Attitudes toward ophthalmology as a prospective career among pre-clinical medical students in China | BMC Medical Education

This study seeks to understand the attitudes and perceptions of medical school students in China to different specialties to determine the factors that lead students to select a particular specialty with a particular focus on the field of ophthalmology. According to the results (Table 2), 89.8% of students report spending most of their time studying with little time for rest. There is a saying that is very popular among Chinese medical students that, “Medical school is like repeating the life of your third-year high school for 5 times.” 29.6% of students regret their decision to enter medical school, and 32.7% of students are dissatisfied with their life recently. This negative attitude towards life likely reflects not only their current life in medical school but also the reports from the media regarding the real environment of being a doctor in China. The mean annual salary in 2015 of Chinese physicians, adjusted for purchasing power, was around U.S. $27,000, which is many times lower than the average physician salary in some developed countries [10]. Doctors in China also face considerable professional pressure. The demand for healthcare services in China is rising rapidly but the number of doctors has not increased accordingly [11]. Poor doctor-patient relationship is becoming a big problem. There were about 70,000 medical conflicts and more than 10,000 violent attacks on healthcare workers in China in 2013 [12]. The incidence of anxiety and depressive symptoms among physicians in China was higher than that in other countries [13].

In this study, we investigated 362 students in the 5-year program. We found that most (68.0%) of them will choose to further their study in the future (Table 2). Most provinces in China recently required every physician to pass the Standardized Resident Training (SRT) program before finding employment. This takes 3 years, which is the same amount of time as getting a master’s degree. Most students will choose to pursue further training in medical research in this study for a greater chance of publishing and easier access to a doctorate degree, which can lead to a more promising future. The students can also go through the first-level of SRT during these 3 years. After getting the master’s degree or the doctorate degree, most of the students will choose to work at the top ranking hospitals in cities rather than the rural hospitals, which will perpetuate the situation of the dearth of ophthalmologists in rural and remote places.

The reasons students choose to be a doctor is demonstrated in Fig. 1. Most students chose to enter medical school for idealistic reasons like the ability to help patients, interesting and challenging work, and prestige. But after four/six years of medical school, the reasons for choosing a specialty become more realistic, including the students considering more career upward mobility, the ability to find employment, and financial reward. All these results demonstrate that the medical school students have changed significantly in their mindset during these years. After four years in medical school, students consider more about their future life. This change is inseparable from the burden of studying in school, and media reports about the working environment of doctors in China.

Few studies [8, 14, 15] have focused on these nine attitudes towards ophthalmology as students decide their future career, especially the attitudes on the ability to find employment, career upward mobility, professional pressure, and doctor-patient relationship. Our finding (Table 1) indicated that for clinical medicine students, 5.6% (five-year) and 3.4% (eight-year) of them ranked ophthalmology as their first choice career. For the anesthesia and oral medicine students, 69.4% anesthesia medicine students and 89.6% oral medicine students preferred to choose the same specialty as before. Most students who have a specialty (e.g., anesthesia medicine and oral medicine) will choose to continue their specialties after graduation. This suggests that encouraging medical schools to launch ophthalmology as a specialty could recruit more future ophthalmologists.

Towards these nine attitudes (Fig. 3), ophthalmology seems to receive a high rating on the ability to help others, interesting and challenging work, stable job, financial reward, prestige, good doctor-patient relationship, and professional pressure. But for the ability to find employment and career upward mobility, students expressed a negative assessment about ophthalmology. These were very important for the students in making the decision for their future specialty. Even though their assessment on the other factors was positive, the students appeared to face realistic problems which reduced their interest in entering the field of ophthalmology.

This survey reflects the students’ perception of reality. Students likely have misunderstandings on each specialty. Students perceived that career upward mobility is comparably slow for ophthalmologists or possibly for all the surgeons in China. In this study, surgical opportunities and observing surgery are especially important factors that students took into consideration when choosing to be ophthalmologists (Fig. 3). It is reported [16] that most surgeries in large Chinese hospitals are done by a small group of senior doctors. Less than 5% of surgeries were performed by doctors under the age of 43. A study showed that mainland Chinese ophthalmology residents had undertaken a median of 0 independent cataract operations during their training, compared with 100 cases for trainees in the Hong Kong Special Administrative Region over a similar period [17]. In the United States, ophthalmology residents are required to complete a minimum of 86 cataract surgeries as primary surgeon to complete their residency [18].

China is characterized by extreme imbalance and differences in regional development. The geographic and demographic distribution of doctors in China is unequal. One study [19] showed that the prior medical system reforms with price regulation in China drove medical staff and patients to larger hospitals. This results in congestion in larger hospitals and idle resources in smaller hospitals. In this study, most (70%) of students will choose to further their study to get a master’s degree or even a doctorate degree. Most of them probably won’t choose to go to the smaller hospitals to work. Since 60% of the Chinese population lives in rural areas [20], the prevalence of visual impairment and blindness is high in rural populations [11]. But the hospitals in rural locations often cannot attract ophthalmologists to work there, and there is less need for ophthalmologists in hospitals in urban places.

About the financial reward for Chinese doctors, this aspect is always perceived as a key factor affecting job satisfaction. The salary of Chinese physicians is comparably lower than physicians in America, Canada, and some European countries. A survey [21] in China showed that 78% of physicians who wouldn’t want their children to be physicians ranked low salary and long work hours as the top 2 reasons. Also, in our study, financial reward is a priority factor that influences the students’ choice for a future specialty. A report [10] of the salary of physicians in different specialties in China revealed that the three highest income specialties are ophthalmology, otolaryngology, and dentistry. In our study, students perceive them to be surgery, dentistry, and ophthalmology. The three lowest income specialties in China are pediatrics, internal medicine, and emergency medicine. In our study, students perceive them to be infectious diseases, emergency medicine, and pediatrics. From this comparison, students’ attitudes closely mirror reality. Ophthalmology has a great advantage on this aspect. However there is significant regional and district differences in salary, and the mean salary of Chinese physicians in the district in which this study was conducted is lower than other districts [10].

Recently, numerous reports and debates around violence in Chinese healthcare settings are taking place [21, 22]. According to a survey [23] by the Chinese Hospital Association between December 2012 and July 2013, hospital violence has increased during the past 5 years. 96% of healthcare workers have been abused or injured in 2012, and 39.8% of them planned to give up the medical profession or switch to another profession.

Regarding perceptions of stable life, prestige, interesting and challenging life, and the ability to help patients, ophthalmology receives a high-rating on these four attitudes. In a study [24] in America, the top three annual specialties for work hours are surgery, obstetrics & gynecology, and internal medicine; the bottom three are dermatology, emergency medicine, and psychiatry. Medical practices are different in China so this likely does not represent the situation in China. Teachers can make their class more attractive to students by increasing opportunities to enter the operation room and observing surgery and operating under supervision (Fig. 4). This could recruit more promising students to select the field and cultivate more future ophthalmologists and physicians to treat ocular diseases.