Abstract
Objective The growing shortage of neurologists is in part due to suboptimal recruitment. Little is known about students' decision making regarding a career in neurology, particularly early in training. Using a longitudinal qualitative approach, we aimed to understand factors that influence first-year medical students' decisions about neurology.
Methods We conducted 1-on-1 semistructured interviews with 15 first-year medical students at 1 institution before and after the preclinical neurology course (2018–2019). In the first interview, we asked about career intentions, factors likely to influence specialty choice, and perceptions of neurology. In the second interview, we asked about changes in students' views over the year. Using thematic analysis, we generated codes and clustered coded data into themes.
Results The 2 most prominent factors influencing career choice in general were lifestyle and personal interest. No students expressed concerns about lifestyle in neurology. Most students were neutral about neurology or had a positive personal interest, which typically increased after the neurology course. Students frequently worried about content difficulty and the curative potential of neurology.
Conclusions Interventions should include early education about the factors important to students in determining specialty choice, including lifestyle, and address potentially negative perceptions of neurology. Increasing time allotment to the preclinical neurology course may combat perception of the content as difficult.
A 19% shortfall of practicing neurologists in the United States is projected by 2025,1 in part due to suboptimal medical student recruitment. In 2020, only 2.2% of US senior medical students matched into residency positions in adult neurology and 0.5% in child neurology.2 Efforts aimed at increasing recruitment require knowledge of how students make decisions about careers in neurology.
Prior studies have identified a variety of factors that enhance interest in neurology as a career, including its intellectual content; an undergraduate major in neuroscience or psychology; adequate exposure in medical school; high ratings of the basic neuroscience course and neurology clerkship; early clinical correlations; inspiration by role models; and mentorship.3,–,11 Studies of factors that decrease interest in neurology have generally focused on students' perception that the subject matter is daunting.9,12,–,18 In addition, a recent study found that students who placed a higher priority on salary and work/life balance were less likely to pursue neurology.10
These studies are important starting points, but nearly all have been retrospective and subject to recall bias. Moreover, nearly all studies have used a quantitative approach, limiting the ability to capture the breadth and depth of students' perceptions. An exception is a recent qualitative study that included focus groups of early medical students,11 but these students had already expressed interest in neurology, so the initial factors drawing students toward or pushing them away from neurology were not explored. Also missing from the literature is research on the way students' thoughts about neurology evolve as they progress through medical school.
To address this gap, we are conducting a longitudinal qualitative study exploring the factors that influence medical students' ideas about neurology over a 4-year period. In this article, we report findings from the preclinical phase, building on prior literature, which has suggested that students' early perceptions of careers may shape their subsequent medical school experiences and ultimate career choices.19
Methods
Context
Students enrolled in the study began their first (M1) year of medical school at the University of Michigan in August 2018. The M1 curriculum was predominantly preclinical with the first structured exposure to neurology occurring in spring 2019 in the 3.5-week, primarily lecture-based neurology course.
Methodologic Approach
We used a longitudinal qualitative research approach with repeat interviews of the same first-year medical students (M1s).20 A qualitative approach allowed us to explore factors the students spontaneously identified as important without imposition of a preconceived framework. In contrast, quantitative research requires prospective delineation of variables to be measured. The qualitative approach helps capture the breadth and richness of the students' responses. This study complies with published standards for reporting qualitative research.21 Table 1 provides definitions of terms used in this article that may be new to readers less familiar with qualitative research.
Definitions of Qualitative Research Terminology
Participants and Interview Procedures
R.G.-S. recruited M1s who identified as being favorably disposed toward a career in neurology (neurology inclined) or ambivalent (neurology neutral) at an activities fair and a Student Interest Group in Neurology event. Snowball sampling was then used to recruit students who thought it unlikely that they would go into neurology (neurology disinclined).22 In this qualitative study, our sampling goal was to identify key informants representing each of these 3 groups (neurology inclined, neurology disinclined, and neurology neutral); we were not aiming for the sample to be representative of the entire M1 class. Participation was voluntary, without incentives for participation. Fifteen students were initially recruited, and all agreed to participate. Because of scheduling conflicts, 1 student's participation was deferred, and another was recruited to include additional male representation. We created an initial interview guide informed by literature on medical student career choice.19,23
Standard Protocol Approvals, Registrations, and Participant Consents
The study was deemed exempt by the Institutional Review Board at the University of Michigan. We obtained verbal consent from all participants.
Data Collection and Analysis
R.G.-S. conducted 1-on-1 semistructured interviews with each student before and after the preclinical neurology course (figure 1). Interview 1 (conducted between October 2018 and January 2019) focused on students' current interest in specialties, factors that would likely influence their specialty choice, and how these factors applied to neurology and the other specialties they were considering. Interview 2 (conducted in May and June 2019, after the March/April preclinical neurology course) focused on changes in the students' career intentions and previously expressed influential factors. Each student was also asked to assign relative point values (of 100) to each of the top 10 factors that emerged from interview 1. The complete interview guides are available as supplemental material (links.lww.com/CPJ/A267 and links.lww.com/CPJ/A268). All interviews were transcribed verbatim.
R.G.-S. used MAXQDA version 2018.2 software to manage data.24 Data collection overlapped with data analysis. R.G.-S. inductively created codes from important concepts in the data. Codes were iteratively revised based on incoming data and applied to transcripts. The initial code book was reviewed by the research team; codes were adjusted to achieve consensus. To establish intercoder reliability, 4 team members reviewed 6 excerpts initially coded by R.G.-S., which included 27 codes. They did not know the specific codes that R.G.-S. had previously assigned for those excerpts. There was at least 3/5 consensus on 24/27 codes. In line with principles of thematic analysis, we clustered coded data into themes that aligned with student-identified factors and perceptions of neurology.25,26 We used data displays to deepen discussion. D.B., familiar with longitudinal qualitative research, provided intermittent feedback about the analysis.
Trustworthiness
Trustworthiness, or the truth value of a qualitative study, is based on 4 metrics: credibility, transferability, confirmability, and dependability (table 1).
To establish credibility, in addition to prolonged engagement and persistent observations of the participants, we engaged in member checking: all students were queried in interview 2 about the most relevant factors to them and their peers that emerged from interview 1. Participants were also later asked to review the themes that emerged from our analysis and agreed with the findings. No revisions were suggested. For transferability, we provide a detailed account of the participants and setting. To establish confirmability and dependability, we kept a detailed audit trail regarding code development and analysis. Furthermore, we engaged in reflexivity, identifying and reflecting on our own characteristics as researchers. Our team consists mostly of neurologists and neurology trainees. D.J.G. directs the preclinical neurology course and also taught some of the students in other contexts. He was blinded to the identities of the participants. At the time of the interviews, no other team member was involved in M1 teaching. D.F.B., the only non-neurologist, is a qualitative research expert.
Data Availability
Anonymized data not published within this article will be made available by request from any qualified investigator.
Results
Of the 169 M1s who matriculated in 2018, 15 (8.9%) participated (table 2). Ten of the 15 students (67%) identified as female, reflecting the composition of the M1 class (65% female). The mean participant age at the initial interview was 23.6 years. Interview length ranged from 14 to 67 minutes, depending on participant responses. Interviews were continued until all questions were answered with adequate quality and depth as determined by the interviewer. Despite our efforts to recruit roughly equal numbers from the 3 groups, we were unable to find many M1s who had strong feelings about a career in neurology. At interview 1, 2 students identified as neurology inclined, 9 as neurology neutral, and 4 as neurology disinclined. There was minimal transition between interviews: 1 neurology-inclined and 1 neurology-disinclined student transitioned to neurology neutral.
Student Demographics
In the first section, we present the most prominent factors influencing career choice in general. In the second section, we describe student perceptions of neurology with respect to these factors, as well as 1 additional factor students often mentioned when discussing neurology (but not other career choices): difficulty of the subject matter. In both of these sections, we discuss the evolution of responses between the first and second interviews. Finally, we share student-generated ideas to increase recruitment. Student quotes are identified by participant number and interview in table 3.
Participant Quotes
Prominent Factors Influencing Career Choice
Figure 2 shows the 10 factors most commonly cited by students during interview 1 as important in their decision-making about choosing a specialty and the relative point values (of 100) that they assigned those factors in interview 2. Two of the initial 10 factors, lifestyle and time for family, were merged based on student input (see below). The 2 most influential factors were lifestyle and personal interest.
*Per student input, time for family was combined with lifestyle.
Lifestyle
Lifestyle received the highest rating of all the factors, with 6 of the 15 students rating it the most important factor influencing career choice; for 3 additional students, lifestyle tied for most important with one or more other factors. Neurology-inclined, neurology-neutral, and neurology-disinclined students rated lifestyle similarly.
Most students considered family to be an important component of lifestyle. In fact, several students considered lifestyle and family to be synonymous (table 3, quote 1). Several students discussed future child bearing and being present for their children (table 3, quote 2). Other aspects of lifestyle valued by students included work hours and flexibility. With 1 exception, students either did not mention personal compensation or considered it of lesser importance (table 3, quote 3).
There was no gender difference in lifestyle ratings, although several female participants incorporated their gender identity into discussions about lifestyle (table 3, quote 4). One participant specifically expressed concerns about maternity leave (table 3, quote 5).
Lifestyle remained a dominant theme in interview 2. Five students described class-wide burnout, and several described how this increased the relative importance of work/life balance for them (table 3, quote 6).
Personal Interest
Five of the 15 students rated personal interest the most important factor in deciding between specialties, and for 2 other students, it tied for most important. As with lifestyle, there was no difference between groups or genders. Students used words such as intellectual stimulation, passion, and excitement (table 3, quote 7).
In interview 1, many students recognized that their current knowledge was limited, so they had trouble knowing which specialties they found most interesting. By interview 2, as students gained preclinical knowledge, the relative importance of personal interest increased for some (table 3, quote 8). Many recognized that this might change again with more clinical experience (table 3, quote 9).
Fixing or Curing the Problem
Together, lifestyle and personal interest accounted for 47% of the weight students assigned the 10 factors. Students considered the remaining factors to be less influential, with weights ranging from 5% to 11%. We highlight one of these factors—fixing or curing the problem—because half the students initially described this as a significant concern about neurology. Students who prioritized fixing the problem tended to focus on procedural specialties (table 3, quote 10).
M1 Perceptions of Neurology
In interview 1, despite all students identifying at least some prior exposure to neurology (table 2), all but 1 student described a lack of knowledge about neurology. When asked about their inclinations toward neurology, most students responded that they were undecided due to this lack of knowledge (table 3, quote 11). Even the 2 students who initially identified as neurology inclined emphasized their lack of knowledge (table 3, quote 12).
Lifestyle
Even in interview 2, 2 months after the preclinical neurology course, some expressed uncertainty about specific aspects of a career in neurology, including lifestyle (table 3, quote 13). Students generally thought that neurologists have a better lifestyle than surgeons do (table 3, quote 14). No student expressed concerns about lifestyle in neurology.
Personal Interest
Most students were neutral about neurology or had a positive personal interest, which typically increased between the 2 interviews after the neurology course (table 3, quote 15). The initial 4 neurology-disinclined students described a specific lack of interest in neurology in interview 1; 2 described slightly increased personal interest after the course, although only 1 transitioned from neurology disinclined to neurology neutral.
Some students described the unknown as a factor that augmented personal interest in neurology, particularly in interview 1 (table 3, quote 16). For a few, the unknown was a concern (table 3, quote 17).
Fixing or Curing the Problem
Half of the students initially expressed concerns about the ability to cure neurologic diseases (table 3, quote 18). This persisted for some in interview 2, although students seemed to temper their concerns slightly (table 3, quote 19). Others were drawn to the palliative aspect of the specialty, and some emphasized the distinction between making an impact and fixing or curing the problem.
Neurology as Difficult
Difficulty of specialty content was not a prominent factor when students described specialty choice in general, but did seem to influence student attraction to neurology specifically. Ten students in interview 2, compared with 6 in interview 1, described neurology as difficult. For some students, this difficulty increased their attraction to neurology (table 3, quote 20). For others, the difficulty was a deterrent (table 3, quote 21).
The preclinical neurology final course grade was not a factor in the students' perception of the field's difficulty or their attraction to the field. By the time interview 2 was conducted, all study participants knew that they had passed the course (which, like all preclinical courses at our school, is graded on a pass-fail basis). In contrast, the students' scores on quizzes and examinations during the course could have influenced their perception of difficulty. We have no way to separate their performance on those assessments from their views of the course content and its delivery. Although some students offered comments about their performance on quizzes and examinations, we did not ask about this routinely, and we did not ask any students to provide their actual scores.
Many students felt that there was insufficient time allotted to the preclinical neurology course. Several students said that the course difficulty and short course duration accentuated class-wide burnout.
How to Increase Recruitment
When asked about how to increase recruitment into neurology, many students suggested publicizing shadowing and research opportunities. Table 4 shows other student suggestions, including more patient presentations, career seminars, and skills sessions. One student recommended creating a pipeline program similar to an ophthalmology program for students underrepresented in medicine.
Recommendations to Increase M1 Knowledge of and Attraction to Neurology
Discussion
Students highlighted lifestyle and personal interest among the factors influencing their career decisions, but recognized that they knew very little about neurology with respect to these factors. Based on the students' comments in the interviews, we agree with their self-assessment. We were surprised by what they did not know about neurology, even after the preclinical neurology course. This result suggests the need to educate students about neurology early in medical school in ways that prompt them to explore it more actively and favorably. Early exposure and knowledge could be particularly important in light of previous research suggesting that students' early career inclinations and expectations may cause them to take actions that reinforce and solidify their initial inclinations, such as studying harder in certain courses or pursuing certain types of research or other extracurricular activities.19 Based on our initial data, we recommend focusing early education on the factors that students consider most prominent in specialty choice, including lifestyle, and directly addressing potentially negative perceptions of neurology.
The students' emphasis on lifestyle, particularly family roles, mirrored previous researchers' observation that students imagine their future lives in different specialties.23 Early exposure to neurologists who are able to balance family roles with career responsibilities could help students imagine a future life in neurology in a more positive light. In contrast to a recent study of graduating medical students that found that those who placed a higher priority on work/life balance were less likely to choose neurology,10 none of the M1s we interviewed identified neurology as a career associated with a poor lifestyle. It may be that M1s divide specialties into 2 broad categories, surgical and nonsurgical, whereas graduating students consider a wider array of options including some that they rate more favorably than neurology with respect to work/life balance. Another possible explanation is that after the M1 year students are exposed to neurologists, including house officers, who are experiencing difficulty with work/life balance.27,–,29 In future interviews with the students, we will explore how perceptions of lifestyle in neurology evolve as participants enter the clinical phase.
Neurology is a complex subject, and many students commented that it would be less overwhelming if they had more time to learn it. This may be the ideal, but it may be difficult to convince medical schools to allocate increased time to preclinical neurology courses at a time when many schools are shortening preclinical curricula. At a minimum, we can leverage preclinical neurology courses to correct mixed or negative perceptions of neurology, such as the notion that neurologists cannot help their patients. Courses should stress neurologists' positive impact on patients' lives, highlighting current and emerging therapies, both curative and symptomatic, as well as palliative medicine. As the students noted, patient presentations can be an effective way of doing this.
Some of the limitations of our study derive directly from the nature of qualitative research, which aims to explore subjects' thoughts at a deeper level than standard surveys allow. This requires interviewers to adapt their questions based on subjects' responses, rather than following a predetermined script. Because the interviews are much longer than they would be in a traditional survey format, only a limited number of subjects can be interviewed. The goal is not to sample a large or representative subset of the population, but rather to generate hypotheses based on close analysis of the responses of a small subpopulation. This may limit transferability. Specifically, as other studies had already investigated students with an early interest in neurology, we wanted to include students who were neurology neutral or disinclined. In fact, only 2 of the students expressed initial attraction to neurology, so the responses may not extend to all students with an early attraction. Future quantitative research on the preclinical phase of medical school could use our results to inform survey design and sample larger cohorts of students.
Another limitation of our study is that R.G.-S., a child neurologist, conducted the interviews, which may have influenced student responses. The distinction between adult and child neurology was not a focus of our study; students mainly described adult neurology in their responses, and we may not have captured unique aspects of decision making related to child neurology.
This study begins to address a current gap in the literature, following students longitudinally from early in medical school as they progress in their decision making about neurology. Previous studies have focused on more advanced trainees, whose observations about the factors that influenced their career choices were subject to recall bias. Based on our interviews with students in the preclinical phase of medical school, we have already identified several key interventions that may attract medical students to neurology: (1) exposing preclinical students to role models in neurology who successfully balance career responsibilities and family roles; (2) emphasizing neurologists' positive impact on patients' lives; and (3) advocating for longer preclinical course duration. We anticipate that the clinical phase of training will have at least as much impact on students' career decision making as the preclinical phase. We plan to follow our participants as they progress through clerkships and look forward to learning how their perceptions and plans evolve.
Acknowledgment
The authors thank the medical student participants who shared their perceptions and experiences with them.
Study Funding
American Academy of Neurology Medical Education Research Training Fellowship (2018–2019).
Disclosure
R. Gottlieb-Smith was a recipient of the American Academy of Neurology Medical Education Research Training Fellowship from 2018 to 2019; she has received royalties from MedLink for authorship of topics related to febrile seizures. D.J. Gelb receives royalties from Oxford University Press and UpToDate and honoraria from MedLink and the AAN (for Continuum MCQs). B. Becker, B. Dymm, O. Gutgsell, N. Patel, and D.F. Balmer report no disclosures relevant to the manuscript. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.
TAKE-HOME POINTS
→ First-year medical students identified lifestyle and personal interest as the most important considerations in their career choice within medicine.
→ Students have little knowledge of neurology before the preclinical neurology course. After the course, they know more about neurologic diseases, but they still have limited knowledge about the practice of neurology and the lifestyle of neurologists.
→ Interventions that may increase student attraction to neurology include: exposure to role models in neurology who successfully balance career responsibilities and family roles; emphasizing neurologists' positive impact on patients' lives; longer preclinical course duration.
Appendix Authors
Footnotes
Funding information and disclosures are provided at the end of the article. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.
- Received October 21, 2020.
- Accepted January 19, 2021.
- © 2021 American Academy of Neurology
References
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