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- MD/MBA Students: An Analysis of Medical Student Career Choice

Career choice theory - Implications for medical students electing business training - Ginzburg and colleagues described vocational choice as part of a process taking place through many years of maturation. Early aspirations are eventually mediated by more realistic selections as a person has experiences and learns about his own capacities as well as the realities of the labor market and the resources available. The final choices represent a compromise between the person's interests, capacities and values as well as the opportunities and limitations in the world.2 In assessing occupational choice, Blau3 suggests that analysis of the processes followed by an individual in making occupational choices should be accompanied by a review of social and economic conditions. Social structure influences occupational choice in two ways: by influencing the personal development of the choosers and by defining the socioeconomic conditions of selection.4

In their 1985 book, Ernst and Yett cited three related hypotheses about physicians' career choice.5 The first is the "experiential" hypothesis that states that experiences during medical school and education are the most important influence on career. Second is the "taste" hypothesis, stating that students begin medical education with previously establish career plans, based on background and personality characteristics. The economics hypothesis, states that, all other factors equal, physician choice of career is determined by perceptions concerning maximized value of lifetime earnings. Little research has focused specifically on the impact of economic factors on specialty choice, but recent work by health economists has suggested that the potential for higher lifetime earnings increases the probability that a specialty is chosen.6

In a review of related literature by David and colleaques7, the two major areas of research on influences on medical career choice were identified as personal and societal. Sociologists and economists have increasingly begun to examine structural aspects of the labor market for health professions and have noted that economic and sociopolitical factors have become more of a constraint for physician career development. Societal and sociopolitical forces in career choice are often ignored in research, 6 and these factors could be most important in influencing medical students to seek business education.

Numerous studies have demonstrated that the major influences on educational and occupational choice and attainment are socioeconomic factors, intelligence, race and sex as well as mediating variables such as family and education. Yet studies that ignore factors such as the demand for labor and business cycles are inadequate.4 In the case of medical students, the decision to obtain the second degree may be more related to perceptions of demand for physician executives than the more traditional influences on educational choices.

It is generally believed that financial return is an element in the decision making process concerning careers and education. According to the human capital theory of career choice, individuals maximize financial gains over a lifetime by choosing an optimal mix of training and working. If investment in work skills is considered, education has a significant payoff. It appears that this holds true for business training for physicians. As the demand for physician executives increases, compensation levels have also risen. Recent compensation surveys reflect salary and compensation packages for physician executives well above the median for clinically based practicing physicians.8

According to Freeman9, students respond to the market in making career and education decisions, and career decisions are particularly impacted by the economic fortunes of high-level occupations such as medicine. Freeman characterizes a cobweb feedback system, which leads to market oscillations. As high salaries and job opportunities induce students to enter a field, a flood of graduates is produced a few years later. The surplus in turn reduces salaries and employment opportunities, with a subsequent influence on educational programs.

A similar pattern may be seen in dual degree programs. Currently, job opportunities for physician executives are plentiful, inducing medical schools to begin such programs. As the market niche fills, a related leveling effect may be seen in program growth and educational demand.

In offering dual degree educational programs, medical schools are influencing the career decisions of students. According to Levine4, schools and families are the two great "socializing agents" in our society. Schools directly influence educational and occupational choices by offering special programs of training, thus offering a context of opportunities and constraints within which career choices are made. By offering dual degree programs, medical schools are recognizing an exception to the traditional approach to medical education. Thus, they are influencing student’s career decisions as well as their perceptions of the legitimacy of the role and function of the physician executive.

In "Social Change, Organizational Diversity and Individual Careers", Michael Hanna10 considers theories of career choice behavior, analyzing relationships between careers and larger scale social change by focusing on the role of organizations as important intermediary actors. Institutional and organizational dynamics define a set of opportunities and constraints for an individual, while individual choices influence the dynamics of organization and institutions. Applied to the example of dual degree programs, one might suggest that organizations (medical schools) serve as a vehicle for expressing preferences of individuals or for affecting change in a larger system, whether by implementing new programs in response to the demand of individuals within the system (medical students) or the dictates of the larger social system (increasing market for physician executives). Either way, educational programs transmit the influence of the larger social system or market to individuals and vice versa.

Specifically, medical schools are offering new programs to provide physicians with business training. This provides the context for the changing role of physicians within society. The programs are developing new options and, as such, are enabling physicians to enhance their roles in the health care system. Consequently, changes in physician careers constitute larger scale social change within the health care system, as physicians reestablish themselves as leaders.

Most prospective physicians are set into a career track by the time they finish high school. One fourth of future physicians made this career choice before high school.12 Because career decision making often occurs early, redirecting the career plans of medical students toward business can be challenging. In addition, the traditional medical school culture does not encourage business training. In Boys in White, Becker and colleagues extensively profiled medical students of the 1950s, stating that the focus on patient care was one of the basic assumptions about future careers that students make when entering medical school. "Let us recall, first of all, that these students intend to go into the private practice of medicine. Though a few may conceive of alternatives, students ordinarily take it for granted that, sometime after graduation, they will be installed in a doctor's office, seeking and treating patients. They do not expect to go into research or into administration."11 Even the current medical student is usually attracted to medicine by visions of working in patient care and media-influenced notions of emergency treatment rather than the idea of working for a corporation or insurance company. To impact these perceptions, society and medical schools must value people who pursue less traditional paths in medicine. 13

The Influence of medical school - The medical school environment has a major impact on students' perceptions of the practice of medicine and their related career decisions. Medical school often represents the students' first contact with medical culture, the shared understanding and perspective of the medical profession.

The medical school experience presents a great deal of information that must be prioritized by the student. According to Becker, medical students quickly become aware that they cannot learn all of the material presented, thus they economize of learning by determining if something is important according to whether it is important in actual medical practice. Peter Conrad notes that, often material that is "triaged" as less important is related to the social and organizational aspects of medicine. The nature of the educational experience communicates priorities to students regarding education, such as business, that might be extraneous to "real" medicine, the clinical care. He observes that material related to the general theory behind problems such as historical points, social impact and cost factors can often be ignored by medical students as they focus on clinical details.14

According to Ajzen and Fishbein, behavior and intentions are a function of two factors: attitudes toward an act and the perceived normative beliefs of reference groups, mediated by the person's motivation to comply with group expectations.15 In regard to choices concerning business education, students' decisions are likely influenced by one important reference group in particular, other students. If the medical school culture is one of clinical superiority, negative beliefs toward business training and managerial roles for physicians may be reflected in the career decisions or attitudes of the students. By offering dual degree programs, medical schools are incorporating change to traditional medical education. Thus, the significant of the role of physician executives and business concept is enhanced.

Traditionally, the medical school culture has not encouraged interest in business education. This situation is influenced by the powerful reference groups and the medical school socialization process. Although the medical school culture is a powerful socializing force, and clinical training has been the sole focus, new programs are giving rise to change. Faculty serving as physician executives provide models to follow and emulate, and new initiatives such as dual degree programs are offering business training to medical students.

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