**6. The stability of the student and resident population selecting OB/GYN**

Regardless of the country examined, most medical students will change their mind about what specialty they want to enter. This occurs between the times when they first matriculate to when they finally select a residency program. The exceptions are those students who are

et al., 2008). Newton (2008) proposed that the loss of innate empathy makes it difficult to maintain cognitive empathy. Thus, interventions to improve empathic behavior have to be taught on a repeated basis. Given that students who enter an OB/GYN residency have the highest BEES score, i.e., they better maintain their vicarious empathy than students entering other specialties, it is possible that interventions to improve empathic behavior may have a greater impact on these students as compared to those who enter other residencies. However, this suggestion must be weighed against cognitive empathy data that show students desiring an OB/GYN residency have JSPE scores which lie midway in the values for all specialty choices. It may be more desirable for students to have OB/GYN JSPE scores ranked near the top of the specialties, since having both high vicarious and cognitive

All students and physicians, whether in OB/GYN or not, must walk a fine line between being too emotionally attached to patients or being perceived as too aloof and emotionally detached. All humans are naturally repulsed by illness and death and tend to draw away from it (Rosenfield & Jones, 2004). Yet, physicians have selected a profession that deals with what is naturally repulsive. Therefore, it seems only natural that emotional conflicts arise. It is all too easy for a student or physician to depersonalize patients and transform them into a disease, or a cold list of laboratory numbers or physical findings in a medical record (Carmel & Glick, 1996). The increasing use of ever more sophisticated technology makes the depersonalization process all the more pernicious. Depending solely on "concrete numbers and images" hinders the ability to build a meaningful doctor/patient rapport. Spiro (2009) states, "Listening can create empathy – if physicians remain open to be moved by the stories

Despite decreases in student empathy as they progress through medical school, there are a number of suggested interventions to help improve empathy and, ergo, patient satisfaction. Mindfulness-based stress reduction, self-awareness training, Balint groups, and meaningful experience and reflective practice discussions have been suggested (cf. refs. in Neumann et al., 2011). Rosenfield and Jones (2004) suggested the dilemmas that erode empathy can be

broken down into four different areas, each with a given solution:

4. "reaction vs. inaction" with "know when to act"

1. "pathology vs. health" can be balanced with "get to know the whole person"

2. "not knowing vs. knowing too much" with "tolerate ambiguity and remain curious" 3. "vulnerability vs. denial" with "acknowledge the developmental stages you go

Success in maintaining empathy depends on having faculty and residents exhibiting and promoting empathic behavior so that they can be role models for the students. Without a doubt, students entering into the clerkships will take on the persona of those to whom they

Regardless of the country examined, most medical students will change their mind about what specialty they want to enter. This occurs between the times when they first matriculate to when they finally select a residency program. The exceptions are those students who are

**6. The stability of the student and resident population selecting OB/GYN** 

empathy scores suggests a better outcome for interventions to improve empathy.

they hear."

through"

are exposed.

100% sure they want to enter a particular specialty. In those rare cases, the cons of entering a specialty do not play a significant role in their decision making process. An eighteen-year longitudinal study (1975-1992) at an eastern US medical school revealed only 19% of students who showed an initial interest in OB/GYN, actually entered an OB/GYN residency program. The students who left OB/GYN, usually went into IM (19%) or SURG (17%). In comparison to OB/GYN data, 40% of students stayed with IM, 39% for FM and 22% for PED (Forouzan & Hojat, 1993). Compton and colleagues (2008) sampled the graduating class of 2003 at fifteen US medical schools, and found that at matriculation, 40 out of 942 students indicated an interest in OB/GYN. Of those, ten students (25%) placed into an OB/GYN residency, four (10%) changed their mind after going through the OB/GYN clerkship, five (13%) switched to another primary care residency and twenty-one (53%) switched to a non-primary care residency. In contrast to the OB/GYN data, 15% stayed with PED, 17% with IM and 23% with FM. In all of these cases, those who decided not to enter PED, IM, or FM also switched to non-primary care residencies.

Jeffe et al. (2010) looked all US graduates from 1997 to 2006, and found that the number of students desiring a primary care residency dropped within that time frame. Those desiring OB/GYN remained the most stable, but with low student interest. The numbers of graduates entering OB/GYN dropped from 8.2% to 6.1%. IM dropped from 15.7% to 6.7%. FM dropped from 17.6% to 6.9%, and PED dropped from 10.2% to 6.6%. Of those who entered an OB/GYN residency, 22.7% were male and 77.3% were female. In the UK, from 1974 to 2002, the number of male students who entered OB/GYN dropped from 2.6 to 1.1%. Meanwhile the female percentage dropped from 4.6 to 2%. Overall the number of UK graduates entering into OB/GYN dropped from 3.2 to 2.0% (Turner et al., 2006).

The gender disparity among students interested in OB/GYN was examined by a number of researchers. Gerber et al. (2006) reports that whereas the number of graduates entering OB/GYN residencies remained relatively stable from 1985 to 2000 (6% to 8%), the number of females practicing OB/GYN increased from 12% in 1980 to 32% in 2000. Accordingly, the number of female residents increased from 44% to 74%. Although the number of female OB/GYNs is steadily increasing, it must be remembered that the majority of patients have no gender preference in selecting an OB/GYN, and that only 14.7% of respondents in the study by Johnson and colleagues (2005) thought female OB/GYNs were better physicians than their male counterparts.

An unexpected consequence of the gender shift is that female OB/GYNs tend to work fewer hours than their male counterparts, and are only 85% as productive as full-time OB/GYNs (Pearse et al., 2001). This led the authors to conclude that increasing numbers of female OB/GYNs will lead to an aggregate decrease in OB/GYN productivity. This is occurring at a time when there are increasing numbers of women of all ages in the US, and that a workforce shortage would occur by 2010. (At the time this chapter was written, it's too early to tell if the prediction has come to fruition.)

#### **6.1 How do US students select an OB/GYN residency and what attracts them?**

Before the question posed by the section heading can be answered, we must first consider what factors medical students use to select a residency. It appears that for many students the selection of a specialty is somewhat haphazard. Allen (1999) found that UK students are

Who Selects Obstetrics and Gynecology as a Career and Why, and What Traits Do They Possess? 13

that a negative OB/GYN clerkship experience strongly deterred students from entering an OB/GYN residency. Some students felt a patient population restricted to women and/or female reproductive issues did not have a large enough variety of diseases and patients to provide job satisfaction. McAlister and colleagues (2007) found that Asians, Pacific Islanders, and students with no medical school debt, did not consider OB/GYN as a career. Two studies found that male students did not enter OB/GYN because of the perception that patients preferred a female OB/GYN, and/or, there were too many females in OB/GYN residencies so that males would constitute a minority (Hammoud et al., 2006; Schnuth et al.,

Factors that were rated as neutral, were little concern over salary and medical school debt. The cost of malpractice insurance was an issue to a few students, but not a deciding factor if the person was determined to enter an OB/GYN career. Once again, those who were sure about entering an OB/GYN residency did not let the perceived detractors alter their choice. The opposite was true for those who had an initial interest in OB/GYN but were not

In 2005, both Blanchard and colleagues and Nuthalapaty et al. determined which nonmedically-related factors were most important for students selecting an OB/GYN residency. There were similarities found in both studies. Many of the highly desirable residency traits were related to the "atmosphere/collegiality" of the residency program. For example, the degree of camaraderie between the residents was very highly rated, as well as how well the faculty cared about, and responded to, resident concerns. Faculty accessibility, commitment to resident education, and geographic location also played an important role for either gender. Females rated having family and friends in the area, the amount of primary care offered by the program, and the resident gender mix as significantly more important than the male's ratings. Males tended to view hospital facilities as more important than females. Males also rated salary and moonlighting opportunities as significantly more important than females, but the rank order of these two factors was near the bottom of the list, indicating that the other aforementioned factors played a much larger role in the decision making process. Results from a 1990 study by Simmonds and colleagues showed the same results. This demonstrated that what students are looking for in a residency has remained

resolved to practice it (Fogarty et al., 2003; Gariti et al., 2005; Metheny et al., 1991).

**6.2 How do students in other countries select an OB/GYN residency?** 

A Canadian study found residency selection results that were similar to the US students, i.e., having OB/GYN as their first choice when entering medical school, being female, and desiring a narrow scope of practice were strong determinants for an individual to enter OB/GYN. Like US students, being exposed to a good clerkship experience and excellent mentors were very important influences for deciding to practice OB/GYN (Scott et al., 2010). It is important to note, that good mentors in other specialties can draw students away

In non-North American countries, the reasons to enter OB/GYN vary. In Switzerland, being female, having an in initial desire to enter OB/GYN, being driven to succeed and being "people oriented" were positive attractors (Buddeberg-Fischer et al., 2006). In Germany, 10% of students are interested in OB/GYN because of its positive image, the ability to have a

2003).

stable over a fifteen year period.

from OB/GYN (Bédard et al., 2006).

given improper advice on what it means to be an MD. Counseling students on specialties is spotty and often anecdotal. There are few good role models (especially female) to emulate, and faculty advice rarely takes into account medical student abilities and aptitudes. Students are not encouraged enough and are given menial tasks to perform while on the clerkships. This discourages them from entering a particular specialty. Indeed, often a specialty choice is selected via the rejection of specialties until a few remain which are less onerous (Allen, 1999; Kassebaum & Szenas, 1995).

There are a large number of studies which have examined the reasons why entering medical students want to practice OB/GYN, especially if OB/GYN is considered a primary care specialty vs. a surgical subspecialty. Studies reveal that most students who enter into OB/GYN are from a cadre who had expressed a desire to practice in primary care. The remainder of this section summarizes these data, since many studies reveal similar findings.

Prior to the 1980s many of the top students selected IM or SURG residencies. This has steadily shifted to where top students desire residencies that have a controllable lifestyle, e.g., radiology, anesthesiology, pathology, vs. those specialties that are considered to have an non-controllable lifestyle, e.g., IM, FM, OB/GYN (Jarecky et al., 1993; Schwartz et al., 1990). Because of this shift, many students who selected non-controllable lifestyle, primary care residencies tend to have lower undergraduate science grades and lower medical school entrance exam scores, parents with a lesser amount of education, and a rural upbringing. Students who desire a primary care specialty usually state so upon matriculation, and are usually female, older, and a minority. These students have performed a greater amount of community service than the average applicant, espouse pro-social values, appreciate a broad scope of practice, and desire to ensure patients are counseled and educated on healthrelated issues (Bland et al., 1995; Owen et al., 2002; Reed et al., 2001; Schieberl et al., 1996). Schools which emphasize the importance of primary care, or whose mission is to produce primary care physicians, naturally have more graduates in OB/GYN, IM, FM and PED (Martini et al., 1994). considered

With special reference to OB/GYN, a series of seven studies, spanning 1991-2007, examined what influenced medical students to enter or reject an OB/GYN career (Fogarty et al., 2003; Gariti et al., 2005; Hammoud et al., 2006; McAlister et al., 2007; Metheny et al., 1991; 2005; Schnuth et al., 2003). Highly rated attractors common to five of the studies were; the student being female, having a positive OB/GYN clerkship experience, as well as being encouraged during the clerkship. (This latter finding was also found to be extremely important by Blanchard et al. (2005).) Expressing a strong desire to practice OB/GYN when entering medical school is also a good predictor. Also viewed as important attractors; were having continuity of patient care, seeing healthy patients, being devoted to patient education, disease prevention, and having strong opinions about reproductive health. Being exposed to a positive role-model was a variable attractor among these studies and influenced some students more than others.

The above seven studies also mention factors that discouraged students from considering OB/GYN. The issue of a non-controllable lifestyle was a variable factor, i.e., it mattered a great deal for some students, but was found to be of little or no concern for others. However, if a student was clearly devoted to entering OB/GYN, the issue of a non-controllable lifestyle, although known by the student, was not a significant detractor. It was very clear

given improper advice on what it means to be an MD. Counseling students on specialties is spotty and often anecdotal. There are few good role models (especially female) to emulate, and faculty advice rarely takes into account medical student abilities and aptitudes. Students are not encouraged enough and are given menial tasks to perform while on the clerkships. This discourages them from entering a particular specialty. Indeed, often a specialty choice is selected via the rejection of specialties until a few remain which are less

There are a large number of studies which have examined the reasons why entering medical students want to practice OB/GYN, especially if OB/GYN is considered a primary care specialty vs. a surgical subspecialty. Studies reveal that most students who enter into OB/GYN are from a cadre who had expressed a desire to practice in primary care. The remainder of this section summarizes these data, since many studies reveal similar findings. Prior to the 1980s many of the top students selected IM or SURG residencies. This has steadily shifted to where top students desire residencies that have a controllable lifestyle, e.g., radiology, anesthesiology, pathology, vs. those specialties that are considered to have an non-controllable lifestyle, e.g., IM, FM, OB/GYN (Jarecky et al., 1993; Schwartz et al., 1990). Because of this shift, many students who selected non-controllable lifestyle, primary care residencies tend to have lower undergraduate science grades and lower medical school entrance exam scores, parents with a lesser amount of education, and a rural upbringing. Students who desire a primary care specialty usually state so upon matriculation, and are usually female, older, and a minority. These students have performed a greater amount of community service than the average applicant, espouse pro-social values, appreciate a broad scope of practice, and desire to ensure patients are counseled and educated on healthrelated issues (Bland et al., 1995; Owen et al., 2002; Reed et al., 2001; Schieberl et al., 1996). Schools which emphasize the importance of primary care, or whose mission is to produce primary care physicians, naturally have more graduates in OB/GYN, IM, FM and PED

With special reference to OB/GYN, a series of seven studies, spanning 1991-2007, examined what influenced medical students to enter or reject an OB/GYN career (Fogarty et al., 2003; Gariti et al., 2005; Hammoud et al., 2006; McAlister et al., 2007; Metheny et al., 1991; 2005; Schnuth et al., 2003). Highly rated attractors common to five of the studies were; the student being female, having a positive OB/GYN clerkship experience, as well as being encouraged during the clerkship. (This latter finding was also found to be extremely important by Blanchard et al. (2005).) Expressing a strong desire to practice OB/GYN when entering medical school is also a good predictor. Also viewed as important attractors; were having continuity of patient care, seeing healthy patients, being devoted to patient education, disease prevention, and having strong opinions about reproductive health. Being exposed to a positive role-model was a variable attractor among these studies and influenced some

The above seven studies also mention factors that discouraged students from considering OB/GYN. The issue of a non-controllable lifestyle was a variable factor, i.e., it mattered a great deal for some students, but was found to be of little or no concern for others. However, if a student was clearly devoted to entering OB/GYN, the issue of a non-controllable lifestyle, although known by the student, was not a significant detractor. It was very clear

onerous (Allen, 1999; Kassebaum & Szenas, 1995).

(Martini et al., 1994).

students more than others.

that a negative OB/GYN clerkship experience strongly deterred students from entering an OB/GYN residency. Some students felt a patient population restricted to women and/or female reproductive issues did not have a large enough variety of diseases and patients to provide job satisfaction. McAlister and colleagues (2007) found that Asians, Pacific Islanders, and students with no medical school debt, did not consider OB/GYN as a career. Two studies found that male students did not enter OB/GYN because of the perception that patients preferred a female OB/GYN, and/or, there were too many females in OB/GYN residencies so that males would constitute a minority (Hammoud et al., 2006; Schnuth et al., 2003).

Factors that were rated as neutral, were little concern over salary and medical school debt. The cost of malpractice insurance was an issue to a few students, but not a deciding factor if the person was determined to enter an OB/GYN career. Once again, those who were sure about entering an OB/GYN residency did not let the perceived detractors alter their choice. The opposite was true for those who had an initial interest in OB/GYN but were not resolved to practice it (Fogarty et al., 2003; Gariti et al., 2005; Metheny et al., 1991).

In 2005, both Blanchard and colleagues and Nuthalapaty et al. determined which nonmedically-related factors were most important for students selecting an OB/GYN residency. There were similarities found in both studies. Many of the highly desirable residency traits were related to the "atmosphere/collegiality" of the residency program. For example, the degree of camaraderie between the residents was very highly rated, as well as how well the faculty cared about, and responded to, resident concerns. Faculty accessibility, commitment to resident education, and geographic location also played an important role for either gender. Females rated having family and friends in the area, the amount of primary care offered by the program, and the resident gender mix as significantly more important than the male's ratings. Males tended to view hospital facilities as more important than females. Males also rated salary and moonlighting opportunities as significantly more important than females, but the rank order of these two factors was near the bottom of the list, indicating that the other aforementioned factors played a much larger role in the decision making process. Results from a 1990 study by Simmonds and colleagues showed the same results. This demonstrated that what students are looking for in a residency has remained stable over a fifteen year period. near
