|Year : 2014 | Volume
| Issue : 4 | Page : 485-490
Specialty choices among graduating medical students in University of Calabar, Nigeria: implications for anesthesia practice
Oboko O Oku1, Afiong O Oku2, Teresa Edentekhe1, Queeneth Kalu1, Bassey E Edem3
1 Department of Anaesthesia, University of Calabar, Calabar, Nigeria
2 Department of Community Medicine, University of Calabar, Calabar, Nigeria
3 Department of Anaesthesia & Intensive Care, Federal Medical Centre, Makurdi, Nigeria
|Date of Submission||26-May-2014|
|Date of Acceptance||05-Jun-2014|
|Date of Web Publication||28-Nov-2014|
Bassey E Edem
Department of Anaesthesia & Intensive Care, Federal Medical Centre, Makurdi
Source of Support: None, Conflict of Interest: None
Despite its strategic role in health-care delivery, anesthesia does not attract medical manpower in developing countries, more so among medical trainees. This has resulted in an alarming lack of physician anesthetists. This study aims to determine the rate of selection of anesthesia as a specialty choice and factors that influence medical students when choosing specialties.
Patients and methods
A cross-sectional study was conducted on final-year medical students in the University of Calabar. A semistructured self-administered questionnaire was distributed to a total of 105 final-year students who had undergone their posting in anesthesia. Summarization of data was done using frequencies/proportions and graphs, and significance level was set at P-value less than 0.05.
The mean age of respondents was 27.2 ± 4.15 years. Of the students, 72 (69%) were male, whereas 33 (31%) were female. Of them, 96 (91%) indicated interest in specializing, 34 (32%) preferred obstetrics and gynecology, 20 (19%) wanted pediatrics, 13 (12%) preferred family medicine and three (3%) preferred anesthesia. Factors that influenced choice of specialty among the graduating students included: personal interests in 85 students (81%), future job opportunities in the field in 66 students (63%) and requirement of specialized skill in 65 students (62%). In all, 46 respondents (44%) reported that their anesthesia posting experience was interesting, whereas 27 respondents (28%) reported it as very educative. The duration of the posting was rated very short by 25 students (24%).
With less than 5% of the graduating medical students indicating interest in anesthesia specialization, improvement in training facilities and provision of incentives to intending trainees are strongly recommended.
Keywords: anesthesia, medical students, specialty choices
|How to cite this article:|
Oku OO, Oku AO, Edentekhe T, Kalu Q, Edem BE. Specialty choices among graduating medical students in University of Calabar, Nigeria: implications for anesthesia practice. Ain-Shams J Anaesthesiol 2014;7:485-90
|How to cite this URL:|
Oku OO, Oku AO, Edentekhe T, Kalu Q, Edem BE. Specialty choices among graduating medical students in University of Calabar, Nigeria: implications for anesthesia practice. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2021 May 5];7:485-90. Available from: http://www.asja.eg.net/text.asp?2014/7/4/485/145673
| Introduction|| |
Anesthetists are multiskilled physicians who, in addition to ensuring patient safety and stability before, during and after surgery, participate in a vast array of hospital activities ranging from the alleviation of acute and chronic pain to running ICUs, gaining specialized intravenous access and emergency management of life-threatening events. Despite its strategic role in health-care delivery, anesthesia has failed to attract medical manpower in the most developing countries, resulting in an alarming lack of physician anesthetists [1-3]. This may be so because most newly qualified doctors in Nigeria do not consider a career in anesthesia when embarking on residency training [4-7]. This is even more troubling when one realizes that medical students are exposed to a wide range of medical subspecialties including anesthesia, in the course of their medical education. Furthermore, the number of trained anesthetists does not seem to commensurate with the increasing numbers of other surgical specialists and specialties. Quite often, newly qualified doctors are forced to pursue a career in anesthesia because their initial specialty choices are oversaturated.
Although the domain of anesthesia has now extended far beyond the exclusive ambit of the operating theater, the extent to which this is appreciated by medical students remains unknown. Previous studies have recommended more space to be made for anesthesia posting in the curriculum so as to increase student contact time with anesthesia and thus increase its attractiveness. This has been done in most universities. Yet anesthesia has remained unpopular as a career choice among graduating medical students [2, 4, 6-8]. As the future workforce of our health-care system is influenced by choices these students make, this study was conducted to determine the rate of selection of anesthesia as a specialty choice among the current crop of final-year medical students, and the factors that may influence these medical students when choosing a career.
| Patients and methods|| |
This study was conducted on final-year medical students of the College of Medicine, University of Calabar, Cross River State, Nigeria. A semistructured self-administered questionnaire was distributed to a total of 105 students in the final-year class who had undergone their undergraduate training in anesthesia. The class representative distributed the questionnaires immediately after a lecture after consent had been sought, and at completion, submitted them to members of the research team. The response rate was 100%. The questionnaire used elicited information on sociodemographic characteristics, decisions about specialization, and possible factors that affected choice of specialty. The factors selected were obtained from the literature review and discussions held with medical students. Demographic characteristics included age, sex, marital status, and religion, and decision regarding specialization and three specialties they would most likely consider after graduation, ranking them in order of priority. Specialty options included anesthesia, community medicine, family medicine, internal medicine, obstetrics and gynecology, pediatrics, laboratory medicine, radiology, otolaryngology, ophthalmology, psychiatry, and surgery. A total of 25 factors indicated in the questionnaire as influencing choice of specialty were categorized into experiences during undergraduate training, personal factors and specialty-related factors. Provision was also made for other factors not included in the questionnaire. Questions regarding perception of anesthesia as a specialty were also elicited from the respondents.
After data collection, questionnaires were manually sorted out, coded before entry and cleaned after entry into the computer for statistical analysis using SPSS version 19.0 (Statistical Package for Social Sciences; SAS Institute Inc., Cary, North Carolina, USA). Data analysis was performed using descriptive statistics (frequency, proportions, means, and SD) to summarize variables. The level of significance was set at 5%.
| Results|| |
A total of 105 completed forms were returned. The mean age of respondents was 27.2 ± 4.15 years. Of the students, 72 (69%) were male and 33 (31%) were female, with 90 (86%) being single, whereas 15 (14%) were married. Of the students, 59 resided off campus, whereas 46 (44%) lived on campus; 99 (94%) were Christians, whereas six (6%) were Muslims ([Table 1]). [Figure 1] shows respondents' decision regarding specialization. Of the students, 96 indicated interest in specializing after completion of the undergraduate training.
|Table 1 Frequency distribution table showing sociodemographic characteristics of respondents|
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Overall, the most preferred specialty among the students interviewed was obstetrics and gynecology. This was followed by pediatrics and family medicine ([Figure 2]). As the first choice, the most preferred specialty was obstetrics and gynecology (32.4%); this was followed by pediatrics (19.0%) and internal medicine (12.4%) at third place. As the second choice, the most preferred specialty remained obstetrics and gynecology (26.7%) at first place, followed by pediatrics (15.2%) and family medicine (13.3%). As the third choice, family medicine (14.3%) and pediatrics (14.3%) tied at the first place as the most preferred specialties, followed by community medicine (13.3%) and obstetrics and gynecology (11.4%) at third place. However, anesthesia remained in the fifth (2.9%), seventh (2.9%), and sixth positions (7.6%), respectively. This is shown in [Figure 3].
According to students' perception of anesthesia as a specialty and posting ([Table 2]) it was found that 46 students (44%) reported their anesthesia posting to be interesting, whereas 27 students (23%) said it was very educative. More than one-fifth, that is, 24 students (23%), reported that the duration of the posting was too short, while more than three-fifth, that is, 64 students (61%), were of the opinion that anesthesia was an interesting and an important specialty; however, 12 students (11%) thought it was too technical and boring. [Table 3] shows the factors that influenced the students' choice of specialty. The most common factors that influenced the choice of specialty among the respondents included personal interests in 85 respondents (81%), future job opportunities in the field in 66 respondents (63%), and requirement of specialized skill in 65 respondents (62%). Influence by a mentor was chosen as a factor by 31 respondents (30%).
| Discussion|| |
Several factors affect career choices. These may either be intrinsic, extrinsic, or circumstantial. This study agrees with previous reports that there is a very low level of interest for anesthesia among medical undergraduates [5,6]. In the 1980s, none of the 54 students studied selected anesthesia as their first choice. The specialty ranked sixth among the 67 final-year medical students in another institution . Of them, 80% found anesthesia to be interesting and important, but none would pick anesthesia as a first choice for a future career. One-third of the students did not even consider it . In Israel, just 1% of their medical graduates,  and 5-6% of the medical graduates in the USA, chose anesthesia . This, however, contrasted significantly with 17.7% of the Australian medical students intending to choose anesthesia .
There is a disturbing trend observed in our study. A similar study conducted by Ilori et al.  a decade ago, in the same center, showed that 8% of the students chose anesthesia as their specialty and that placed anesthesia at the fourth position. This study shows that only 4.5% of the graduating students would choose anesthesia, putting it in the seventh position as choice specialty. This has serious implication for the future workforce of physician anesthetists. The present study further revealed that the majority of the students interviewed (61%) were of the opinion that the specialty was interesting, and this was higher than that observed in a study by Akinyemi and Soyannwo  in southwestern Nigeria, in which 36% of the students viewed anesthesia as interesting. However, this did not translate to more students choosing anesthesia, as was the case in our study. Furthermore, slightly over one-tenth of the students perceived anesthesia specialty as being too technical, which may further contribute to the unattractiveness of the specialty.
Anesthesia is commonly taught to medical students, but the duration and content of such teaching varies . At the University of Calabar, the exposure is for 2 weeks. If these students are given a positive undergraduate experience by way of thorough teaching and lecturing, future recruitment into most disciplines of medicine, including anesthesia, would be enhanced . This point was buttressed in a study by Notzer and Tur-Kaspa  where intense dedicated clerkship in oncology led to 25% of the medical students considering this branch of medicine.
The most common reasons behind choosing a career among the undergraduate medical trainees were personal interests such as future job opportunity in the field and requirement of specialized skill. Personal interest was also seen as a reason in a study conducted in Pakistan. 
In addition, in a survey on over 5000 new medical graduates in the UK, 45% of them were influenced in their choice of career by the exposure they had to the specialties as undergraduates, whereas 25% of them were influenced by a role model . This was consistent with the findings in our study that almost one-third (30%) of the respondents were influenced by a mentor. In a similar study, two-third of the students identified a positive role model in their anesthesia teachers and that this was significantly associated with a satisfactory learning experience and a career intention in anesthesia .
Several studies have suggested that there are areas that are often inadequately taught at undergraduate level [15,16]. In addition, short duration of exposure to anesthesia, insufficient participation in practical anesthesia sessions and lack of provision of adequate teaching aids such as manikins have been cited as contributory factors to the problem of limited or noninterest in anesthesia . This has resulted in the diminishing of medical students' clinical skills such as basic airway management, acute, and chronic pain management, and basic life support . To circumvent this problem, it is recommended that students be made to learn advanced anesthetic skills while posting to anesthesia, as such students are more likely to be interested in anesthesia as a career .
Considering that anesthetists have a very important role in medicine and medical education, [18,19] the challenge of recruiting young medical graduates into it has remained a daunting task. About three decades ago, Levin et al.  noted that the lack of interest in anesthesia as a specialty was because it was seen as unchallenging and lacking in primary patient care. This was attributed to lack of early exposure to the specialty. However, this was not the case in a study by Ene and Akpan  who found that, despite early and intense exposure to the specialty, senior medical students still did not choose a career in anesthesia.
One major implication of this trend is a reduction in workforce and subsequent overburdening of the existing workforce. Currently, anesthesia has widened its scope of practice to involve diagnostic procedures for pediatrics, radiology, gastroenterology, and respiratory medicine. Other areas include lithotripsy, dental surgery, palliative care, trauma care, resuscitation, emergency medicine, and transport of the critically ill . This in addition to its classic role of providing the best and safest conditions for the performance of surgery after preoperative assessment and postoperative care in the recovery rooms, obstetric analgesia (epidurals) in delivery rooms, and the running of ICUs, pain clinics, and acute pain services . The growth and advancement of surgery would be stunted without adequate supply of anesthetists.
The further implication for consideration is increase in the role of the nonphysician anesthetist. This stems from the paucity of physician anesthetists. The ratio of anesthetist to the population in Nigeria is 1 : 300 000 . A favorable outcome of surgery is dependent on the caliber and safety of the anesthetic administered. More morbidities and mortalities in this era of 'safe surgery saves lives' would be appalling. Some associations such as the Israel Medical Association and the Israel Society of Anesthesiologists strongly believe that replacing physicians with technicians or nurses is a dangerous step that may cause deterioration in the level of practice and patient safety . In a study on students in Jordanian University Medical Schools, none of the male students chose a career in anesthesia. This was attributed to the increase in the number of nurse anesthetists employed at University hospitals, which seemed to suggest to the students a lack of career opportunities in this field . As has been observed in this study and a similar study in the same setting a decade ago, the trend of the dearth of anesthetists may continue into the next decade if the situation is not rectified. Previous studies have shown that increasing the exposure of the students to anesthesia alone did not equate to more students choosing the specialty. The authors recommend that, in addition to increasing the period of exposure during anesthesia posting to at least 4 weeks, provision of adequate resources for the anesthesia education of medical students should be paramount. Skill acquisition laboratories replete with manikins for peripheral and central line placement, cardiopulmonary resuscitation, and automated external defibrillator should be provided. Simulations in these laboratories on peripheral nerve blocks, central neural blocks, and airway skills should be routinely carried out for all undergraduates training in anesthesia. This will make anesthesia real and attractive to them as a career choice.
| Conclusion|| |
The ultimate goal of the anesthetist is the provision of safe anesthesia. Therefore, there is the need to change outdated equipment, facilities and practices. For instance, the act of manual ventilation, 'bagging', and manual blood pressure recording should be discouraged by the provision of modern ventilators and monitoring equipment. Anesthesia residents in the developing countries should be made to spend a year abroad before completing their residency training. This will achieve two objectives: it will serve as an incentive for those who may aspire to become physician anesthetists, and it will also expose the trainees to modern day advances in the specialty. Work stress on the anesthetist can be reduced by providing a wide variety of drugs and consumables. Appropriate drug for appropriate situation will present the anesthetist to the undergraduate as a physician with wide choice who has any situation that may arise under control. The current situation in most resource-poor settings where the anesthetist 'manages' and improvises everything can only present him as miserable and unattractive. The medical student needs to be exposed to a good working knowledge of the roles and responsibilities of the anesthetist within and outside of the operating theater.
Limitations of the study
Certain limitations of the study should be recognized. The cross-sectional nature of the survey did not allow for inferences to be drawn as to a causal relationship among variables.
| Acknowledgements|| |
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]