Virtual Mentor. August 2006, Volume 8, Number 8: 529-532.

Medicine and Society

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The Influence of Controllable Lifestyle on Medical Student Specialty Choice

A physician discusses the trend towrad medical students selecting medical specialties based on the lifestyle they provide.

Jack S. Resneck Jr., MD

The field of dermatology is frequently cited as a beneficiary of recent trends among medical students to seek careers with more controllable lifestyles. Indeed, while the number of dermatology residency positions in the U.S. has remained relatively static at about 300 per year for more than three decades [1], the number of applicants has continued to climb [2]. A little bit of data and overwhelming anecdotal evidence suggest that the quality of those applicants only gets higher [3]. Students who have not performed at or near the top of their medical school classes often don't bother to apply, and many of us who serve on residency admission committees struggle to comprehend board scores and deans' letters that place so many of our applicants among the top one to two percent nationwide. We are constantly delighted (and bewildered) by how much these applicants have already accomplished in professional and other venues before seeking dermatology residencies.

A few other specialties described as "lifestyle-friendly" have reported similar experiences, particularly radiology [4], ophthalmology [5] and anesthesiology [6]. Meanwhile, an increasing number of general surgery residency programs are not filling their slots [7]. Primary care fields also have struggled to attract medical school graduates. The proportion of family practice residency positions filled by graduates of U.S. allopathic medical schools decreased from 73 percent in 1996 to 45 percent in 2005 [6,8].

Many have suggested that a quest for a manageable lifestyle—defined as having control of professional hours and thereby having more time for family, leisure and avocational pursuits—is what's driving the stampede out of primary care and general surgery [7,9-11]. Students entering dermatology, radiology, ophthalmology and anesthesiology cited lifestyle as being more influential in their career choice than did students who chose most other specialties [12]. Practicing as a physician in a field that has benefited from increasing interest, I can only hope that applicants are drawn to dermatology by far more than lifestyle considerations. The situation does, however, raise some basic questions. Should dermatologists feel guilty about their specialty's current popularity? Is there anything wrong with valuing life outside of clinical work?

Influence of lifestyle on specialty choice

Influence of lifestyle on specialty choice may represent a larger societal trend [13]. A growing body of evidence has noted the contrast between the attitudes towards careers exhibited by the baby boomers (born 1945–1964) and the generation Xers (born 1965–1980) [14]. Generation Xers are commonly described as having a desire for autonomy and flexible schedules, placing more emphasis on friends and family than on material success, and harboring some cynicism about larger organizations [15-17]. Members of this generation who are physicians may see the practice of medicine as only one part of their identity. Baby boomers, who are described as having a strong work ethic and loyalty to their employers [18], criticize generation Xers for their lack of commitment to their careers.

The appearance of generation X in the physician workforce has been accompanied by a dramatic increase in the number of women entering medicine. The majority of entrants to dermatology residency programs are now women, leading to a steady rise in the number of women in practice [19,20]. Some have suggested that the shifting gender balance in medicine has brought about the increasing popularity of more lifestyle-friendly specialties, but this is not supported by the evidence. While women in dermatology do work fewer hours during their child-bearing years, both women and men in medicine have shown similar rates of migration away from careers with less controllable lifestyles [2,21]. Contrary to what might be expected, a greater percentage of women than men actually choose careers with uncontrollable lifestyles [2,21].

In some cases, perceptions of work hours may not be accurate. Some dermatologists take ER calls, teach, perform research and work many more hours than alleged [22]. Nevertheless, it is true that dermatologists are working fewer hours than they did in the past [23], and, compared with specialties which by their nature involve a great deal of night and weekend time devoted to work, dermatology is certainly more flexible. This may be one of the factors leading to extremely high levels of job satisfaction among dermatologists. In one study, dermatology had the fourth highest proportion of "very satisfied" physicians of all specialties [24]. In a recent large survey, practicing dermatologists reported extremely high satisfaction levels (mean scores greater than 4 on a 5-point scale) with their careers, income and work-life balance [23].

Even to the extent that generational differences may be influencing specialty choice, an increasing desire for a controllable lifestyle may be only one of many factors. Medical students currently flocking to dermatology may also be influenced by their perceived personality fit with the specialty, skill-fit with the specialty, role models, clerkship experiences and anticipated income. Generation Xers might also be less influenced by pressures within medicine that have held specialties with intense work-hours to be more prestigious.

If controllable lifestyle is a driving factor, it is difficult to uniformly judge generation Xers (of whom I am one) who value their families and their interests outside of work and who choose specialties like dermatology (which I chose as well). On the other hand, many of us in generation X would like to have primary care doctors and general surgeons to care for us as we age. If we're going to replace the baby boomer doctors in those "lifestyle-unfriendly" specialties as they retire, we need to think carefully about how to redesign medical training, medical careers and health care delivery systems so that family physicians and general surgeons will have satisfaction levels as high as those of dermatologists. Maybe that will help ensure that members of "generation Y" or the "millennial generation" will choose those careers in the future.

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References

1. Resneck J Jr. Too few or too many dermatologists? Difficulties in assessing optimal workforce size. Arch Dermatol. 2001;137:1295-1301.
2. Lambert EM, Holmboe ES. The relationship between specialty choice and gender of U.S. medical students, 1990-2003. Acad Med. 2005;80:797-802.
3. Wu JJ, Tyring SK. The academic strength of current dermatology residency applicants. Dermatol Online J. 2003; 9:22. Available at: http://dermatology.cdlib.org/93/editorial/residency/wu2.html. Accessed July 5, 2006.
4. Anzilotti K, Kamin DS, Sunshine JH, Forman HP. Relative attractiveness of diagnostic radiology: assessment with data from the National Residency Matching Program and comparison with the strength of the job market. Radiology. 2001;221:87-91.
5. Andriole DA, Schechtman KB, Ryan K, Whelan A, Diemer K. How competitive is my surgical specialty? Am J Surg. 2002;184:1-5.
6. Pugno PA, Schmittling GT, Fetter GT Jr, Kahn NB Jr. Results of the 2005 national resident matching program: family medicine. Fam Med. 2005;37:555-564.
7. Bland KI, Isaacs G. Contemporary trends in student selection of medical specialties: the potential impact on general surgery. Arch Surg. 2002;137:259-267.
8. National Resident Matching Program. Tables 10-11. In: NRMP Data. Washington, DC: National Resident Matching Program;1996:14-15.
9. Schwartz RW, Haley JV, Williams C, et al. The controllable lifestyle factor and students' attitudes about specialty selection. Acad Med. 1990;65:207-210.
10. Schwartz RW, Jarecky RK, Strodel WE, Haley JV, Young B, Griffen WO Jr. Controllable lifestyle: a new factor in career choice by medical students. Acad Med. 1989;64:606-609.
11. Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA. 2003;290:1173-1178. Erratum in: JAMA. 2003;290:2666.
12. Newton DA, Grayson MS, Thompson LF. The variable influence of lifestyle and income on medical students' career specialty choices: data from two U.S. medical schools, 1998-2004. Acad Med. 2005;80:809-814.
13. Bond J, Galinsky E, Swanberg J. National Study of the Changing Workforce. New York, NY: Families and Work Institute; 1998.
14. Jovic E, Wallace JE, Lemaire J. The generation and gender shifts in medicine: an exploratory survey of internal medicine physicians. BMC Health Serv Res. 2006;6:55.
15. Washburn ER. Are you ready for Generation X? Physician Exec. 2000;26:51-57.
16. Wah L. Managing Gen Xers strategically. Manag Review. 2000;89:47.
17. Borges NJ, Manuel RS, Elam CL, Jones BJ. Comparing millennial and generation X medical students at one medical school. Acad Med. 2006;81:571-576.
18. Smola K, Sutton C. Generational differences: revisiting the generational work values for the new millennium. J Organ Behav. 2002;23:363-382.
19. Jacobson CC, Resneck JS Jr, Kimball AB. Generational differences in practice patterns of dermatologists in the United States: implications for workforce planning. Arch Dermatol. 2004;140:1477-1482.
20. Resneck J Jr, Kimball AB. The dermatology workforce shortage. J Am Acad Dermatol. 2004;50:50-54.
21. Dorsey ER, Jarjoura D, Rutecki GW. The influence of controllable lifestyle and sex on the specialty choices of graduating U.S. medical students, 1996-2003. Acad Med. 2005;80:791-796.
22. Resneck JS Jr, Tierney EP, Kimball AB. Challenges facing academic dermatology: survey data on the faculty workforce. J Am Acad Dermatol. 2006;54:211-216.
23. American Academy of Dermatology. 2002 and 2005 Practice Profile Surveys. Schaumburg, IL: American Academy of Dermatology; 2005.
24. Leigh JP, Kravitz RL, Schembri M, Samuels SJ, Mobley S. Physician career satisfaction across specialties. Arch Intern Med. 2002;162:1577-1584.

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Jack S. Resneck, Jr., MD, is assistant professor of dermatology and health policy with joint appointments in the Department of Dermatology and the Institute for Health Policy Studies at the University of California, San Francisco School of Medicine. His health policy research focuses on physician workforce issues and access to outpatient care.

Disclosure

Dr. Resneck serves in several positions that affect or are affected by physician workforce issues: he is chair of the Workforce Task Force of the American Academy of Dermatology, president of the California Society for Dermatology and Dermatologic Surgery, appointee to Council on Legislation of the American Medical Association and assistant director of the dermatology residency program at the University of California, San Francisco. Dr. Resneck is supported by a career development award from The Dermatology Foundation.