Why do graduates choose to work in a less attractive specialty? A cross-sectional study on the role of personal values and expectations

Despite many efforts to increase the number of physicians serving in primary health care (PHC) specialties, there is still disparity in the distribution of health care staff between hospital and community settings [1, 2]. The need for physicians serving in PHC areas is, however, expected to grow, especially in middle- and low-income countries (MLICs) [2‐4]. In general, medical students’ and graduates’ career preference for primary care specialties has decreased over time [5‐7]. For example, in the United Kingdom, more than 70% of recently qualified doctors expressed preference for a hospital specialty, while 25% specified general practice, and only 1% chose public or community health [8]. There are reasons to expect that the problem will be the same or even larger in MLICs, where fewer medical students choose a PHC career [9, 10]; if they do choose PHC, it is often as a “second choice” specialty [11]. Furthermore, PHC doctors tend to leave their jobs in the community and seek a hospital position after completing post-graduate specialty training [2, 12‐14]. This suggests that scarce resources of students, medical schools, and society may be wasted and result in the diminishing number of physicians in the PHC field.

Although there are several reports on career choices of health care workers who graduated as medical doctors in rural and remote areas [15‐17], little is known about the factors related to motivation of those who studied and graduated from the less popular specialties, such as PHC. In Vietnam, preventive medicine (PM) is a subspecialty of PHC; it constitutes an undergraduate curriculum program that trains specialized staff to work in PM centers and in the community and leads to a Doctor of Preventive Medicine degree. However, our recent study [10] showed that one third of the students who began their study in PM had little knowledge about the specialty and that it was a “second choice” when they failed to qualify for medical school. As a consequence, these “second-choice” students expressed regret and wanted to pursue a “higher prestige” clinical position in the hospital. The tendency of moving away from the community of PHC workers has been reported both in Vietnam [12, 14] and in other countries [13, 15, 17]. The main aim of the current study was to understand the time period at which PHC graduates, specifically graduates in PM, decide on their choice of job and the facilitating and hindering factors that affect their retention in the specialty.

Literature on clinical career paths suggests that it could take at least 3 years after graduation for most medical doctors to make their final decision on career choice [18, 19]. We do not know yet if this period of 3 years would be applicable to PM doctors and, if so, what happens during that time. Addressing these questions would help provide better counseling for PM students and young doctors, especially to those for whom PM was not the first preference career, so that there is greater continuity in their medical career planning.

Several demotivating factors that might impact the decision to maintain or change specialty among PHC doctors have been mentioned in the context of MLICs [15‐17]: low salaries; fewer opportunities for career development; inadequate management, supervision, and training; poor infrastructure and resources; and difficult working conditions. Incentives other than finances play a critical role in increasing PHC staff motivation, including recognition or appreciation by employer, colleagues, and the community; having a stable job and income; and access to training [15, 17]. Intrinsic factors, such as love for the work or “being useful to society and taking care of people,” have also been noted [16]. In contrast, factors in high-income countries seem to be more often related to individual and family issues [19, 20]. For instance, domestic circumstances, perceived lack of collegial support, social isolation from family and friends, and lack of post-graduate training were listed as demotivating factors for staff working in remote areas in Canada and Australia [20]. In European countries, female graduates had greater preference for a community specialty and domestic circumstances were more relevant for female than for male doctors; they were also more important for general practice physicians than for hospital doctors [19]. These findings might be related to a community specialty’s greater compatibility with family life compared to a hospital specialty.

Theoretically, motives for important decisions in life can be understood using Maslow’s motivation theory [21]. According to Maslow, an individual cannot be fulfilled in life unless all five fundamental elements (i.e., physiological needs and needs for safety, love and belonging, esteem, and self-actualization) are met, starting from basic physiological needs and working toward the highest level, self-actualization. Since work plays an important role in the quality of life, Maslow’s theory can be applied to explain work-related needs in an individual’s career. Furthermore, the needs of a person could change during their lifetime in tandem with their age and personal and professional experiences and responsibilities. According to Super’s theory of life role in career development [22], at a certain stage of life, people can simultaneously play multiple roles, as a child, student, citizen, worker, and homemaker; increasing the number of roles in one’s life may mean less commitment to other roles. This theory has been applied to human resource development in a diverse range of contexts [23]. Applying these theories to define PM graduates’ working needs in relation to their roles at the time they make their career decision may give clues to understanding their motivation and expectations for their career pathway. For example, female doctors are expected to fulfill the simultaneous roles of family caretaker and physician; therefore, the need to be settled and able to take care of family might impact their consideration of working in the community. Another example would be if graduates have to support their wider family, which might lead to a choice to work near their parents in their hometown or encourage them to find a position in a hospital based on better income and access to health care for family members. The application of Maslow’s and Super’s theories to understand graduates’ decision to choose and continue with PM is presented in Fig. 1.

There are gaps in our knowledge of the possible impacts of need fulfillment at particular life stages on graduates’ motivation to choose a job in PM (a subspecialty of PHC) and continue in the specialty. The objective of this study was to identify the reasons related to life roles and motivational factors that lead to PM graduates choosing a PM position and staying in the field.

Recruitment and retention of PM staff remains a challenge in many countries. Our study provides new information about PM graduates’ post-educational job choices and interest in continuing to work in this PHC subspecialty, which can inform policy to encourage more PM staff to join and stay in the field. Different factors influenced decisions on job choice and continuing in PM among men and women and between graduates who had or had not chosen PM at the start of their university study.

The results showed that only half of PM graduates were actually working in PM, the majority at the central and provincial levels, while about 10% of half of the graduates worked in hospitals or outside the health sector, and none of them worked in the community. This is consistent with existing evidence that PHC staff in Vietnam move away from the community and from preventive care [12, 14]. In the current study, nearly 40% of the graduates had chosen to study PM without a strong preference, that is, as a second choice. As we have previously reported [11], PM students had misconceptions about what PM doctors really do in practice, which might partly explain graduates’ job choices, although we did not find a significant difference in current jobs between graduates who chose PM as a first or second choice.

In this study, we found that one third of graduates had not decided which specialty to pursue as a career, even though half of them had graduated more than 3 years earlier, and one third were already working in PM. This career decision-making time period is longer than that from previous findings among medical graduates [18, 19] or among more mature graduates of clinical specialties such as nephrology [27] or oncology [28], which reported the time was 1 to 3 years after qualification. This indecision about career choice among graduates in a PHC specialty has been confirmed in both developed [18, 19] and developing countries [10, 13]. The possibility of losing more than half of the graduates who did not choose PM even 3 years after qualification questions the effectiveness of training programs that recruit freshmen straight to the PHC subspecialty training, suggesting that the specialty should be offered as a post-graduate training specialty. However, to be more optimistic, this 3-year period of instability could be seen as an opportunity to engage more graduates who are still undecided, by working to meet their needs and nurturing their preference for work in PHC.

Concerning the influence of life roles on graduates’ career decisions, we found a significant association between the “role of a child” (i.e., staying close to, respecting, and taking care of parents) and the decision to choose a PM job. Additionally, the “role of a citizen” (i.e., serving the community) was related to the decision to stay in the PM field, although not in all subgroups. Responsibility to parents only influenced the choice for PM among male and first-choice graduates. This confirms an observation in our previous study [11], which showed that first-choice PM students were drawn to study PM by the desire to uphold their family traditions and fulfill their parents’ wishes. The fact that the role of a child strongly affected male graduates but not their female peers could be explained by the social norm in Vietnam that expects men to take care of their parents, while women should assist their husbands in that task. Interestingly, a child’s responsibility for their parents encourages particularly second-choice graduates to stay in PM, even though it might not be their preferred specialty. The idea of working in PM, with its offer of stability and sufficient time to care for parents, might help to explain this motivation. This interpretation is supported by another report [14] that Vietnamese doctors expressing interest in stable work and salary were more satisfied with their current job in rural areas. For female graduates, marriage was a significant factor influencing the choice of a PM job, consistent with previous findings in European countries [17, 19]. These advantages of PM work could be emphasized to increase the attractiveness of the specialty to new students and undecided young doctors, especially to women and second-choice graduates.

Interestingly, we found a link between commitment to serve the community (the citizen role) and the tendency to stay in PM, particularly among those for whom PM was their first choice. This confirms the importance of intrinsic factors, such as “being responsible” and “relation with the community” that have been noted as significant motivators from the perspective of health professionals in developing countries [16, 17]. Although our data do not allow us to conclude that the inherent preference for PM of first-choice graduates was the main motivator for them to stay in the field, it might be useful to guide recruitment of “the right students” and “the right staff” in a less popular specialty like PHC. Additionally, our findings enrich the existing application of Super’s role salience theory in human resources development [22] by providing information from the perspective of both health care-related human resources and that of a developing Asian country whose values and cultural context are different from the Western settings the theory and its related literature have mostly focused on. However, we did not investigate the interaction among the roles important to health workers during their career development, including the influence of changing life roles on an individual’s career development strategies. Future longitudinal studies can help in the understanding of the inter-role relationships and the effect of role fluctuation in different life stages on retention of PHC health workers.

Along with the impact of personal life roles, we found that satisfaction with opportunities for continued education was prominent in graduates’ motivation, regardless of gender or PM preference. This motivating factor can be linked to the highest level of Maslow’s pyramid, that is self-actualization, as access to continued education would provide graduates opportunities for professional achievement and advancement. This result is in line with a previous study on motivation of medical staff in a Cyprus public general hospital [29]; however, our results did not reveal a connection of certain factors including remuneration or good relationships with coworkers to lower levels of the pyramid, as reported in that study. Critics of Maslow’s hierarchy of needs also assert that this theory may not be universally applicable and may vary across cultural, organizational, and individual perspectives in different countries [30]. Another possible explanation for this difference is that our participants are PHC workers, a specialty that is considered to have less prestige and be less attractive than hospital-based specialties. Therefore, their desire might be for the opportunity for achievement and to gain respect from colleagues and the community, which can be linked to the achievement needs in Maslow’s pyramid. Our findings also confirm the observation of Witter et al. [14], who listed the lack of opportunity for further training or continued education as an impediment to working in PHC. Interestingly, these authors suggested that a possible underlying reason for health workers’ demands for further training was that better training might be a “passport” for them to leave their lower-level facilities. An implication of our findings on retaining PM doctors therefore includes both providing more trainings (short courses, graduate, and post-graduate) and controlling the final destination of PM staff after achieving higher qualifications. Unexpectedly, we found a negative relationship between satisfaction with job and working conditions and the decision to stay in PM, especially among men and first-choice graduates who decided to stay because of their responsibility to their parents. Our data do not explain this unusual connection; we hypothesize that these graduates felt unhappy because they did not see any other option than continuing in PM. Further study is necessary to explore this issue in more detail.

The present study has several limitations. Firstly, the study design was cross-sectional, which allowed us to examine predictors’ association with PM recruitment and retention at only a single time point. In the future, longitudinal studies should be conducted to follow participants and describe the entire process of their career choices, from the beginning to the final decision. Secondly, participants were PM graduates drawn from one medical school; when this study was conducted, six out of 13 Vietnamese state medical universities offered PM training, including HMU. To increase the generalizability of our results, future studies should recruit graduates from other medical schools that also provide PM training, as differences in training programs, sociodemographic characteristics, facilities, and available positions might impact job choices. Finally, the limited sample size was partly a result of the university’s not yet well-established alumni information system, which caused random missing values. The relatively low response rate from graduates whom we did reach might not be fully representative of our sample, for example, alumni who are dissatisfied with their current situation could have been more inclined to answer than those who are satisfied. Future study could also include the 4-year program graduates, whose motivations may be different because they already have practical health care experience before starting their study. Their perspectives would be relevant and might provide good information to policy makers to focus efforts on people with more experience.

This study, which asked graduates from a PHC subspecialty training program what motivated them to choose a PHC job and to keep working in the field, is the first of its kind. The research provided information about timing of career choices, personal needs, and expectations of graduates that will support the design of interventions aimed at maintaining an adequate PHC workforce. The findings highlight the importance of continuing education and the role of graduates in relation to family and the community in recruiting and retaining health workers in PHC in Vietnam. These findings can inform and inspire policy development to manage human resources for PHC in Vietnam and perhaps globally and might also be useful for other less popular specialties struggling with recruiting and retaining staff.