clerkship, and post-6th-year internshipstudents in surgery (group 3). The questions covered a wide spectrum of data including career choices,influential factors, and satisfaction rates on educational and training issues.Results. From a total of 500 distributed questionnaires 363 were returned. Most students (63.1%)indicated preference toward nonsurgical (medical) specialties. Surgical specialties within the 3 groupsgathered 19.5% (group 1), 26.5% (group 2) and 31.2% (group 3) preference rates. Among surgicalspecialties, general surgery was chosen by 29.4% in group 1, 10.0% in group 2, and 17.9% ingroup 3. The most common criterion for specialty selection was ‘‘quality of life’’ (68.6%) among group1 students and ‘‘patient contact’’ for group 2 and group 3 students (77.3% and 65.3%, respectively).Among the 96 students who chose surgical specialties, the most common criterion for specialty selectionwas ‘‘scientific challenge’’ (100%) in group 1 and ‘‘patient contact’’ in groups 2 and 3 (62.5% and69.2%, respectively). The 3 more frequently chosen factors that influenced the ‘‘picture’’ of surgerypositively were attending live surgery cases in the operating room (37.6%), clinical experience (29.6%),and patient care (14.4%), followed by assisting in the operating room (8.8%).Conclusion. Our survey suggests a limited interest of Greek medical students for surgical specialties andgeneral surgery in particular. As the medical curriculum is restructured, our data underscore the needfor actions by surgical educators and medical school authorities so as to enhance the interest of medicalstudents in general surgery in Greece. (Surgery 2010;148:510-5.)

From the First Department of Surgery,a University of Athens, Laiko General Hospital, Athens; and theDepartments of Hygiene and Epidemiology,b and Anatomy,c University of Athens Medical School, Athens, Greece

RECENT REPORTS FROM SEVERAL COUNTRIES indicate adecrease of the number of medical students inter-ested in a career in general surgery.1-7 Lifestyle,income potential, clerkship experience, quality ofmentorship (role modeling), and training obliga-tions have been identified as responsible factorsfor this decline.8-12 At the same time and underthe increasing demand for subspecialized surgicalpractitioners, several medical schools have gradu-ally started to reform their surgical clerkships toincorporate the existing surgical subspecialties.13

d for publication January 18, 2010.

requests: Emmanouil Pikoulis, MD, First Department ofUniversity of Athens, Laiko General Hospital, 17 AgiouStreet, 11527 Athens, Greece. E-mail: mpikoul@med.

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Mosby, Inc. All rights reserved.

016/j.surg.2010.01.013

URGERY

Although the crucial role of the general surgeonin any health system remains well established, thecombination of a decreased interest for a surgicalcareer together with the increasing need for surgi-cal subspecialization is of concern, as it may resulteventually in a shortage of practitioners in generalsurgery.

In the current study, we attempted to investigatethe mentality of Greek students toward specialtyselection in 3 steps of their medical curriculum.We sought to determine possible trends indicatinga decline in interest for general surgery and toexplore factors exerting a negative and/or positiveinfluence on the preference for surgical specialtiesand general surgery in particular.

MATERIALS AND METHODS

A structured questionnaire was distributed dur-ing the 2006--2007 academic year to students ofAthens School of Medicine (currently representing

Table I. Major specialty selection within student groups

Pre-4th-year surgicalclerkship n (%)

Post-4th-year surgicalclerkship n (%)

Post-6th-year surgicalclerkship N (%) P value

Do not know 2 (2.3) 17 (11.3) 6 (4.8) .705Surgical 17 (19.5) 40 (26.5) 39 (31.2) .061Nonsurgical 68 (78.2) 88 (58.3) 73 (58.4) .006Laboratory* 0 (0.0) 6 (4.0) 7 (5.6) .036

*Indicative results (expected frequencies <5).

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approximately half of the total Greek medicalstudent cohort) during their surgical clerkship orinternship at Laikon University Hospital. We sam-pled 3 groups of students as follows: those imme-diately prior to the 4th-year’s surgical clerkship(group 1), those immediately after the 4th-year’ssurgical clerkship (group 2), and those enrolled inthe final year’s internship in surgery (group 3).The University of Athens Institutional ReviewBoard approved this study.

Questions in the survey offered objective answers(ie, true/false, multiple choice, Likert scale [1--5,strongly disagree to strongly agree], and choicerank). The questions covered the sociodemo-graphic profile, career choices, and criteria at thatpoint of their education and whether they felt moreor less likely to pursue a career in either generalsurgery or other surgical subspecialties. The post-internship survey included additional questions onthe surgical rotation, such as whether educationalobjectives were met, their opinion of their educa-tors, and their satisfaction rate on theoretical andclinical/practical education. Students were alsoasked to describe the factors that had a positiveinfluence on their perception for a surgical career.

STATISTICAL ANALYSIS

The different students’ academic levels werecompared with respect to the recorded informa-tion through the application of chi-square tests fortrend in proportions. The exception was the ques-tion ‘‘If you had to choose a specialty now, howlikely would it be a surgical one?’’ (1 = unlikely to10 = very likely), for which a linear regressionmodel was adopted with the score as dependentvariable and dummy variables indicating the groupof students as covariates, which is equivalent to atest for linear trend. A statistical analysis wasperformed in SPSS 15.0 for Windows (SPSS Inc.,Chicago, IL) and the level of statistical significancewas set equal to a = .05.

RESULTS

Out of 500 distributed questionnaires, 363 werereturned (response rate 72.6%): 87 questionnaires

were from group 1, 151 questionnaires were fromgroup 2, and 125 questionnaires were from group 3.

Specialty selection. Most students preferrednonsurgical (medical) careers. Surgical specialtiesaltogether gathered a 19.5%, 26.5%, and 31.2% ingroups 1, 2, and 3, respectively, which indicated aprogressive increase of preference after ‘‘surgical’’exposure (Table I).

The surgical specialty selection within the 3student groups was as follows: 29.4% (highestranking among all surgical specialties) in group1, 10.0% in group 2, and 17.9% (second highestranking after obstetrics and gynecology) in group3 indicated they chose the general surgery spe-cialty. The final results indicated that 5.58% of allgraduates intended to choose general surgery.

In the question ‘‘If you had to choose a specialtynow, how likely would it be a surgical one?’’ (1 =unlikely to 10 = very likely) the average ranking was5.12 ± 3; when unfolded into subgroups, the resultswere 4.7 ± 2.4 for group 1, 5.45 ± 3.1 for group 2,and 5 ± 3.3 for group 3. The differences were notstatistically significant.

Criteria for specialty selection. We analyzed thisquestion in 2 different ways: In the first approach,we considered the criterion chosen irrespective ofthe rank given (ie, we considered all the criteria[AC] a student marked; Table II). In the secondapproach, only the first criterion [FC] ranked(Table II) was considered.

The most frequent criterion for specialty selec-tion among group 1 students was ‘‘quality of life’’(68.6%), but for those of group 2 and group 3, themost frequently ranked criterion was replaced by‘‘patient contact’’ with a frequency of 77.3% and65.3%, respectively (Table II). For most respon-dents, the first criterion for specialty selection was‘‘interaction with patients’’ (42.9%), followed by‘‘scientific challenge’’ (26.2%), ‘‘other’’ (14.2%),and the ‘‘controllable lifestyle’’ (10.0%). Thewithin-groups rates are summarized in Table II.

Among the 96 students who chose surgicalspecialties, the most frequent criterion for selec-tion was ‘‘scientific challenge’’ (100%) for group1 and ‘‘patient contact’’ for groups 2 and 3 (62.5%

Table II. Criteria for specialty selection among all students

Pre-4th-year surgicalclerkship n (%)

Post-4th-year surgicalclerkship n (%)

Post-6th-year surgicalclerkship n (%) P value

Patient contact ACy 29 (33.7) 110 (77.3) 81 (65.3) <.001FC 24 (27.9) 83 (55.7) 47 (37.9) .346

Active tempo ACy 17 (19.8) 38 (25.3) 35 (28.2) .172FC 2 (2.3) 11 (7.4) 9 (7.3) .175

Quality of life ACy 59 (68.6) 43 (28.7) 39 (31.5) <.001FC 4 (4.7) 12 (8.1) 20 (16.1) .005

Scientific challenge ACy 47 (54.7) 70 (46.7) 71 (57.3) .563FC 40 (46.5) 24 (16.1) 30 (24.2) .002

Short waiting list ACy 4 (4.7) 15 (10.0) 8 (6.5) .761FC* 0 (0.0) 1 (0.7) 1 (0.8) .461

Other ACy* 0 (0.0) 2 (1.3) 1 (0.8) .601FC 16 (18.6) 18 (12.1) 17 (13.7) .381

*Indicative results (expected frequencies <5).yRelative frequencies do not sum to 100% because participants may have selected more than 1 criterion.

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and 69.2%, respectively; Table III). In this subpop-ulation of students, ‘‘scientific challenge’’ was themost common (31.6%) first criterion for specialtyselection, followed by ‘‘patient interaction’’(35.8%) and ‘‘active tempo’’ (16.8 %). Thewithin-groups rates of selection are summarizedin Table III.

Specializing abroad. A total of 83.1% of studentsconsidered the possibility of specializing abroad.These rates were equal for both surgical andnonsurgical proponents (83.3% and 83.0%,respectively).

Student views for surgical education and faculty.This part of the questionnaire concerned onlypostinterns. Using a 1 (worse) to 10 (best) scale,the students’ average rating for their surgicalrotation in total was 6.5 ± 2.2.

The 3 most common factors that exert a positiveinfluence on the ‘‘picture’’ of surgery were asfollows: attending live surgery cases in the operat-ing theater (37.6%), obtaining clinical experience(29.6%), and providing patient care (14.4%),followed by assisting in the operating room(8.8%). Interrelations with the faculty, the resi-dents, and the nursing stuff ranked among theleast influential factors.

In addition, 36% of students claimed (agreed orstrongly agreed) that they were offered efficienteducational material; 50% claimed (agreed orstrongly agreed) that their ward training was effec-tive, and 40% claimed (agreed or strongly agreed)that their training in the operating room wasefficient. Overall, 56% of students claimed (agreedor strongly agreed) that the faculty were effective.

A total of 43% (36% of those selecting surgicalspecialties versus 48% of those selecting

nonsurgical specialties, P = .221) agreed orstrongly agreed that the theoretical part of surgicaleducation corresponded to their expectations.What the students liked most were lectures(63%), and they liked the books (43%) the least.

Overall, 40% agreed or strongly agreed that thepractical/clinical part of surgical education corre-sponded with their expectations. What they likedmost was attending operations (57%), and theyliked the limited assisting potential in the operat-ing room (43%) the least.

DISCUSSION

The career choices made by medical students andtheir preference on specialty selection have beenstudied extensively by multiple foreign universities,13

as they affect both the ‘‘maintenance’’ and the‘‘evolution’’ of any health system. Our survey de-tected a limited interest of Greek medical studentsin surgical specialties and particularly in general sur-gery, which raises concern about the adequacy of thegeneral surgery workforce in the Greek NationalHealth System in the future. The current oversupplyof doctors in Greece,14 who aim to find positions invarious subspecialties,13 probably will not offer an an-swer. The data derived from the Athens MedicalCouncil, which represents approximately 35% ofthe whole cohort of registered Greek doctors, con-firm our findings: The percentage of general sur-geons in Athens decreased from 4.24% in 2002, to4.01% in 2005, and to 3.85% in 2008.15

The medical school curriculum in Greece con-sists of 6 years. The first 3 years are spent on basicsciences (preclinical), whereas clinical educationand training are offered during the last 3 years.Surgical ‘‘stimuli’’ commence with the 4th-year’s

Table III. Criteria for specialty selection among students who wish to pursue a surgical career

Pre-4th-year surgicalclerkship n (%)

Post-4th-year surgicalclerkship n (%)

Post-6th-year surgicalclerkship n (%) P value

Patient contact ACy 3 (18.8) 25 (62.5) 27 (69.2) .002FC 3 (18.8) 17 (42.5) 14 (35.9) .414

Active tempo ACy 0 (0.0) 19 (47.5) 21 (53.8) .001FC 0 (0.0) 8 (20.0) 8 (20.5) .119

Quality of life ACy 13 (81.3) 7 (17.5) 6 (15.4) <.001FC* 0 (0.0) 3 (7.5) 4 (10.3) .212

Scientific challenge ACy 16 (100.0) 19 (47.5) 24 (61.5) .067FC 13 (81.3) 7 (17.5) 10 (25.6) .002

Short waiting list ACy* 0 (0.0) 4 (10.0) 1 (2.6) .894FC* 0 (0.0) 0 (0.0) 0 (0.0) —

Other ACy* 0 (0.0) 1 (2.5) 0 (0.0) .737FC* 0 (0.0) 5 (12.5) 3 (7.7) .588

*Indicative results (expected frequencies <5).yRelative frequencies do not sum to 100% because participants may have selected more than 1 criterion.

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surgical clerkship, which consists of theoreticallessons and limited exposure to surgical patients.Stimulation is maximized during the 3-monthinternship in general surgery in the 6th year, whichincludes active engagement in clinical practice andattendance in the operating room. After gradua-tion, young doctors serve for 1 year as entirelyindependent general practitioners in the Greekcounties (‘‘compulsory rural service’’). At thattime, they become eligible to apply for a residencyprogram. Acceptance and enrollment in residencyprograms is a long process that involves waitingperiods determined by the demand of the specialtyand the availability of a post at the chosen univer-sity or general hospital.

Throughout their studentship, most Greekmedical students seem to prefer a nonsurgicalcareer, although the preference rate for surgicalspecialties doubles after the 6th-year internshipcompared with the one before the 4th-year clerk-ship. The small interest of students, particularlybefore the 4th-year’s clerkship, may indicate thelack of surgical stimuli during the preclinical years.In contrast, the positive attitude toward a surgicalcareer is enhanced gradually and increasingly aftertheir clinical training.

Among the surgical specialties, general surgeryseems considerably popular (highest ranking) inthe preclinical years (29.4%), but the preferencedecreases with the 4th-year’s clerkship (10%) andincreases after the 6th-year’s internship to the sec-ond most preferable specialty (17.9%). The abruptdecrease of preference at the end of the 4th-year’sclerkship can be attributed to a possible inadequacyof our training system to meet the presumably highexpectations of our students and denotes a need for

improvement. The 3 most common factors thatinfluenced the ‘‘picture’’ of surgery positively wereattendance of operations, accumulation of clinicalexperience, and involvement in patient care. Thesefactors indicate that ‘‘surgical exposure of goodquality’’ plays a critical role in attracting studentstoward a surgical career.

The first impression of surgery for a medicalstudent is often generated during the 4th-yearclerkship and is frequently the strongest.16 A nega-tive 4th-year educational experience can radicallyaffect his or her choice in a career in general sur-gery. In our case, after the 4th-year clerkship, oursurgically oriented respondents turned to othersurgical specialties (eg, orthopedics or obstetricsand gynecology). Although the impact of the vastand demanding field of general surgery cannotbe overemphasized, a role for this disappointmentcan be found in the lack of inspiring teachers (rolemodels) and in the absence of clinical--educationalinteraction. Furthermore, as a variable amount ofteaching occasionally falls on the residents, the pic-ture becomes more unappealing.17,18

The decrease of the popularity of general sur-gery we detected in our country might not beuniversal, as applications to surgery remain stableor are increasing in areas of Southeast Asia, SouthAmerica, and Middle East.19-21 However, evidencesuggests that a decline has occurred in both inter-est and recruitment in general surgery in most ofthe Western world, including North America(United States and Canada),1,2,4,7 Australia,6 andthe United Kingdom.3,5 Therefore, this trend is aphenomenon not only in Greece but also in theWestern world, and it reflects potentially a globalchange that has to be addressed.

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A significant portion of today’s medical studentsis choosing more lifestyle friendly specialties inmany countries.1,10 We verified that quality of lifegreatly influences the selection of specialty. TheEuropean Working Time Directive has not yetbeen implemented in Greece. The effect of the48-h work week on the students’ career choice re-mains to be observed. Nevertheless, our surgery-oriented students, who mostly seek the scientificchallenge, seem willing to conform to a surgical ca-reer in its current form.

Another aspect highlighted by our survey is theissues that cause dissatisfaction from the currenteducational system of surgery. Current educa-tional materials and textbooks, as well as theeffectiveness of faculty, all contributed to a nega-tive preference toward surgery. Because the med-ical curriculum needs to be restructured, theresults of our survey may assist in determiningwhich actions should be undertaken by surgicaleducators and medical school authorities. Surgicaleducation should be incorporated in the preclin-ical years, and the general surgery rotation has tobe reformed. The students’ education should besupervised by devoted surgical teachers (poten-tially acting as role models) and not by busyclinicians. Rotation tasks should include specificward duties, clinical management initiatives, the-ater familiarization and assistance, and technicalskill acquisition. We know that the higher theexposure to the surgical field, the higher theapplication rates for general surgery will be.22-29

Consequently, direct contact with the surgicalfield must be an essential component of surgicaleducation. Finally, reinforcing the faculty--studentinteraction cannot be overemphasized.

Our study was limited to only 1 medical school.Although currently this school is the largest inGreece, a bias may exist if generalization isattempted. In contrast, the opinion and choice ofthe respondents will continue to evolve up to thelast minute before applying for a specialty. It wouldcertainly be interesting to follow up our sample asa cohort in the years to come.

We would like to acknowledge Ms F. Perdikologos forher kind contribution to the English ascription of themanuscript and S. Georgopoulos, E. Felekouras, T.Troupis, J. Griniatsos, C. Klonaris, and O. Michail fortheir support in protocol design and data analysis.

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