STRENGTHS AND LIMITATIONS OF THIS STUDY
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This study focused on medical students in the second to fourth year.
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The professionalism and career choice motivation of medical students would change as social circumstances changed.
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A sufficient sample size to ensure the reliability of the findings.
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The cross-sectional design limits the inferences about the causal relationships between career choice motivation and professionalism.
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A single medical school may restrict the generalisability of these findings.
Introduction
Professionalism is a cornerstone of the medical profession.1 It is essential to medical personnel’s clinical behaviour, professional ethics and response to societal expectations.2 Professionalism is defined as ‘commitment to carrying out professional responsibilities and adherence to ethical principles’ by the Association of American Medical Colleges.3 However, the conceptualisation of professionalism is influenced by cultural background.4 There is no consensus on its definition and accepted framework globally. In general, most definitions encompass a range of viewpoints, including values, attitudes and behaviours.2 The most commonly cited professionalism in the literature includes altruism, responsibility, excellence, duty, honour and integrity, and respect for others.3 5
Professionalism affects doctor–patient relationships, patient satisfaction, quality of healthcare and even patient safety.6 The COVID-19 pandemic in particular has exacerbated tensions between professionalism and physician autonomy.7 Training highly qualified physicians who fulfil their duties and adhere to ethical principles has become an urgent need.8 Professionalism has become a hot topic in medical education. However, training in professionalism would begin in the first stage of a physician’s career—undergraduate medical education.9 Medical students are an important group of future healthcare professionals. It is important to strengthen professionalism education among them.
Career choice motivation refers to students’ motivation to pursue a medical career when they enter medical school.10 Students’ choice of a medical specialty depends on several factors, including personal interest, job security, family expectations and more. In a systematic literature review, career choice motivation is categorised into three dimensions: scientific, societal and humanitarian.11 It is also divided into intrinsic and extrinsic motivations.12 Career choice motivation is positively related to academic performance and learning attitudes.13 More importantly, the career choice of medical students is critical to maintain a sufficient medical workforce and a healthy development of the medical system.14 Therefore, understanding the career choice motivation of medical students is important to address the current lack of physicians in various fields.
From a humanistic perspective, there are similarities between career choice motivation and professionalism; however, research in this area remains limited.15 According to Vroon’s motivation theory,16 medical students’ career choice motivation may influence their professional values, attitudes, behaviours and decisions.17 It is agreed that there is a strong correlation between attitudes and behavioural choices. Thus, career choice motivation may be related to the professionalism of medical students. Notably, some studies have found that career motivation and professionalism may be influenced by gender.18 19 Females are more intrinsically motivated and less extrinsically motivated than males.20 Some studies also have yielded different results.21 In addition, there are similar inconsistencies in the literature regarding gender differences in professionalism.22Clarifying gender differences in career choice motivation and professionalism of medical students may help to propose targeted interventions for medical talent training and medical education.
Currently, most scholars pay more attention to the professionalism and career choice motivation of freshmen and graduates, ignoring the medical students in the intermediate stage.23 24 In this study, we focus on the medical students in the second to fourth year. As far as we know, no study has investigated the relationship between career choice motivation and professionalism among male and female medical students in China in the context of the COVID-19 pandemic. Analysing the relationship between career choice motivation and professionalism will shed light on the training of healthcare professionals. Therefore, the aim of this study was to examine the relationship between career choice motivation and professionalism among second-year to fourth-year medical students in the context of the COVID-19 pandemic. In particular, we hope to answer the following questions: (1) Do male and female second-year to fourth-year medical students have different career choice motivations and professionalism?; (2) What is the relationship between career choice motivation and professionalism based on gender?
Methods
Study design and participants
A cross-sectional study was conducted in September 2021 at a medical college in Shanxi, China. Most medical schools in China employ the conventional education model. Medical students study general science in the first year, basic medical courses in the second year, clinical medical courses in the third and fourth years, and an internship in the fifth year.25 However, first-year students are new to the college and have not sufficient profession knowledge. The professionalism of fifth-year students has changed significantly with their participation in hospital. To better understand the professional insights and attitudes of medical students who do not engage in clinical practice during their studies, we examined the second-year to fourth-year students in our study.
The minimum sample size was calculated by Kendall’s rough estimate.26 The sample size should include 20% of invalid participants in addition to 10 times the number of variables. There were 28 variables in our study; a minimum of 336 subjects had to be selected. The cluster sampling method was used to recruit students. 16 classes of each grade and 1780 medical students were invited. Participants were asked to complete a questionnaire on the online platform, Sojump. The platform is recognised as a reliable and convenient way to conduct online surveys.27 Participants can read the preface before taking the survey, which includes the purpose of the research, informed consent information and data confidentiality. They were asked to answer the question ‘Do you agree to participate in this survey?’ Only those who selected ‘yes’ were considered to have agreed to complete the questionnaire. A total of 1488 questionnaires were returned. Questionnaires completed in less than 100 s were considered unusable. 1421 questionnaires were usable and 67 were excluded. More details are shown in online supplemental figure 1.
Supplemental material
Supplemental material
Supplemental material
Measures
The questionnaire included three parts: demographics (7 covariates), career choice motivation (1 question) and professionalism (20 items). It is shown in online supplemental file 1.
Demographics
There are seven covariates included, which are as follows: age, gender, residence, family monthly income, father’s and mother’s occupations, and household size of participants. Residence was categorised as urban and rural. Monthly household income (renminbi (RMB)) was categorised as <2000, 2000–4999, 5000–9999, 10 000–19 999 and >20 000. Household size included ≤3 persons, 4–5 persons and ≥6 persons. Father’s and mother’s occupations were divided into healthcare and other occupations.
Career choice motivations
Career choice motivations of medical students were assessed through a multiple-choice question where they could select any option that applied. The options were as follows: (1) doctors have a noble profession dedicated to healing and saving lives, (2) influenced by family, (3) secure employment, (4) go with the flow, (5) personal interest, (6) advice from parents, (7) popular specialties, (8) other motivations.
The Physician Professionalism Assessment Scale
The Physician Professionalism Assessment Scale was used in this study.28 The scale has been modified to reflect the current situation, reducing it from 7 dimensions and 29 items to 6 dimensions and 20 items. The dimensions are as follows: (1) altruism, (2) honour and integrity, (3) caring, empathic and communicative, (4) respect for others, (5) conscientious and (6) the pursuit of excellence. The items use a 5-point Likert scale from ‘very unimportant’ (coded 1) to ‘very important’ (coded 5). The total score ranges from 20 to 100. Higher scores indicate greater medical professionalism. To facilitate comparisons between the six dimensions, the scores for each dimension were converted to a uniform 5-point scale score. The Cronbach’s alpha in the current study was 0.982.
Statistical analysis
SPSS V.22.0 was used to analyse the data. The sample data were presented as percentages for dichotomous data, and means and SDs for normal distribution. The t-test was used to assess whether the professionalism differed significantly in different genders of medical students. Χ2 test was used to assess whether career choice motivation differed significantly in different genders of medical students. The relationship between career choice motivations and professionalism among medical students of different genders was investigated using linear regression models. A two-tailed probability value of <0.05 was considered statistically significant.
Patient and public involvement
No patients or members of the public were involved in our study.
Results
Characteristics of the study sample
From a total of 1488 participants, the valid sample for this study was 1421 after excluding invalid questionnaires, with an effective response rate of 95.5%. The age of 1421 medical students ranged from 19 to 25 years (M=20.52, SD=1.29). Because the ratio of male to female for this medical college was about 7:1, nearly two-thirds of students were female (n=937, 65.9%) in this study. There were more second-year students (n=628, 440.2%) than in other years, including third year (n=419, 29.5%) and fourth year (n=374, 260.3%). Participants were more from rural (n=809, 560.9%) than urban areas (n=612, 430.1%). The average monthly household income ranged from 2000 to 4999 RMB. 77.1% of the students came from households with more than three members. Male medical students had a higher proportion of parents working in the healthcare field than of females. There were statistically significant differences in monthly household income, household size and father’s occupation on the gender of medical students (p<0.05) (table 1).
Characteristics of medical students by gender (N=1421)
Medical students’ motivations for career choice
In examining the motivations of medical students’ career choices, we found that 70.3% of the students were influenced by the perception that doctors have a noble profession dedicated to healing and saving lives. Among these students, 71.3% were female and 68.4% were male. Males preferred the profession because of influence by family (53.3%) and advice from parents (43.0%). Females were more likely to choose secure employment (47.3%) and personal interests (54.0%). However, popular specialties was chosen by 24.8% of the medical students. Few medical students preferred to go with the flow. The career choice motivations personal interest and other motivations are significantly different between genders (p<0.05) (table 2).
Career choice motivations of medical students of different genders (N=1421)
Professionalism in different genders of medical students
The overall score of medical students in professionalism was 91.87±11.24. Females outperformed males in terms of professionalism (92.70±10.68 vs 90.27±12.10). There were significant differences in professionalism related to gender (t=−3.718, p<0.001). Converting the scores of six dimensions to a 5-point scale score for comparison purposes, the highest score among medical students was in the dimension caring, empathic and communicative, and the lowest score was in the dimension altruism. There were significant gender differences related to the six dimensions of professionalism (p<0.05) (table 3).
Professionalism scores of medical students of different genders
Medical students showed the lowest level of professionalism in the third year and the highest level in the fourth year in terms of grades. There were significant differences in professionalism related to grades (t=4.210, p<0.05). Both male and female medical students from different grades showed this trend in professionalism (online supplemental figure 2).
Professionalism among medical students of different genders based on career choice motivations
The score of professionalism differed based on different career choice motivations. The medical students motivated by personal interest had the highest score for professionalism, while those who go with the flow had the lowest score. There were statistically significant differences in professionalism scores of medical students with regard to the choices doctors have a noble profession dedicated to healing and saving lives, personal interest and secure employment (p<0.05).
In addition, male medical students motivated by personal interest had the highest level of professionalism. Female medical students motivated because doctors have a noble profession dedicated to healing and saving lives and personal interest had the highest level of professionalism. The difference between the professionalism of male and female medical students in terms of the choices doctors have a noble profession dedicated to healing and saving lives, and personal interests was statistically significant (p<0.05) (figure 1).
Professionalism among medical students based on career choice motivations. *p<0.05, **p<0.01, ***p<0.001.
The relationship between gender-specific career choice motivations and professionalism
Linear regression analysis was used to examine the relationship between gender-specific career choice motivations and professionalism. Individual characteristics, family status and career choice motivations were independent variables used to analyse their influence on professionalism. As shown in table 4, age, monthly household income (10 000–19 999 RMB), doctors have a noble profession dedicated to healing and saving lives, personal interest and advice from parents were the factors of professionalism among male medical students (p<0.05). Additionally, the higher the score for the motivations doctors have a noble profession dedicated to healing and saving lives and personal interests, the higher the score for the professionalism of female medical students (p<0.05). In contrast, the higher the score for the motivation go with the flow, the lower the score for the professionalism of female medical students (p<0.05).
Linear regression analysis of career choice motivations and professionalism in different genders
Regarding the dimensions of professionalism, doctors have a noble profession dedicated to healing and saving lives, and personal interests have a positive impact on the six dimensions of male medical students (p<0.05). The higher the score for the motivation advice from parents, the higher the scores for altruism; honour and integrity; caring, empathic and communicative; and conscientious among male medical students (p<0.05). More details can be found in online supplemental table 1. For female medical students, the motivations doctors have a noble profession dedicated to healing and saving lives and personal interests were the factors of altruism; honour and integrity; caring, empathic and communicative; respect for others and the pursuit of excellence (p<0.05). The higher the score for the motivation go with the flow, the lower the score for the dimensions caring, empathic and communicative; respect for others; conscientious and the pursuit of excellence (p<0.05). The higher the score for the motivation personal interest, the higher the scores for the dimensions altruism, honour and integrity, respect for others and the pursuit of excellence (p<0.05). The motivation advice from parents was the factor of the dimension caring, empathic and communicative (p<0.05). More details are shown in online supplemental table 2.
Discussion
During the COVID-19 pandemic, the professional competence of physicians has been tested and the core principles of medical professionalism have also been challenged.7 Meanwhile, the COVID-19 pandemic has influenced medical students’ perceptions of professionalism.29 One study found that medical students’ perceptions of the importance of certain aspects of professionalism changed only a few months after the pandemic began.29 In addition, medical students’ motivation for their career choice has also changed. Medical students are more motivated by a sense of duty during the pandemic.30
To further understand the state of professionalism and career choice motivation during the pandemic, the present study examined the gender-specific associations between career choice motivation and professionalism among medical students in the context of the COVID-19 pandemic. To our knowledge, no previous study has examined medical students for these purposes. Gender differences were observed in both professionalism and career choice motivation in this study. The level of professionalism differed between genders based on different career choice motivations. These results answered our questions. We believe that this study can provide direction for the training of professionalism of medical students.
Our study demonstrated that the professionalism of female medical students outperformed that of males. Empirical findings suggest that females have higher levels of communication, understanding and empathy than male medical students.31 The same result was found in female medical students in Brazil during the COVID-19 pandemic.32 We also found that the level of professionalism exhibited a V-shaped pattern across the grades. Third-year medical students had the lowest level of professionalism, which is consistent with previous studies.33 Second-year medical students are full of expectations of becoming doctors in the future, even if they have not yet begun to learn about their clinical specialties.34 Fourth-year medical students have a solid comprehension of the medical field and have gained enough clinical knowledge and experience.25 Conversely, in the third-year, medical students begin to take on demanding clinical courses that place a heavy academic and psychological burden on them, leading to lowered empathy and decreased professionalism.35 Therefore, more attention should be paid to the cultivation of professionalism among third-year medical students in medical education.
In this study, both male and female students identified being caring, empathic and communicative as important characteristics of professionalism. However, altruism got the lowest score of professionalism for them. From a psychological perspective, altruism is motivated by the desire to enhance the interests and welfare of patients.36 It is a core of medical practice and plays a key role in physicians’ behaviour.37 Some studies have found that altruism influences the professional attitude of physicians and the establishment of harmonious doctor–patient relationships.38 Especially in the COVID-19 pandemic, altruism is a key trait for medical personnel in the fight against it.39 Consequently, the cultivation of altruistic beliefs and behaviours of medical students should be emphasised in medical education. This gives us an important implication in the curriculum. It necessitates the need to introduce altruistic modules early in the preclinical years, including volunteer activities and altruistic role model education to improve students’ attitudes regarding professionalism.37 40
We observed the motivation doctors have a noble profession dedicated to healing and saving lives was the top career choice for medical students. The sense of value and fulfilment of physicians is still the main reason for choosing to become a physician during the COVID-19 pandemic among medical students.34 We also found that career choice motivations differed between genders. Males were more likely to choose the profession because of influence by family and advice from parents. Females preferred to choose personal interests and secure employment. This result is consistent with the previous study.41 According to the self-determination theory, personal interest can be regarded as an intrinsic motivation,42 suggesting that females are more intrinsically motivated than males. One explanation for this difference may be that psychological maturity and brain development are related to gender.20 In general, males reach psychological maturity 3 years later than females of the same age.20
Whether and how career choice motivations are related to different dimensions of professionalism was a central question of our study. In this study, the level of professionalism among medical students varies based on different career choice motivations. Medical students motivated by personal interest had the highest level of professionalism, while those who go with the flow had the lowest. This can be explained by the expectancy value theory.43 It suggests that interest in medicine can be regarded as the motivation for enjoyment value, which is the most important for students’ achievement outcomes.44 Individuals motivated by enjoyment value will act highly autonomously.24 They further regulate their behaviour by observing, imitating and learning from role models in the process of clinical training. The best way to promote professionalism is through observation and role modelling.45 46 Notably, some scholars found that the interest in medicine of students significantly increased during the COVID-19 pandemic.44
More importantly, we discovered that the level of professionalism differed between genders based on different career choice motivations. Male medical students’ professionalism was positively impacted by the motivation advice from parents. Parents who are physicians are facilitators for students entering the medical profession.21 Both quantitative and qualitative studies have revealed that parents are seen as role models by medical students.46 47 Furthermore, female medical students’ professionalism was negatively impacted by the motivation go with the flow. Research in medical education has shown that medical students with higher autonomy are crucial to the development of professionalism.48 However, those who go with the flow lack autonomy and can be viewed as amotivation.49 One study found that unmotivated students exhibited the least clinical behaviours and performance.50 Therefore, nurturing the autonomous motivation of medical students is necessary.51 Medical educators could consider career choice motivation as a starting point for building professionalism education, focusing on individuals who lack motivation.15
Implications and limitations
There are some implications in this study. As far as we know, no research has analysed the relationship between career choice motivation and professionalism based on gender in the context of the COVID-19 pandemic. The results of this study clarify the relationship between career choice motivation and professionalism and take career choice motivation as a starting point to focus on the core elements of professionalism. These will serve as the cornerstone for cultivating medical talents and improving medical quality. In addition, this study focused on the second-year to fourth-year medical students, which provides a comprehensive understanding of the state of professionalism among mid-level medical students. More importantly, this study focused on the role of gender. The findings on gendered professionalism may help to develop targeted interventions for medical students in medical education, especially for male students and those who lack motivation. Ultimately, professionalism is nurtured rather than innate. Altruistic education and role modelling can be adopted to further improve the professionalism of medical students in medical education.
It might be worth considering several limitations of this study. First, our respondents came from a single medical school, which may restrict the generalisability of our findings. Second, the cross-sectional design of this study cannot infer causal relationships between career choice motivations and professionalism among medical students. A combination of longitudinal and qualitative research is needed in the next study. Third, there were no direct items about the pandemic in the questionnaire. The present study cannot provide direct evidence of the impact of COVID-19 on professionalism and career choice motivation. It illustrates the relationship between professionalism and career choice motivation in the context of COVID-19 pandemic. Finally, the study was conducted during the COVID-19 pandemic. With the development and change in social conditions, the understanding of professionalism would alter, and the career choices of medical students would also be changed; thus, their relationship could show different characteristics. Based on this study, future research should focus on whether the professionalism and career choice motivation of medical students change with the medical education process.
Conclusion
The study provided evidence of the career choice motivation and professionalism of medical students of different genders. Female medical students outperformed males in professionalism. Third-year medical students have the lowest level of professionalism irrespective of gender. Females are more intrinsically motivated than males in career choice motivation. More importantly, the level of professionalism differed between genders based on different career choice motivations. Thus, career choice motivation can be used as an entry point for professionalism education among medical students. Targeted interventions should be made to improve professionalism based on gender-specific career choice motivation, especially for male medical students and unmotivated students.
Data availability statement
Data are available upon reasonable request. The datasets analysed during the current study are available from the corresponding author upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and ethical approval was acquired from the Ethics Committee of Changzhi Medical College (RT2023032). All participants who participated had signed an electronic informed consent form.
Acknowledgments
We would like to thank all the participants in the present study.
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