Obstetrics and Gynaecology as a Career Choice: A Cohort Study of Canadian Medical Students

EDUCATION EDUCATION

Obstetrics and Gynaecology as a Career Choice: A Cohort Study of Canadian Medical Students Ian M. Scott, MD, MSc,1 Trudy Nasmith, BA,2 Margot C. Gowans, M Nut Diet,1 Bruce J. Wright, MD,3 Fraser R. Brenneis, MD4 1

Department of Family Practice, University of British Columbia, Vancouver BC

2

Faculty of Medicine, McGill University, Montreal QC

3

Department of Family Medicine, University of Calgary, Calgary AB

4

Department of Family Medicine, University of Alberta, Edmonton AB

Abstract Objective: To describe the characteristics of medical students interested in obstetrics and gynaecology and to build a model that predicts which of these students will choose obstetrics and gynaecology as their career. Study Design: Students were surveyed in 2002, 2003, and 2004 at the commencement of their medical studies. Data were collected on career choice, attitudes to practice, and demographics at medical school entry and on career choice at medical school exit. Results: Three items present at entry to medical school were predictive of students ultimately choosing a career in obstetrics and gynaecology: having this career as one of their first three career choices at entry (having it as their first choice was the strongest predictor), being female, and desiring a narrow scope of practice. Conclusion: Students choosing a career in obstetrics and gynaecology have attributes at medical school entry that differentiate them from students interested in other specialties. Identifying these attributes may guide education in and recruitment to obstetrics and gynaecology.

Résumé Objectif : Décrire les caractéristiques des étudiants de médecine qui s’intéressent à l’obstétrique-gynécologie et bâtir un modèle permettant de prédire l’identité de ceux qui, parmi ces étudiants, feront carrière dans le domaine l’obstétrique-gynécologie. Conception de l’étude : En 2002, en 2003 et en 2004, nous avons mené un sondage auprès des étudiants qui en étaient aux débuts de leurs études de médecine. Nous avons recueilli des données sur le choix de carrière, les attitudes envers la pratique et les caractéristiques démographiques au moment de l’admission à la faculté de médecine, ainsi que sur le choix de carrière à la sortie de la faculté de médecine.

Key Words: Career choice, obstetrics and gynaecology, undergraduate medical education Competing Interests: None declared. Received on June 9, 2010 Accepted on July 22, 2010

Résultats : Trois paramètres présents au moment de l’admission à la faculté de médecine ont permis de prédire l’identité des étudiants qui, en bout de ligne, ont choisi une carrière en obstétrique-gynécologie : le fait d’avoir choisi cette carrière comme l’un de leurs trois premiers choix de carrière au moment de l’admission (lorsqu’ils en avaient fait leur premier choix, ce paramètre devenait le facteur prédictif le plus marqué), le fait d’être de sexe féminin et le souhait de rétrécir son champ de pratique. Conclusion : Les étudiants qui choisissent une carrière en obstétrique-gynécologie présentent, au moment de l’admission à la faculté de médecine, des attributs qui les différencient des étudiants s’intéressant à d’autres spécialités. L’identification de ces attributs pourrait guider l’enseignement et le recrutement dans le domaine de l’obstétrique-gynécologie. J Obstet Gynaecol Can 2010;32(11):1063–1069

INTRODUCTION

hile the birth rate in Canada has declined since the 1950s and 1960s, the absolute number of births continues to increase. In 2008–2009 a five-year peak was reached with 377 703 live births.1 At the same time, the number of physicians providing obstetrical care is declining. Between 1992 and 2002 the number of obstetriciangynaecologists providing obstetrical care in Ontario fell by 9% annually, with a large number of Canadian obstetriciangynaecologists planning to retire.2 In addition, the Canadian National Physician Survey showed a reduction in the proportion of family physicians offering intrapartum care from 13% in 20043 to 11.1% in 2007.4

W

In an effort to allow medical educators to target and support students who are most likely to choose a career in obstetrics and gynaecology, our study aimed to determine the variables that predict a student choosing a career in obstetrics and gynaecology. Thus this study supports a number of recommendations in “A National Birthing Initiative for Canada,” particularly Priority 3 (“Establish a NOVEMBER JOGC NOVEMBRE 2010 l 1063

EDUCATION

process for collection of data and information on maternity care providers and outcomes”).2 MATERIALS AND METHODS

From 2002 to 2004, students in 15 Canadian medical school classes were surveyed at the beginning of their medical studies. The resulting entry data were subsequently matched to first residency choices on graduation and analyzed for associations. The sample included three classes from the University of British Columbia (2002, 2003, and 2004); two classes each from the University of Calgary (2003, 2004), the University of Toronto (2003, 2004), McMaster University (2003, 2004), Queen’s University (2003, 2004), and the University of Western Ontario (2003, 2004); and one class each from the University of Alberta (2002) and the University of Ottawa (2003). This convenience sample included classes from half of the medical schools in Canada at that time, and was chosen because of contacts at and interest from these schools. Starting with schools in Western Canada we added schools from Ontario. This resulted in different sampling periods because some schools that started this research withdrew after one or more years. A 41-item survey was distributed to first-year students in these classes within two weeks of commencing their medical studies. Items in the survey were chosen based on a literature review and in consultation with medical students, residents, physicians, and educational leaders. The survey was also distributed to a subset of these same groups to verify item comprehensiveness and appropriateness. The survey was then piloted with one class and modified. Further details of the item selection and validation have been described elsewhere.5 On the survey students were asked to consider eight career options (emergency medicine, family medicine, internal medicine, obstetrics and gynaecology, pediatrics, psychiatry, surgery and “other” [a write-in choice]), to indicate which of these disciplines they considered for a possible career, and to rank their first three career choices. Students then evaluated the extent to which their career interests were influenced by 27 different items (Table 1) using a 5-point Likert scale ranging from 1 (no influence) to 5 (major influence). The survey also collected demographic data. In order to limit the number of statistical tests and thus reduce the possibility of spuriously significant results, student

ABBREVIATIONS CAPER

Canadian Post-M.D. Education Registry

CaRMS

Canadian Residency Matching Service

1064 l NOVEMBER JOGC NOVEMBRE 2010

career choices were collapsed into three groups based on a classification used by the Canadian Institute for Health Information.6 The three groups were family medicine, medical specialties, and surgical specialties. Obstetrics and gynaecology was excluded from the surgical specialties category in which it is classified by the Canadian Institute for Health Information,7 thus allowing students indicating an interest in obstetrics and gynaecology to be compared with other students interested in each of the three broad career options. This grouping of careers is appropriate from a practice perspective because obstetrics and gynaecology encompasses both surgical and medical interventions. Students’ entry data were then linked anonymously with their first CaRMS career choice by an independent third party, CAPER. CaRMS is a not-for-profit organization that provides an electronic application and residency matching service to all medical students entering postgraduate medical training in Canada.8 Established in 1986, CAPER is a partnership of professional medical organizations and federal, provincial, and territorial governments.9 Data analysis was performed using SPSS version 17.0 (SPSS Inc, Chicago, IL). Descriptive statistics were employed to profile the students interested in obstetrics and gynaecology. Demographic differences according to career interest were identified using analysis of variance with Scheffe’s post-hoc test for continuous variables and crosstabulation with the chi-square test statistic for categorical variables. Factor analysis was performed to condense the 27 career influences into a smaller number of overarching factors. To be included in a factor, variables were required to have an eigenvalue of > 1.0 and a factor loading of > 0.6. Analysis of variance with Scheffe’s post hoc test was used to identify differences in the resulting factors according to career interest. Logistic regression was used to identify the strongest predictors of career choice. In all cases, P £ 0.05 were considered statistically significant. Ethics approval for the study was provided by the University of British Columbia Research Ethics Board. RESULTS

A total of 1941 students who graduated from the 15 participating classes were eligible for the study, and 1542 students contributed to the final analysis (Figure). Of the eight possible career choices, 75 students (4.9%) applied for obstetrics and gynaecology on their CaRMS application. This was not significantly different from the 4.7% of students nationally who named obstetrics and gynaecology as their preferred career choice during the time period of data collection (c 2 = 0.092, df = 1, P = 0.76).10

Obstetrics and Gynaecology as a Career Choice: A Cohort Study of Canadian Medical Students

Recruitment and follow-up of cohort

Of the 75 students applying for an obstetrics and gynaecology residency, 21 (28.0%) had named this as their preferred career option on entry to medical school and 42 (56.0%) had included it as one of their first three choices on entry to medical school. In contrast, significantly fewer of the students applying for a residency other than obstetrics and gynaecology had named obstetrics and gynaecology as their preferred career option on entry to medical school (3.2%) or included it as one of their first three choices on entry to medical school (18.4%). Factor analysis condensed the 27 attitudinal variables studied into six factors containing 20 of these variables (Table 1). These factors, named by the authors according to their component variables, were Medical Lifestyle, Social Orientation, Prestige, Hospital Orientation, Varied Scope of Practice, and Role Model. The seven items not included in any factor were treated as separate variables in the subsequent analyses. Univariate analysis found five of these six factors, as well as three of the remaining seven items, to vary significantly according to career choice (Table 2).

Univariate analysis also showed students who chose a career in obstetrics and gynaecology differed from their colleagues in a number of demographic variables. (Table 2) Logistic regression analysis was then used to identify which variables could be used to predict a career choice of obstetrics and gynaecology (Table 3). Predictors of such a career choice were having named obstetrics and gynaecology as their first choice of career on entry to medical school, being female, and having an interest in a narrow scope of practice. With a specificity (true negative rate) of 71.0% and a sensitivity (true positive rate) of 80.0%, this logistic regression model predicted correctly whether or not a student named obstetrics and gynaecology as their first choice of career on their CaRMS application in 71.4% of cases. Only one variable (interest in a varied scope of practice) was identified as predictive of switching away from a career interest in obstetrics and gynaecology (OR 2.70; 95% CI 1.08 to 6.75). With a specificity of 81.0% and a sensitivity of 76.6%, this logistic regression model predicted correctly whether or not a student switched from obstetrics and NOVEMBER JOGC NOVEMBRE 2010 l 1065

EDUCATION

Table 1. The factors and underlying influences Factor 1. medical lifestyle

X. Flexibility outside of medicine V. Acceptable hours of practice W. Flexibility inside of medicine N. Acceptable on-call schedule Y. Keeping options open

Factor 2. societal orientation

U. Health promotion important L. Long-term relationship with patients F. Focus on patients in the community S. Social commitment

Factor 3. prestige

K. High income potential J. Adequate income to eliminate debt M. Status among colleagues T. Stable/secure future

Factor 4. hospital orientation

G. Focus on urgent care E. Focus on in-hospital care I. Results of interventions immediately available

Factor 5. varied scope of practice

A. Wide variety of patient problems B. Narrow variety of patient problems*

Factor 6. role model Z. Meaningful past experience with physician Q. Emulate a physician Items not loading into any factor

C. Good match to this career D. Interesting patient population H. Focus on non-urgent care O. Dislike for uncertainty P. Prefer medical to social problems R. Research interest AA. Short postgraduate training

gynaecology in 77.9% of cases. Two variables were found to predict which students would switch from a career interest other than obstetrics and gynaecology on entry to medical school to a residency application in obstetrics and gynaecology. These were having named obstetrics and gynaecology as one of their first three career preferences on entry to medical school (OR 1.92; 95% CI 1.05 to 3.50) and being female (OR 8.99; 95% CI 3.09 to 26.12). With a specificity of 64.3% and a sensitivity of 87.0%, this logistic regression model predicted correctly whether or not a student switched to obstetrics and gynaecology in 65.1% of cases. 1066 l NOVEMBER JOGC NOVEMBRE 2010

DISCUSSION

With the number of practising obstetricians in Canada decreasing, medical schools will need to either create more obstetrics and gynaecology residency positions or support an expanded role for other birth providers (family physicians, midwives, nurses).2 Should the decision be made to increase training positions, admission to medical school of an adequate supply of students interested in this career is vital. We analyzed our data in two ways: first examining the differences between students who choose a career in obstetrics and gynaecology, medical specialties, surgical specialties, or family medicine specialties, and then building a model that distinguished students who choose a career in obstetrics and gynaecology from all other students. Students who choose a career in obstetrics and gynaecology have demographic characteristics that distinguish them from those choosing careers in family medicine and the surgical and medical specialties. Most significantly, women were much more interested than men in obstetrics and gynaecology, and this is consistent with other studies.11–18 Nearly 95% of students in our study choosing a career in obstetrics and gynaecology were women, thus demonstrating that the future face of obstetrics and gynaecology will be at variance with the current workforce in which 44.7% of practising obstetrician-gynaecologists in Canada are female.6 Items not previously reported that were found in our study are that students interested in a career in obstetrics and gynaecology are younger, have higher parental education, have grown up in a larger town (vs. those interested in family medicine) and spent less of their childhood in a rural setting (vs. those interested in family medicine and surgical specialties). Students choosing a career in obstetrics and gynaecology demonstrated a mixture of attitudinal similarities to and differences from students choosing other surgical specialties, medical specialties, and family medicine. This attitudinal profile, present on entry to medical school, may reflect an “obstetrics and gynaecology personality” in students who ultimately choose a career in obstetrics and gynaecology. While we found that students interested in obstetrics and gynaecology in this study demonstrated a strong social orientation compared with students interested in other surgical specialties, their social orientation was lower than that of students choosing family medicine. This finding corroborates the work of Buddeberg-Fischer et al.,16 who reported that obstetrics and gynaecology residents show “people orientation” and have life goals aimed at satisfying social relationships. In addition, students interested in obstetrics and gynaecology also had a lower hospital orientation than their

Obstetrics and Gynaecology as a Career Choice: A Cohort Study of Canadian Medical Students

Table 2. Comparison of demographic and attitudinal factors according to exit career choice Obstetrics and gynaecology n = 75

Other surgical n = 285

Other medical n = 701

Family medicine n = 481

Age years

23.2

23.5

23.8

24.9*

Sex, % female

94.7

36.8*

57.3*

65.1*

Relationship status, % single

72.0

76.5

75.0

61.5

Pre-medical education, % postgraduate

21.3

16.1

18.5

18.1

Parental education, % postgraduate

53.3

49.5

46.8

37.0*

Family/friends practising medicine, %

33.3

45.3

40.8

33.5

Population of home town, % < 50 000

16.0

22.8

17.1

28.1*

Rural childhood, > 50%

13.3

24.2*

17.3

28.3*

Rural parents, %

20.0

23.9

18.7

30.1

Exit choice of career specialty

Factor and item scores, mean: Factor 1. Medical lifestyle

3.24

3.37

3.58*

3.72*

Factor 2. Social orientation

3.36

3.00*

3.32

3.74*

Factor 3. Prestige

1.75

2.19*

2.05*

1.8

Factor 4. Hospital orientation

2.89

3.36*

3.00

2.72

Factor 5. Varied scope of practice

2.87

3.18

3.31*

3.85*

Factor 6. Role model

2.77

2.85

2.73

2.69

Item P. Prefer medical to social problems

2.44

3.20*

2.58

2.12

Item R. Research interest

2.16

2.71*

2.57

1.95

Item AA. Short postgraduate training

1.58

1.57

1.83

2.26*

*P < 0.001 for difference from obstetrics and gynaecology group

Table 3. Multivariable logistic regression analysis of factors found to be significantly associated with an exit career choice of obstetrics and gynaecology Obstetrics and gynaecology residency choice n (%) or mean (SD)

Crude OR (95% CI)

aOR (95% CI)

Obstetrics and gynaecology career choice on entry Not considered

21 (12.0)

1.0*

1.0*

First choice

21 (29.5)

17.04 (8.80 to 32.98)

5.55 (2.67 to 11.56)

Second or third choice

10 (12.0)

3.61 (1.96 to 6.64)

1.84 (0.96 to 3.53)

Considered, but not in first three

23 (29.5)

1.19 (0.56 to 2.52)

0.77 (0.36 to 1.68)

2.9 (1.1)

0.60 (0.48 to 0.75)

0.75 (0.59 to 0.96)

Factor 5. varied scope of practice† Sex Male

4 (0.6)

1.0*

1.0*

Female

71 (8.0)

14.01 (5.09 to 38.55)

10.38 (3.59 to 30.03)

*reference category †Each unit increase on Likert scale is associated with the stated increase in the odds ratio.

NOVEMBER JOGC NOVEMBRE 2010 l 1067

EDUCATION

surgical colleagues, which may also signal such students’ interest in providing care in the community. Students choosing a career in obstetrics and gynaecology were less focused on prestige at medical school entry than students choosing surgical or medical careers. This factor included variables defining both status and income in our study. Blanchard et al.12 also found prestige and potential income to be among the least important factors for students considering a career in obstetrics and gynaecology. In contrast, McAlister et al.15 reported that students with no debt were less likely to choose obstetrics and gynaecology as their specialty, while Newton et al.19 found that income held large importance for students choosing a career in obstetrics and gynaecology. The reason for the disparity between these findings is not clear, but such heterogeneity may partially be due to all three studies being conducted in the United States, where the cost of education is higher. With the increasing debt load experience of medical graduates in Canada and the United States,20–22 a further investigation into the importance of income and prestige on Canadian final year students choosing a residency in obstetrics and gynaecology may be warranted. We found that students choosing obstetrics and gynaecology considered a varied scope of practice less important than students selecting medical or family medicine careers. This contrasts with the Blanchard et al. study that ranked variety of clinical experience as one of the most important factors influencing fourth-year students’ choice of obstetrics and gynaecology residency.12 The low importance that students who chose a career in obstetrics and gynaecology placed on lifestyle may represent an accurate assessment of the future expected lifestyle of their career, but the possible link between lifestyle expectations and declining interest in obstetrics as a career has engendered much concern among obstetrical educators.19,23–25 In an effort to predict which students at medical school entry would choose a career in obstetrics and gynaecology, we combined all students not choosing obstetrics and gynaecology and identified a small number of variables that could predict those students who would choose this career. We identified three variables that predicted with 71.4% accuracy which students entering medical school would go on to apply for a residency in obstetrics and gynaecology after graduation. Using these variables to identify these students may be useful in ensuring, through mentoring, involvement in interest groups, or targeted clinical experiences, that an adequate supply of interested students continues to choose this career. Of these, the factor most strongly predictive of a career choice in obstetrics and gynaecology was being female. This finding of women 1068 l NOVEMBER JOGC NOVEMBRE 2010

being particularly interested in obstetrics and gynaecology is consistent with that of many other studies.11–18 Also predictive of choosing a career in obstetrics and gynaecology was an interest in a narrow scope of practice. While this has been associated with a career choice in obstetrics and gynaecology, it has not to our knowledge been shown to be predictive at medical school entry of a student choosing a career in obstetrics and gynaecology at the end of medical school.23 An interest in obstetrics and gynaecology at entry to medical school was also a strong predictor of choosing obstetrics and gynaecology at graduation. Of the 75 students choosing obstetrics and gynaecology on graduation from medical school, over one quarter had named this as their first choice, and over one half had ranked obstetrics and gynaecology as one of their first three choices on entry to medical school. This early orientation to obstetrics and gynaecology has been seen in another study in which students were asked about their career intentions in the immediate pre-clerkship period.24 Our study, by surveying students in the first weeks of medical school, shows even more convincingly that many medical students begin their medical studies with clear ideas of what careers they will ultimately choose. Nevertheless, despite the strong association between entry career interests and final residency choice, a large number of students switched their interest from obstetrics and gynaecology as a career choice (47 students) or to obstetrics and gynaecology (54 students) during their schooling. Of particular interest to obstetrical educators is the finding that nearly half of the students who ultimately chose obstetrics and gynaecology at graduation did not have it as one of their first three career choices at medical school entry, thus demonstrating that a pool of medical students moves towards a career in obstetrics and gynaecology during their medical undergraduate studies. While previous studies have shown a number of the associations we identified, our study is unique in that it developed a predictive model based on demographics and a wide range of student attitudes at medical school entry that predicted a career choice in obstetrics and gynaecology at graduation. There are several limitations to this study. Our study sampled a subset of Canadian medical schools between 2002 and 2004 and may not be representative of other time frames and other populations. We asked students if they were interested in obstetrics and gynaecology as a career rather that whether they were interested in delivering babies. Given that not all practising obstetrician-gynaecologists provide obstetrical care, and that numerous students interested in intrapartum care opt for a career in family medicine, our findings may miss part of the picture. It should be noted that our attitudinal and demographic data

Obstetrics and Gynaecology as a Career Choice: A Cohort Study of Canadian Medical Students

were collected from entering students who had only experienced two weeks of medical school, and their attitudes to obstetrics and gynaecology are therefore based on perceptions at school entry. Given the small sample size of students choosing obstetrics and gynaecology, we may have missed some predictors of a career in this field. Thus, we would suggest our model be validated before it is applied widely. CONCLUSION

Students choosing a career in obstetrics and gynaecology at medical school exit have attributes at medical school entry that differentiate them from students interested in other specialties. Identification of these attributes may guide education in and recruitment to obstetrics and gynaecology. ACKNOWLEDGEMENTS

The authors wish to thank the undergraduate directors of family medicine and other staff members involved at the participating medical schools across Canada for their contribution to data collection, as well as the many students who volunteered their time for this study. They also wish to thank Sandra Banner and Jim Boone at CaRMS for providing the career choice data and Steve Slade at CAPER for linking the entry data with the CaRMS career choice data. Funding for this study was provided by the Council of Ontario Universities. REFERENCES 1. Statistics Canada. Births and birth rate, by province and territory: 2008/2009. Ottawa: Statistics Canada; 2010. Available at: http://www40.statcan.gc.ca/ l01/cst01/demo04a-eng.htm. Accessed May 29, 2010. 2. The Society of Obstetricians and Gynaecologists of Canada. A national birthing initiative for Canada. Ottawa: SOGC; 2008. Available at: http:// www.sogc.org/projects/pdf/BirthingStrategyVersioncJan2008.pdf. Accessed May 29, 2010. 3. College of Family Physicians of Canada. National Physician Survey 2004: Results for family physicians. Q8: Which of the following procedures do you perform as part of your practice? Available at: http://www.nationalphysiciansurvey.ca/ nps/results/PDF-e/SP/Specialty/Family_Med/CCFP_D.pdf. Accessed May 29, 2010. 4. College of Family Physicians of Canada. National Physician Survey, 2007. Results for family physicians/general practitioners. Q28b. Please indicate if you offer the following to your patients. Available at: http://www.nationalphysiciansurvey.ca/ nps/2007_Survey/Results/ENG/FP/Certification/Q28/Q28bi_combined.pdf. Accessed May 29, 2010. 5. Wright B, Scott I, Woloschuk W, Brenneis F, Bradley J. Career choice of new medical students at three Canadian universities: family medicine versus specialty medicine. CMAJ 2004;170:1920–4. 6. Canadian Institute for Health Information. Supply, distribution and migration of Canadian physicians, 2008. Ottawa: CIHI; 2009. Available at: http://www.secure.cihi.ca/cihiweb/products/SMDB_2008_e.pdf. Accessed May 28, 2010. 7. Canadian Institute for Health Information (CIHI). Full-time equivalent physicians report, fee-for-service physicians in Canada, 2004–2005. Ottawa:

CIHI; 2006. Available at: http://secure.cihi.ca/cihiweb/products/ FTE_2004_e.pdf. Accessed May 28, 2010. 8. Canadian Resident Matching Service (CaRMS). About CaRMS. Ottawa: CaRMS; 2010. Available at: http://www.carms.ca/eng/index.shtml. Accessed May 28, 2010. 9. Associated Faculties of Medicine of Canada (AFMC). The Canadian Post-M.D. Education Registry (CAPER). Ottawa: AFMC. Available at: http://www.afmc.ca/publications-caper-e.php. Accessed May 28, 2010. 10. Canadian Resident Matching Service (CaRMS). Operations: reports & statistics—R-1 match reports. Ottawa: CaRMS; 2010. Available at: http://www.carms.ca/eng/operations_R1reports_e.shtml Accessed May 28, 2010. 11. Fogarty CA, Bonebrake RG, Fleming AD, Haynatzki G. Obstetrics and gynecology—to be or not to be? Factors influencing one’s decision. Am J Obstet Gynecol 2003;189:652–4. 12. Blanchard MH, Autry AM, Brown HL, Musich JR, Kaufman L, Wells DR, et al. A multicenter study to determine motivating factors for residents pursuing obstetrics and gynecology. Am J Obstet Gynecol 2005;193:1835–41. 13. Schnuth RL, Vasilenko P, Mavis B, Marshall J. What influences medical students to pursue careers in obstetrics and gynecology? Am J Obstet Gynecol 2003;189:639–43. 14. Turner G, Lambert TW, Goldacre MJ, Barlow D. Career choices for obstetrics and gynaecology: national surveys of graduates of 1974–2002 from UK medical schools. BJOG 2006;113:350–6. 15. McAlister RP, Andriole DA, Rowland PA, Jeffe DB. Have predictors of obstetrics and gynecology career choice among contemporary US medical graduates changed over time? Am J Obstet Gynecol 2007;196:275.e1–7. 16. Buddeberg-Fischer B, Klaghofer R, Abel T, Buddeberg C. Swiss residents’ speciality choices—impact of gender, personality traits, career motivation and life goals. BMC Health Serv Res 2006;6:137. 17. Bédard MJ, Berthiaume S, Beaulieu MD, Leclerc C. Factors influencing the decision to practise obstetrics among Quebec medical students: a survey. J Obstet Gynaecol Can 2006;28:1075–82. 18. McAlister RP, Andriole DA, Brotherton SE, Jeffe DB. Are entering obstetrics/gynecology residents more similar to the entering primary care or surgery resident workforce? Am J Obstet Gynecol 2007;197:536.e1–6. 19. 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;80:809–14. 20. Association of American Medical Colleges. AAMC Reporter: December 2008. Graduates report higher debt, primary care interest. Available at: http://www.aamc.org/newsroom/reporter/dec08/graduates.htm. Accessed May 28, 2010. 21. Baker LC, Barker DC. Factors associated with the perception that debt influences physicians’ specialty choices. Acad Med 1997;72:1088–96. 22. Sullivan P. Medical student debt problems appear to be worsening. Ottawa: Canadian Medical Association; 2005. Available at: http://www.cma.ca/ index.cfm?ci_id=10026669&la_id=1. Accessed May 28, 2010. 23. Gariti DL, Zollinger TW, Look KY. Factors detracting students from applying for an obstetrics and gynecology residency. Am J Obstet Gynecol 2005;193:289–93. 24. Hammoud MM, Stansfield RB, Katz NT, Dugoff L, McCarthy J, White CB. The effect of the obstetrics and gynecology clerkship on students’ interest in a career in obstetrics and gynecology. Am J Obstet Gynecol 2006;195:1422–6. 25. Ogburn T, Espey E, Autry A, Leeman L, Bachofer S. Why obstetrics/ gynecology, and what if it were not an option? A survey of resident applicants. Am J Obstet Gynecol 2007;197:538.e1–4.

NOVEMBER JOGC NOVEMBRE 2010 l 1069