Medical Education 1988, 22, 214-221

Career preferences and career outcomes of Australian medical students

M . C. S H A P I R O t , J. S . W E S T E R N t & D . S . A N D E R S O N $

t University of Queensland, St Lucia, Queensland and $Australian National University, Canberra

Summary. Students entering three Australian medical schools were followed over a 15-year period to trace both movement into the profes- sion and the longer-term outcomes of early career aspirations. A variety of student entry characteristics are examined together with aspirations, attainments and self-images. The results indicate that women, rather than men, are more likely to enter medical school with aspira- tions that involve specialty training. As they pro- ceed through medical school, both groups move away from the idea of pursuing specialty train- ing, although women tend to decide earlier than men that speciality practice is not for them. Women students are more likely than men to attain career goals if these involve general prac- tice and less likely to if these involve specializa- tion. The results indicate that although at graduation women medical practitioners have the same career goals and desires as men, if addi- tional training is required women are unlikely to have their aspirations fulfilled.

Key words: *career choice; *students, medical; Australia; sex factors; family practice; social class; specialties, medical; marriage

Introduction

It has been suggested that a substantial compo- nent ofthe process ofmedical education has to do with the development o f a professional identity

Correspondence: Ms M. C. Shapiro BA (Hons), Department of Anthropology and Sociology, Univer- sity of Queensland, St Lucia, Queensland 4067, Australia.

by students. The long training period, combined with internship and residency, provides the environment for young initiates to gain skills and capabilities whilst learning the attitudes and values that are perceived as appropriate to the profession. This ‘role acquisition’ is said to be communicated as a result of the contact students have with instructors, peers, patients and other health workers (Merton et a l . 1957). Through this process students are said to acquire a profes- sional identity.

Various researchers suggest that women may not be subject to the same formal and informal communications that men experience and that women may consequently emerge from their training with a professional self-image and iden- tity which differs from that reported by men. Often the development of interpersonal relations with mentors and colleagues is restricted to men (Oritz 1975). Rinke (1981) suggests that women are prevented from fully incorporating a profes- sional identity because of this tendency to exclude them from peer activities. Exclusion from informal networks also reduces women’s ability to operate within the power structure and may virtually eliminate the methods by which some students attain ‘sponsorship’ into high status positions. In this sense women may lack the control over medical resources in the form of support from teachers.

As medicine is largely male-centred, it seems not surprising to find that women report more role conflict and less role support as their medical training progresses (Loyd & Gartrell 1981). In medical school women must compete in a male world. Earlier socialization may impart tradi-

Career preferences and career outcomes of Australian students 21s

tionally ‘feminine’ characteristics to women stu- dents whereas medical training may stress assertiveness and independence, traditionally ‘masculine’ attributes. A degree of role conflict may result (Nadelson & Nothman 1972). When the woman medical student adopts the profes- sional role she may feel less comfortable than the man medical student, who is simply reinforcing his gender identity. The woman student’s male mentor may also feel less comfortable, as the behaviour the woman student is exhibiting is contrary to masculine expectations.

In addition to these factors, a variety of researchers have commented on the special prob- lems experienced by women in medicine who choose to marry (Lopate 1968; Westling- Wikstrand et al . 1970; Fett 1974; Brown & Klein 1982). To combine a medical career or a post- graduate training programme with child-care responsibilities may prove especially difficult. Several studies have found that when medical students are asked about marriage and child-care responsibilities some interesting contradictions arise (O’Connell & Beighton 1979; Bonar 1982). Many women realize that they have to organize their careers around the demands of family life. To offset the disadvantages that accrue from marriage and family responsibilities, some women may choose not to marry.

A question that needs to be investigated con- cerns the extent to which specific groups of medical practitioners achieve the goals and aspirations they see for themselves. It could be that some groups are disadvantaged in their attempt to move into specialty and postgraduate programmes. A further consideration germane is that little is known of Australian professionals. Most of the literature in this area comes from North America or the UK and may not be readily transposed to Australian conditions. T o our knowledge, there have been no longitudinal studies reporting the progress of Australian medical graduates through university and into later professional careers. A great deal has been written in Australia about the way in which the educational system works to ‘weed out’ students along class and gender lines prior to secondary education (Branson & Miller 1979; Connell et al . 1982) but there has been little interest in this process at the university level, in particular among specific professional groups.

It could be that the same ‘weeding-out’ process is working at both secondary and tertiary levels. As a consequence, women may be less likely than men to desire postgraduate education and specialization. To address these concerns, we need to consider a number of interlinking issues: ( I ) do women have the same aspirations as men?; (2) are the aspirations of men and women equally met? and (3) to what degree is class a factor in the career aspirations of students both men and women?

Methods

The study commenced in February 1967 when the entire intake of first-year students entering three Australian medical schools (at Melbourne, Monash and Queensland Universities) were given a self-administered questionnaire to com- plete. Questionnaires were given in the first week of the first year of the programme, which spans 6 years and typically recruits students directly from secondary school.

Data were collected over 1 5 years on eight different occasions. Earlier questionnaires inves- tigated a number of themes (Anderson & Western 1972) in addition to the career pre- ferences of students. In the area of career pre- ferences students were asked to indicate the field of medicine in which they would like to con- centrate their life’s work. The categories were general practice, specialty practice, research, teaching and undecided. Career outcomes have been restricted to two possible outcomes- general practice and specialty practice. The career data were obtained in 1982 when respondents were asked to report their career outcomes.

In 1967, at entry to the study, a 96% response rate resulted in a sample of 572 students. Ofthose students who entered medicine at the three universities, 401 graduated, with the majority of these graduating in 1972. A check of the Australian medical registrations shows that in 1972 a total of 878 medical graduates received their degrees from eight universities. The 401 students who were part of this study comprise some 46.4% of the 878 medical students who graduated in 1972. O f the 401 students who graduated, 285, or 71%, still remain in the sam- ple. The social background, gender and age of students, plus the university they attended, were

216 M. C. Shapiro et al.

contrasted to determine whether there were identifiable differences between those who remained in the study and those lost to follow- up. A number of attitudinal responses to profes- sional issues from university days were also com- pared. As there were no significant differences between the existing sample and the original group of graduates, and as the original group comprises some 46% of all graduate students from the year 1972, we believe we can have some confidence in the general applicability of our results within Australia.

Results and discussion

Tests of significance are not employed in the analyses reported below. The sample was not drawn at random from a defined population but represented specific cohorts from selected universities. Under this situation and following the argument put forward by Babbie (1975), Atkins & Jarrett (1981) and others, significance testing was decided not to be appropriate.

Entering students were found to comprise a homogeneous group drawn from predominately upper middle-class homes and with private school backgrounds. Thirteen per cent reported their parents were medical practitioners. Women, who made up 20% of the sample, differed in a number of ways. They were more likely to come from lower-income families, to have won a scholarship to university and to have decided on a medical career earlier than their men classmates. Women were also less likely to have friends commencing the medical course with them than were men. When asked to self-report the academic pass they expected to achieve, women expressed lower expectations than men.

Non-graduates

There were no gender differences between those who graduated in medicine and those who failed to finish the course. Differences did emerge depending on the student’s social support net- work. Students who entered medicine with one or more friends enrolled in the same course were more likely to graduate than those without friends in the course. Students who were living away from the parental home, especially if they were staying outside campus in lodgings or non- university colleges, were at a particular disadvan- tage with regard to finishing the course. Those who were living outside campus, with students or others, were twice as likely to fail to finish the course than were their classmates who lived either at home or on campus in residential stu- dent colleges.

Career preferences

Table I reports the preferred career choices students reported at three points in time: at the beginning of their course, 3 years later at the end of the preclinical programme and after a further 3 years, at graduation. The choice of general prac- tice as a career outcome was at its lowest at time of entry to university. At this point only one quarter of the group regarded general practice as the field of medicine in which they wished to work. As students moved into the clinical area, perhaps the more structured period, they tended increasingly to nominate general practice as their preferred option. This could be a function of the role models to which they were exposed, or more likely a realization that the opportunities for specialization were limited, As can be seen (Table I), there was little movement over the

Table I. Career preferences reported by medical students at three points in time during their medical course (column percentages)

Entry to medical Completion of pre- At graduation Preferred field course (1967) clinical years (1969) (1972)

General practice Specialty practice Teaching/other Undecided

2s 3 0 17 28

Career preferences and career outcomes of Australian students 217

training period in the number of people wishing to enter specialty practice.

Only a minority of students reported teaching or research as a career choice. The number had declined to around 6% at the time the preclinical training had been completed and remained cons- tant at this figure for the final 3 years. Lack of appropriate role models and difficulty of entry to the teaching-research areas very probably both contribute to this result.

Not all students made firm career choices. On each occasion surveyed, a little over one quarter reported they were unsure ofthe area of medicine in which they would like to work. The training period apparently did little to improve this situa- tion. It could be there were conflicting messages from teachers, community or peers, confusing the decision-making process. Additionally, stu- dents may have been delaying career commit- ments until after internship, when presumably political lobbying for ‘glamour’ positions is critical.

Class differences

Table z reports the career preferences of stu- dents at the three time periods already mentioned by the occupational status of their father reported at the time students entered university. General practice increasingly became the preferred career for all students as time progressed, although stu- dents from lower status backgrounds were more likely to make that choice at an earlier stage of their medical training than were students from higher status backgrounds, for whom the deci- sion was most likely to be made by time of

graduation. Specialty practice was a consistently preferred option of students from higher status backgrounds. This may be due to a realistic appraisal by lower status students of the added costs incurred in embarking on postgraduate education necessary for specialty practice, or it could be that the messages they receive from teachers encourage them to seek a career in general practice. The evidence of a positive rela- tionship between deferment of career decision and low status background may add further to the proposition that financial considerations are important. Forty-one per cent of students from low status backgrounds were still undecided at graduation as to their future career paths. Stu- dents from low status backgrounds may be deferring their decision-making until they see more clearly the financial options available to them.

Gender di&erences

Women were marginally less inclined than men towards general practice at the time of entry to the medical course, reflecting a difference in socio-economic status noted above. However, by the completion of the preclinical years the proportion of women stating a preference for general practice doubled, while the proportion of men making a similar choice remained the same. The men have ‘caught up’ with the women by graduation when slightly more than 40% ofboth groups are preferring general practice. Control- ling for the effect of socio-economic status reveals that other things being equal, women change their career aspirations at an earlier point

Table 2. Career preferences reported by medical students at three points in time during their medical course by fathers’ occupational status* (column percentages)

Fathers’ occupational status

Entry to medical Completion of pre- At graduation

High Low High Low High Low course (1967) clinical years (1969) (1972)

General practice 26 22 29 37 43 39 Specialty practice 3 0 29 37 25 26 15 Teaching/other 1 5 22 6 4 8 4 Undecided 28 26 27 3 3 23 41

Total 236 49 224 48 207 46 toccupational status has been collapsed into high, meaning white collar occupations,

and low, meaning blue collar occupations.

2 1 8 M . C. Shapiro et al.

Table 3. Career preferences of men and women undergraduates reported at three points in time during their medical course (column percentages)

Entry to medical Completion of pre- At graduation course (1967) clinical years (1969) (1972)

Preferred field Men Women Men Women Men Women

General practice 26 22 27 44 42 43

Teaching/other 17 19 7 2 7 9 Undecided 28 22 3 1 20 28 20

Total 225 60 217 5 5 200 53

Specialty practice 29 37 35 33 23 28

in time than men. By the completion of the pre- clinical years the proportion of women stating a preference for general practice doubled, while the proportion of men making a similar choice remained the same (Table 3) . This is more than likely a realistic response to the environment in which the women students find themselves. Firstly, there are few role models in medical school for women to emulate and secondly, women who are considering marriage may be acutely aware of the necessity to follow a career path that will not involve them in additional formal study.

Caveev outcomes

In considering career outcomes it is useful to ses whether students become more likely to match career preference with outcome as time progresses and graduation becomes imminent. Table 4 shows that to some degree this did occur. In the first column of the table the percentage of students correctly predicting their career in 1982 at time of entry to the medical course is given. In

the second and third columns the correct predic- tion of the 1982 career at completion of preclini- cal training and at graduation are provided.

As can be seen, predictions became more accurate with the passage of time. At time of entry to medical school 5 5 % of the students cor- rectly predicted the area of medicine they would be working in some 10 years later. By graduation this figure had risen to 65%. There were notice- able specialist-general practitioner differences. O f those students who stated at graduation that they wanted to become specialists, 52% were specialists in 1982; of those who stated that they wanted to work in general practice, 77% were working in that area of medicine in 1982. The corresponding percentages correctly predicting activity when questioned at time of entry to university were 41% and 69%.

Effects ofclass on outcomes

Socio-economic status, as measured by father’s occupation and father or relatives in the medical profession, was investigated to see if

Table 4. Percentage of medical students correctly predicting their professional activity in 1982 at three points in their training (column percentages)

Percentage correctly predicting professional activity in 1982 at:

Entry to medical Completion of pre- Graduation course (1967) clinical years ( I 969) ( 1972)

% % Yo 1982 career (n) (n) (n)

Specialist 41 45 52 (87) (93) (SY)

General practitioner 69 72 77 (74) (81) (10s)

Total current practitioners 5 5 58 65 (161) (174) (164)

Career preferences and career outcomes of Australian students 219

students from different socio-economic backgrounds had differing levels of success in predicting their subsequent career activities. There were no noticeable differences (results not shown). Once the students had decided on a career option, socio-economic origins appeared to play no part in realization of plans.

Effects of gender on outcomes

The percentage ofmen and women who stated a preference for general practice in medical school and who are now working in that area appears in Table 5 . At graduation two-thirds of men students correctly predicted that they would work in this area of medicine. However, women were very much better predictors, as 90% of women who said in their graduation year that they wanted to work in general practice were in fact working in that area in 1982.

There were differences, however, as far as specialty practice is concerned (Table 6). Women were very poor predictors. For those women who said they wanted to work as specialists there was very little relationship between preferences

and outcome. Less than 30% achieved their goal. This seems to support the earlier data which showed that women tend to move away from specialty aspirations earlier than men. Some women were apparently aware that their chances of entering specialties were remote; those who lacked foresight found their plans thwarted. Men on the other hand showed a slightly better suc- cess rate than they did for general practice.

Marriage and career outcomes

The marital status of respondents in 1982 is shown in Table 7. The majority of respondents, regardless of whether they are general practi- tioners or specialists, are married, or have been married at least once.

There were differences between the sexes. Men medical practitioners overwhelmingly tended to be married or have been married (Table 8). Women practitioners were different. They are more likely to remain unmarried, particularly if in speciality practice. Thirty-one per cent of women specialists stated that they have never married (Table 8). A closer examination of the

Table 5. Percentage of men and women medical students correctly predicting work in general practice in 1982 at three points in their training

Percentage correctly predicting general practice in 1982 at:

Entry to medical Completion of pre- Graduation course (1967) clinical years (1969) (1972)

YO YQ YO

(4 (4 (4 Men

Women

Table 6. Percentage of men and women medical students correctly predicting specialty practice in 1982 at three points in their training

Percentage correctly predicting specialty practice in 1982 at:

Entry to medical Completion of pre- Graduation course (1967) clinical years (1969) (1972)

Yo Yo YQ (4 (4 (4

220 M . C. Shapiro et a1

Table 7. The marital status of general practitioners and specialists in 1982 (column percentages)

General practioners Specialists

Never married I 0 17 Marriedldivorced 89 82

Total 150 103

Table 8. The marital status of general practitioners and specialists by gender (column percentages)

General practitioners Specialists

Men Women Men Women

Never married 9 12 4 31 Married/divorced 91 87 96 69 Total 109 41 94 13

data (not shown) revealed that women who had planned to be specialists, but failed to realize their plans, were more likely to report that they were married than women who had successfully realized their specialist plans. The numbers are quite small and the results should therefore be treated with caution. They are nevertheless con- sistent with the differential in family respon- sibilities and obligations that befall men and women.

Conclusion

Women entered the three Australian medical schools, on which the study has been based, with a high standard of academic achievement behind them. Even though they performed at a high level during the training period, they were less likely to attain the prestigious specialty qualifica- tions that one might expect or that their men colleagues achieved. The results show that women, rather than men, are more likely to decide against following a specialist career early in their training years. This may be in part a consequence of the ‘messages’ they receive from teachers and class-mates. Women may not be encouraged to maintain their desire for specialty training in the same way as men. It could also be that women come to see general practice as more compatible with the humanistic side of medicine and therefore turn towards general practice as a

career earlier than their men class-mates. This of course does not explain why women are not so successful as men in achieving specialty status.

The interesting finding is that at graduation women are as likely as men to be planning to move into specialty areas. Yet compared to men, women are markedly unsuccessful in attaining this goal. As women make up a minority group in medicine, their lack of success could be said to be a result of their minority status. However, the literature suggests that women may not receive the same ‘sponsorship’ as men and further, that many of the specialties that are open to men are not so readily open to women (Lorber 1984). Although there are no formal restrictions on women students entering specialization, the sex- ual division of labour may be such that certain specialties may be considered male domains. The problem may be further complicated for married women with children as ‘on-the-job’ child care facilities are seldom provided.

In addition to this, discrimination in a much more subtle guise may be at work. Early child- hood conditioning provides images of ideal societal and occupational male and female roles. The preferred female role is seen in terms of warmth, empathy, deference and dependence. An orientation towards home and family is basic. The expectation is that women will take charge of and coordinate all facets of family life. Contra- dictions arise for the woman who challenges this role by attempting to enter a male-dominated profession such as medicine.

The higher professions are characterized by the masculine role which implies independence, aggressiveness and a career orientation. Women who take on a profession run counter to societal expectations of them. ‘Being professional’ infers a total dedication and commitment to career regardless of domestic arrangements. The results suggest that some women may become aware of role strain early in their medical training and opt for career paths that involve less role conflict. Others choose not to marry and thus avoid the clash of career and family responsibilities. The evidence suggests that for married professional women, and no doubt most married women in the workforce, role conflict is an everyday reality limiting options and retarding professional growth. A not unusual statement by one of our women respondents exemplifies some of these

Career preferences and career outcomes of Australian students 22 I

frustrations:

’I have three small children and a workaholic for a husband. I can’t take on full-time work and feel competent in both my roles as wife arid mother and as a doctor.’

The present study showed a clear pattern in which women students were, in the main, obliged to change their specialty career goals or face the situation whereby their aspirations remained unfulfilled. The evidence suggests that women who were unlikely to attain their goals were those who failed to anticipate the role con- flict that was destined to arise when specialist training clashed with family demands. Class differentials were not significant in the realization of students’ plans. This is not surprising as the homogeneity of the medical student intake means that class differences are not great. While medical students still come from privileged social backgrounds, the proportion of women in medi- cal school has risen from around 20% in the 1960s to around 40% at the present time. The extent to which the present intake of women experience the same problems of realization of career goals, as reported in this paper, is unlikely to be known for another 1 5 years.

The data from this study suggest that many bright young women, who are attracted to medicine with an expectation ofsome freedom of occupational choice, fail to have this choice realized. The social system of medicine appears restricting for women graduates.

Although it may be recognized that women make a valuable contribution to medical practice the evidence from this study suggests that there are structural constraints to equality of access to scarce and valued positions.

References

Anderson D. & Western J. (1972) Professional socialisation. In: Socialisation in Australia (ed. by

F. J. Hunt), pp. 288-306. Angus and Robertson, Sydney.

Atkins L. & Jarrett D. (1981) The significance of sig- nificance tests. In: Demystifying Social Statistics (ed. by I. Miles & J. Evans), pp. 86109. Pluto Press, London.

Babbie E. (1975) The Practice of Social Research. Wadsworth Publishing, Belmont, California.

Bonar J. (1982) Sex differences in career and family plans of medical students. Journal of the American Medical Women’s Association 37, 30-4.

Branson J. & Miller D. (1979) Class, Sex and Education in Capitalist Society. Sorret Publishing, Victoria.

Brown S. & Klein R. (1982) Woman power in the medical hierarchy. Journal of the American Medical Women’s Association 37, I 55-64.

Connell R., Ashenden D., Kessler S. & Dowsett G. (1982) Making the Dtference: Schools, Family and Social Division. George, Allen and Unwin, Australia.

Fett I. (1974) Australian medical graduates. Medical Journal ofAustralia I , 689-98.

Lopate C. (1968) Women in Medicine. Johns Hopkins Press, Baltimore.

Lorber J. (1984) Women Physicians: Career Status and Power. Tavistock Publications, New York.

Loyd C. & Gartrell N. (1981) Sex differences in medical students mental health. AmericanJournal of Psychia- try 138, 1346-51.

Merton R., Reader G. & Kendall P. (1957) The Student Physician. Harvard University Press, Cambridge, Massachusetts.

Nadelson C. & Nothman M. (1972) The woman physician. Journal ofMedical Education 47, 176-83.

O’Connell M. & Beighton F. (1979) Students’ career plans and the medical profession. Journal ofMedical Education 54. 509-1 I .

Oritz I . (1975) Women and medicine: the process of professional incorporation. Journal of the American Medical Women’s Association 30, 18-30.

Rinke C. (1981) The economic and academic status of women physicians. Journal of the American Medical Women’s Association 245, 2305-6.

Westling-Wikstrand H., Monk A. & Thomas C. (1970) Some characteristics related to the career status of women physicians. johns Hopkins Medical Journal 127,273-86.

Received 5 September 1986; editorial comments to authors 20 November 1986; 6 March 1987; accepted for publication I I November 1987