Background: Demographic change, technical progress, and changing patterns of service use influence the future demand for physicians in the German health care system. The attitudes of medical students towards their later work in the health system is important for current health care planning. For that reason a nationwide survey aimed to identify major trends in preferred specialty, workplace characteristics (regional location, hospital) and perceived hindrances for clinical work.
Methods: A questionnaire consisting of 34 closed questions was developed at the University of Mainz in 2009 and administered over the Internet in June and July 2010 to all medical students in Germany. The questions addressed the students’ intentions regarding specialty training, location of practice, workload, and regional preference, as well as potential reasons why they might choose not to practice clinical medicine in the future.
Results: 12 518 web-based questionnaires were filled in (approx. 15.7% of all medical students in Germany in 2010). The mean age was 24.9 years, with 64% female and 36% male. Favored specialties were internal medicine (42.6%), family medicine (29.6%), pediatrics (27.0%) and surgery (26.8%). Nearly all respondents (96%) stated that they attached importance to compatibility of work and family life. Working in a salaried position (92.2%) was preferred to working in private practice (77.7%). General practice, in particular in rural locations, was significantly less favored than work as a specialist in cities.
Conclusion: Although the coming generation of physicians anticipate working in clincial settings in the future, shortfalls in the areas of primary care and in rural locations are likely if medical students adhere to their preferences stated in the questionnaire.
Experts believe that demographic developments and medical progress are combining to bring about large-scale changes in the medical care of the general population (1). Increasing life expectancy and the associated multimorbidity, together with increasing urbanization and the breakdown of social support structures such as the family, are changing the settings of care and influencing medical service provision. Physicians are also affected: The average age of the membership of the German National Association of Statutory Health Insurance Physicians rose from 46.6 years in 1993 to 51.9 years in 2009, and the Association estimates that around 28 000 vacancies will have to be filled by 2015. Simultaneously, expectations regarding the medical profession are changing, as shown by numerous surveys of medical students (2–4).
In the German context, two large quantitative nationwide surveys have shed light on the attitudes of medical students towards their later work as doctors (5, 6). The results of qualitative investigations are also available (7). In common with surveys from other countries, these studies reveal increasing preferences for working as a specialist and for practicing medicine in urbanized regions. They also reflect the increasing proportion of women in the medical profession.
In view of the emerging challenges to health care provision, the University of Trier, supported by the National Association of Statutory Health Insurance Physicians, adapted a survey initially conducted in the German federal state of Rheinland-Palatinate for application nationwide. Accurate knowledge of medical students’ preferences for future specialty, their flexibility regarding location and workload, and their views on the compatibility of work and family life is essential for the planning of provision. We therefore set out to survey medical students’ attitudes towards their later work in the medical profession, specifically their intentions with regard to specialty, workplace characteristics, and location.
Based on a previous survey of all students of medicine at the University of Mainz in 2009, a web-based questionnaire consisting of 34 predominantly closed questions was administered to the students of all medical faculties in Germany via personally addressed e-mails in June 2010. With the support of the Medical Faculty Conference (Medizinischer Fakultätentag), all faculties were requested to forward the invitation to participate in the survey to their students. The software SPSS 18.0 was used for statistical evaluation; the analysis is described in detail in the eMethods and in a recently published monograph (8).
Sample: response rate and respondents
A total of 12 518 questionnaires were completed. Disregarding the possibility of multiple response, which cannot be absolutely excluded, this represented a response rate of 15.7%, based on the total of 79 929 medical students registered at the 36 medical faculties in Germany in 2010. At six faculties (Essen, Halle, Münster, Regensburg, Witten-Herdecke, and Würzburg), fewer than 10 students completed the questionnaire. Sixty-four percent of the respondents were female, corresponding closely with the proportion among medical students in general—61.3% in the winter half-year 2009/10, according to the data of the German Federal Statistical Office (9). The average age of the participants was 24.9 years (standard deviation 3.6). Some 96.5% of the respondents were German citizens. With regard to geographical location, 27.1% of the sample were studying at medical schools in southern Germany, 9.0% in the city states of Berlin, Bremen, and Hamburg, 18.8% in the federal states corresponding to the territory of the previous East Germany, and 45.0% from the remaining states of western Germany (n = 9945).
According to the data provided by the students who responded, 32.1% were at the preclinical stage of education at the time of the survey, 53.0% in the clinical phase, and 15.0% in their final year of practical training (n = 10 104). There was a strikingly high rate of previous contact with the health care sector: 55.3% reported practical experience in the health services before starting to study medicine, 24.2% had physicians as parents, 31.1% had other family members who were physicians, and as many as 13.6% stated that they might have the opportunity of taking over the office of an acquaintance or relative (multiple answers possible). Some 5.5% of the respondents (n = 12 516) already had children (women 6.0%, men 4.5%). In this respect the medical students in our survey resembled students in general: The 19th survey of the German National Association for Student Affairs, carried out in 2009, showed that 5.0% of students had children (10).
Compatibility of work and family life
Altogether, 95.5% of the respondents stated that good compatibility of work and family life was important to them (n = 11 776). There was hardly any difference between the sexes: 97.0% of the women and 93.0% of the men placed importance on a balanced relationship between work and family. The sexes also differed hardly at all with regard to desire for children. Overall, 88.8% of the medical students (n = 9705) wanted children later (women 89.7%, men 87.3%).
From a list of 14 medical disciplines, the participants were asked to name no more than three preferences for future specialty training (n = 12 058). Table 1 summarizes their responses. The favored specialties varied as students progressed through their training, but the five most popular specialties remained stable. Moreover, the number of disciplines nominated decreased significantly with increasing duration of training. Preclinical students chose an average of 3.1, clinical students picked 2.8, and those in the final year of practical training selected 2.3 specialties. A total of 12.6% of the respondents specified one or more unlisted specialties under “Others”, most frequently pathology (149 nominations) and forensic medicine (141 nominations).
The preferences for future specialization differed considerably and, given the sample size, significantly between men and women. The greatest variations were seen in gynecology, pediatrics, orthopedics, and surgery.
A total of 75.5% of the respondents (n = 10 245) thought it would be important to decide for themselves when and how long they worked, and 60.9% expressed the wish to be able to work part-time. There was no difference between women (74.7%) and men (75.7%) in the desire to determine their own working hours, but a clear difference regarding part-time work. While 77.2% of the female medical students thought it important to have the possibility of working part-time, only 32.1% of their male counterparts shared this view. The proportion of respondents who wanted to be able to work part-time increased during the course of training: 54.2% at the preclinical stage, 63.7% in the clinical phase, and 64.8% in the final year of practical training (n = 10 081).
The great majority of the sample—around 87%—expected to work (at least initially) in a full-time post, and almost half assumed they would work more than 50 hours per week. The mean values were similar, and the averages for men and women and for students in the different phases of training also lay between 51 and 52 hours (Table 2).
Type of employment
The questionnaire listed nine options for future type of employment; more than one box could be checked. Overall, “salaried physician in a hospital” and “specialist with own office” were chosen equally often. The students expressed a preference for working in patient care. Other options, e.g., employment in research (nominated by only 18.9%), were much less popular. Salaried employment was much more attractive than self-employment, but only if a hospital post was involved. The differences between men and women were statistically significant at greatly varying levels almost throughout, with two exceptions: working as a specialist in one’s own office was equally attractive for both sexes, while employment by a health insurance provider was equally unattractive.
Women selected salaried employment much more frequently than men, and also had a somewhat higher preference for employment in a public health service post or in primary care. The overall willingness to set up an office (as specialist or primary care physician) was comparable for men and women (Table 3).
Analysis of barriers to establishment of an office and hospital employment
A total of 11 095 respondents answered the question regarding factors that speak against establishing one’s own office. These were, in descending order:
Principal component analysis showed associations among the items, which can be grouped as follows (varimax rotation, KMO.659):
The respondents expressed the wish for these obstacles to be overcome by:
Different emphases emerged when the medical students checked the factors that spoke against hospital employment. A total of 10 688 students specified reasons for not taking up a hospital post. The most frequently mentioned reasons were high workload (63.1%), poor compatibility of work and family life (60.5%), the inadequate amount of time available for treating patients (55.1%), and the rigid hierarchy in hospitals (53.2%). Fewer than half of the respondents named, in descending order, “little leisure time,” “low income,” “on-call duty and night shifts,” “high degree of non-medical tasks and bureaucracy,” and “little opportunity for promotion” as reasons not to work in a hospital. Principal component analysis (varimax rotation, KMO.816) extracted two central factors: An unfavorable balance between work and leisure time deterred 65.5% of the students from working in a hospital, and 27.6% would be put off by (excessively) low income and precarious career perspectives.
The distribution of anticipated net earnings is striking (Table 4). The phase of training at the time of the survey had no influence on income expectations—no significant differences were found between students at the beginning of their course and those in the final year of practical training. The differences between the sexes, however, were significant. Judged by the standard deviations of expected incomes, female students were much more homogeneous than their male counterparts and were content with much lower earnings.
Location of practice, regions
Only 3.4% of all respondents stated they by no means wanted to work in Germany, while 7.9% said they would definitely not take up a post abroad. With regard to working within Germany, the students showed a clear preference for staying close to home as they had done when choosing where to attend university. Over half of them (52.2%, n = 10 413) would definitely consider working in their home area, just under half (49.7%, n = 10 375) in their own federal state, and under one third (28.0%, n = 10 382) in another state. The emphasis was therefore very clearly on Germany.
Attachment to home area showed regional differences, however. It was strongest in southern Germany (93.1%), followed by the city states (91.8%), western Germany (85.6%), and finally eastern Germany (76.7%). Among the students prepared to move to another region, the three federal states most frequently mentioned were Hamburg (63.1%), Bavaria (57.2%), and Baden-Württemberg (55.2%).
Table 5 shows the respondents’ preference for larger towns and cities. Place of origin and sociospatial socialization played a decisive role in aversion to rural areas. Students who themselves were socialized in the countryside were significantly more frequently prepared to live and work in a small town or village. The sex of the respondents also had a significant influence: Women were more willing than men to go to a rural area. In contrast, the phase of training at the time of the survey had no influence on the responses (Table 5).
The results of this study show that the medical students who represent the coming generation of physicians are highly interested in working in clinical care and anticipate having to work more hours than average, upwards of 40 hours per week. The survey reflected the general trend towards women making up a higher proportion of physicians than used to be the case. It also mirrored general developments in our society. Living and working in the country was considered relatively unattractive; doctors too are attracted to larger towns and cities. Compatibility of work and family life has become much more important to both men and women, and this is shown not least by the increased interest in salaried employment.
Our findings are largely in agreement with those of the two previous German surveys (5, 6) and studies from other countries (2, 3, 11–13). Differences from the two large German surveys (5, 6) can be seen in the choice of future specialty and in the definitive intention to work abroad. While internal medicine is the most popular specialty in all of the surveys, it was followed in the two earlier German surveys by surgery, family medicine, anesthesiology, and then pediatrics. In our study the ranking is different with family practice on the second rank, pediatrics on the third, and surgery on the fourth. Comparing the preferred specialties of students in the final year of practical training with those in earlier phases of their medical education, the top five specialties are the same but in a different order. In the study by Osenberg et al. (5) there is a further significant difference: A far higher proportion of respondents stated they would be willing to work abroad, albeit with differently weighted questions.
There are considerable discrepancies between the specialty preferences and actual future requirements. The eventual choice of specialty is affected by various factors after qualification, so the preferences stated in the survey are not necessarily final. If all students were to follow these preferences, however, shortfalls could be anticipated (compared with the status quo) in primary care, and also in ophthalmology and ENT. This development is accentuated by the tendency to view primary care as unattractive, particularly in the countryside, and by the unfavorable assessment of career prospects expressed by practicing primary care physicians in an international comparison (14). Studies in other countries also show that primary care in rural areas constitutes a particular problem (11). In interviews with Australian medical students, Tolhurst and Stewart established that great importance was attached to the future physician’s own family, the potential for working part-time, and the opportunity to take extended sabbaticals (4).
Numerous studies have highlighted the significance of a student’s training in the subsequent decision on where to work (15) and in what specialty (16). It seems clear that the availability of internships and periods of practical training in rural areas have a positive influence on medical students’ career choices (17, 18). According to the respondents to our survey, intensified provision of advice and the financial security of the future work were crucial. These points should play a role in planning health care provision for the future, and indeed have already been adopted to some extent. Our study may thus help to show how future physicians can be won over to clinical care.
This nationwide survey of all medical students has limitations. It is difficult to determine whether the results are representative, because the preferences of the non-respondents are unknown. The estimated response rate of 15.7%, without accurate knowledge of the total number of medical students in summer 2010, reinforces this effect. Moreover, multiple responses cannot be excluded.
Conflict of interest statement
The authors declare that no conflict of interest exists.
Manuscript received on 13 September 2011, revised version accepted on
2 February 2012.
Translated from the original German by David Roseveare.
Dr. med. Bernhard Gibis
Dezernat 4 – Verträge und Verordnungsmanagement
10623 Berlin, Germany
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