Dorsey ER, Jarjoura D, Rutecki GW. Influence of Controllable Lifestyle on Recent Trends in Specialty Choice by US Medical Students. JAMA. 2003;290(9):1173-1178. doi:10.1001/jama.290.9.1173
Author Affiliations: Evanston Northwestern Healthcare (Drs Dorsey and Rutecki) and The Feinberg School of Medicine, Northwestern University (Dr Rutecki), Chicago, Ill; and Northeastern Ohio Universities College of Medicine (Dr Jarjoura) Rootstown. Dr Dorsey is now at the University of Pennsylvania Medical Center Philadelphia.
Context Recent specialty choices of graduating US medical students suggest that
lifestyle may be an increasingly important factor in their career decision
Objective To determine whether and to what degree controllable lifestyle and other
specialty-related characteristics are associated with recent (1996-2002) changes
in the specialty preferences of US senior medical students.
Design and Setting Specialty preference was based on analysis of results from the National
Resident Matching Program, the San Francisco Matching Program, and the American
Urological Association Matching Program from 1996 to 2002. Specialty lifestyle
(controllable vs uncontrollable) was classified using earlier research. Log-linear
models were developed that examined specialty preference and the specialty's
controllability, income, work hours, and years of graduate medical education
Main Outcome Measure Proportion of variability in specialty preference from 1996 to 2002
explained by controllable lifestyle.
Results The specialty preferences of US senior medical students, as determined
by the distribution of applicants across selected specialties, changed significantly
from 1996 to 2002 (P<.001). In the log-linear
model, controllable lifestyle explained 55% of the variability in specialty
preference from 1996 to 2002 after controlling for income, work hours, and
years of graduate medical education required (P<.001).
Conclusion Perception of controllable lifestyle accounts for most of the variability
in recent changing patterns in the specialty choices of graduating US medical
Many factors influence the career specialty decisions that medical students
make.1- 8 These
factors range across a wide spectrum from individual characteristics such
as personality1 to anticipation of specialty-related
income.2- 6 Recently,
specialty-related lifestyle has drawn increased attention as US medical students
have applied in increasing numbers to radiology9- 11 and
anesthesiology9,10 programs and
in decreasing numbers to general surgery and family practice programs.9,10,12,13 Studies
have suggested that a so-called controllable lifestyle has become a determinant
in students' specialty selection criteria.8,13- 15 In
the context of the medical specialties, these studies have defined a controllable
lifestyle by the following characteristics: personal time free of practice
requirements for leisure, family, and avocational pursuits and control of
total weekly hours spent on professional responsibilities. This is related
to the amount of time remaining for activities independent of medical practice
and is a reflection both of total hours worked and number of nights on call.
In their study of 346 medical students from 9 US medical schools, Schwartz
et al8 found that students were most inclined
to select specialties that had fewer number of practice work hours per week,
allowed adequate time for the pursuit of avocational activities, and seemed
to have a decreased number of call nights. These aspects of lifestyle were
found to be more influential than more traditional motivators, such as remuneration,
prestige, and length of training.
Another study15 has suggested that lifestyle
is a factor in later career changes by physicians in practice. One hundred
twenty-three of 723 surveyed physicians changed to other specialties after
an initial practice experience. The respondents rated time for avocational
pursuits and family activities (both lifestyle issues) as important to their
decision. Finally, while the number of unfilled general surgery programs increased
from 5 in 1997 to 41 in 2001, the percentage of senior medical students who
perceived that general surgeons have "inadequate control over their time"
increased from 67% to 92%.13
Studies of the influence of lifestyle on specialty choice, however,
have yielded conflicting results.2,8,9,14 In
1989, Schwartz et al14 first introduced the
term controllable lifestyle, which was initially
defined as "control of work hours" and was related to choice of specialty.
In contrast, Kassebaum and Szenas3 analyzed
the 1993 Association of American Medical Colleges Medical School Graduation
Questionnaire (GQ) in an effort to examine lifestyle attributes and found
that for "the 1993 GQ respondents overall, . . . lifestyle variables . . .
were given relatively low ratings" in terms of influence. We sought to determine
whether the specialty preferences of US medical seniors have changed significantly
in recent years and, if so, to estimate the influence of controllable lifestyle
and other characteristics of medical specialties.
We examined only specialties to which US seniors could apply. Based
on data available from the 2000-2002 edition of Physician
Socioeconomic Statistics published by the American Medical Association
(AMA),16 the following 16 specialties were
identified for study: anesthesiology, dermatology, emergency medicine, family
practice, internal medicine, neurology, obstetrics and gynecology, ophthalmology,
orthopedic surgery, otolaryngology, pathology, pediatrics, psychiatry, radiology
(diagnostic), surgery (general), and urology.
For each of the selected specialties, the number of US seniors ranking
a particular specialty as his/her first choice from 1996 to 2002 was determined.
Data were gathered from the National Resident Matching Program (NRMP),17- 23 the
San Francisco Matching Program (SFMatch),24- 26 and
the American Urological Association (AUA) Residency Matching Program publications,
from Web sites, or directly through the organization (M. Galbreath, AUA residency
match coordinator, unpublished data, September 2002). For the NRMP, a specialty
was considered to be a first choice if a student ranked that specialty as
his/her first choice. For the SFMatch and the AUA Residency Matching Program,
which occur before the NRMP, a specialty was considered a student's first
choice if he/she submitted a rank list for that specialty. The number of US
applicants to internal medicine and general surgery reported by the NRMP included
applicants to both preliminary (1-year) and categorical positions.
Based on the work by Schwartz et al,8 the
16 specialties were classified as having either a controllable or uncontrollable
lifestyle. Orthopedic surgery and urology were considered surgical specialties
and thus classified as having an uncontrollable lifestyle.
The average income for each selected specialty was determined by averaging
the median net income after expenses, but before taxes, by specialty from
1993 to 1998 as reported in the AMA's Physician Socioeconomic
Statistics, 2000-2002 edition.16 An
average for this period was used because additional analysis (not reported)
found no significant differences among the income trends across specialties.
The work-hours variable was based on the average number of hours in
professional activities per week by specialty obtained for 1998 and 1999 as
reported in the AMA's Physician Socioeconomic Statistics.16,27 Finally, the years
of graduate medical education (GME) required for the selected specialties
were determined by the minimum years of residency required for each field.28Table 1 summarizes
these characteristics for each of the selected specialties.
To determine whether specialty preferences of US medical seniors changed
from 1996 to 2002, we analyzed a 2-way contingency table (year × specialty)and
computed a standard χ2 test of homogeneity of the distribution
of choices throughout the years.29 Log-linear
models were developed to determine the explanatory power of the 4 variables
(lifestyle, income, work hours, and years of GME required) on the change in
specialty preference. For clarity, the income variable for specialties was
dichotomized into higher or lower-than-average income. The same was done for
work hours. Log-linear models were estimated to include all 4 variables in
combination and each alone. The models excluded the year × specialty
90 df interaction effects (effects that model completely
the change in choices throughout the years). The degree to which each of the
4 variables could explain the change in preferences was determined by comparing
model deviances from the saturated model.28 Likelihood
ratio tests were used for generating P values. Significance
(α level) for each test of the 4 specialty characteristic variables
was set at .01. Analyses were performed with the SAS Proc GENMOD statistical
software program (SAS Institute Inc, Cary, NC).
Table 2 lists the number
and percentages of graduating US medical students who selected each specialty
as their first (or only) choice from 1996 to 2002. The change in percentages
across the years was significant (likelihood ratio χ290 = 2689, P<.001). For example, from 1996
to 2002, the proportion of US seniors ranking anesthesiology as their first
choice demonstrated an increasing trend from 1.2% to 6.4%, whereas the proportion
ranking surgery as their first choice showed a decreasing trend from 10.4%
In the log-linear model, controllable lifestyle, as a factor alone,
explained 37% of the variability in specialty preference from 1996 to 2002. Figure 1 shows the proportion of graduating
students ranking a specialty with a controllable lifestyle as their first
choice from 1996 to 2002. The linear increase in percentages during this period
is statistically significant (P<.001). After controlling
for income, work hours, and years of training, the percentage of variability
accounted for by controllable lifestyle increased from 37% to 55% (P<.001).
Income, work hours, and years of training each explained a statistically
significant proportion of the variability in preference, but none approaches
the explanatory power of controllable lifestyle. Average income, by itself,
explains 9% of the overall variability in specialty preference and, as shown
in Figure 1, demonstrates a trend
for seniors choosing specialties with above average incomes (P<.001). Work hours (Figure 1)
showed a trend in preference toward specialties with higher-than-average work
hours (P<.001), but work hours alone only accounted
for 2% of the variability in specialty preference. Finally, years of GME required
(Figure 2) also demonstrated a statistically
significant trend in favor of specialties with a minimum of 4 years of required
training (P<.001). However, isolating years of
required GME explained only 4% of the variability.
The 4 variables together explained 66% of the variability in specialty
preference from 1996 to 2002. To determine each variable's contribution to
the 66% figure required an arbitrary ordering of the inclusion of variables
into this model. In the most conservative test of the effect of controllability,
we ordered the variables as income, work hours, years of GME required, and
finally controllable lifestyle. This resulted in income explaining 9% of the
variability, 1% of work hours, and 0.3% of years of GME required. Even after
accounting for these sources of variance, controllable lifestyle still accounted
for 55% of the variability in temporal trends.
The increasing preference of US senior medical students for specialties
with a controllable lifestyle has significant implications. Chief among them
is an alteration in the distribution of US medical graduates and potentially
physicians in general by specialty. Family practice and general surgery residency
programs, for example, have experienced significantly lower fill rates during
the last 6 years. The proportion of positions in family practice filled by
US seniors has decreased from 73% in 1996 to 47% in 2002.17,23 For
general surgery, the comparable numbers declined from 89% to 75% during this
period.17,23 General surgery programs
ultimately filled more than 90% of their positions in 2002, whereas family
practice programs filled only 80% of their positions.23
The increasing number of women in medicine,30 the
rising level of debt among medical students,31 and
the changing reward structure in medicine (eg, as a result of decreasing professional
autonomy)32 suggest that lifestyle and income
will continue to be important factors in students' career choices. We have
previously suggested that lifestyle may be a critical factor that motivates
career changes for physicians already in practice.15,33 In
addition, the influence of lifestyle on specialty choice may be representative
of a larger societal trend. Individuals aged 24 through 38 years in 2003 reportedly
want time to devote to life outside work (for avocational pursuits) and thus
weigh lifestyle more heavily when choosing jobs.34,35 Other
professions, such as business36 and engineering,37 are also grappling with innovations that achieve
a balance between work and an outside-work lifestyle undisturbed by professional
Attempts to change lifestyle either during training or after the completion
of GME may have the potential to alter the future preferences of US medical
seniors. For example, the implementation of the 80-hour work week during residency,
as required by the Accreditation Council on Graduate Medical Education, may
mitigate differences among lifestyles specific to different specialties, at
least during residency. Whether lifestyle during and after residency correlates
in any significant way and to exactly what degree is not clear. Other factors,
such as the growth of group practices and the increasing separation of outpatient
and inpatient responsibilities (eg, the emergence of hospitalists), may affect
the lifestyle of different specialties and allow the practitioner more control
over the timing of professional commitments. Future research will be required
to gauge the impact that these and other changes will have on the contingencies
between lifestyle and specialty choice.
Our study has several limitations. First, the assignment of various
specialties to controllable or uncontrollable lifestyle may be open to debate.
Specialty-related lifestyles were initially classified as either controllable
or uncontrollable based on the determinations of Schwartz et al.8 Their
data were acquired from a questionnaire directed at 346 students from 9 medical
schools. Three factors (ie, number of work hours per week in practice, adequate
time remaining for avocational pursuits, and perceived number of call nights
during practice) clearly were weighted more highly than others that have been
more traditional motivators (ie, high remuneration and length of residency
program). The most strongly weighted were identified as lifestyle variables.
Although there may be a subjective component to the classification of certain
specialties (orthopedics is surgical and therefore uncontrollable), the preliminary
lifestyle attributes as determined by Schwartz et al8 have
been validated repeatedly. Large studies have supported lifestyle variables
as integral to physician satisfaction while in practice. Community tracking
of 12 474 physicians demonstrated that increased work hours are strongly
and positively associated with physician practice dissatisfaction.38 A northern California Kaiser study39 described
the perception of dermatology by graduating medical students as "one of the
most attractive (careers) owing to its controllable lifestyle." Even though
lifestyle criteria may have a certain degree of subjectivity, it appears that
the characteristics of lifestyle that affect medicine have been measured consistently
and are known to medical students and practitioners.
Second, it is possible that controllable lifestyle may interact with
other variables, such as income, work hours, and the years of GME required
for certification. In fact, we found a trend, albeit a small one, for US medical
seniors to choose specialties with longer-than-average work weeks, which would
be expected to contribute to a less attractive lifestyle. Our variable of
controllable lifestyle may thus capture other less tangible and even less
easily quantified influences that ultimately affect lifestyle.
Third, the data used to assess specialty preference, income, work hours,
and years of training required for board eligibility may have limitations.
The data for the matching programs reflect only the preferences of US seniors
who used the matching programs to select a residency. For example, in 1996,
a significant number of dermatology programs had not yet joined the NRMP.
This factor may have resulted in an underestimation of fourth-year medical
students' preferences for dermatology that particular year. This limitation
likely contributed to a small overstatement of the association between specialty
preference and controllable lifestyle. Other limitations, such as the inclusion
of both preliminary and categorical applicants for general surgery and internal
medicine in the NRMP data, likely artificially inflated the number of applicants
pursuing those fields. Some of the applicants to those fields were actually
pursuing other specialties (eg, ophthalmology) that require a preliminary
surgery or medicine year.
Fourth, the data on income, work hours, and years of required GME also
have limitations. The data on physician income and work hours do not match
the exact time frame that was used to determine specialty preference. Because
there was little variation across years, however, a single estimate for income
and work hours for each specialty was applied. A separate analysis (not reported)
confirmed the absence of significant differences in trends in physician income
by specialty from 1993 to 1998. The years of GME required reflect the minimum
requirement when, in fact, many applicants choose residencies with additional
years of training.
Finally, although our study found a strong association between the recent
specialty preferences of US medical seniors and controllable lifestyle, this
does not establish a causal relationship. Although controllable lifestyle
is likely important, clearly other factors are also part of what is a complex
career decision-making process that ultimately eventuates in a specific specialty
choice. In addition, many other factors may account for a large proportion
of the difference in preferences seen between 1996 and 2002. One such possible
factor is the trend away from primary care in recent years.9,10 This
transition may be contributing to the 42% decrease in the number of US seniors
applying to family practice residencies during the past 6 years, for example.
Other factors intrinsic to the individual, such as personality,6 age,
or sex, or characteristics of the specialty itself, such as the type of problems
encountered in practice7 or the continuing
development of new technologies, may be playing a role in the preferences
of US medical seniors.
Notwithstanding these limitations, our study found a strong association
between controllable lifestyle and the recent preferences of US medical seniors.
Over time, this could significantly alter the composition of the physician
workforce. More study is needed to investigate the present and future impact
of lifestyle issues in career choice.