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Arch Aesthetic Plast Surg > Volume 29(1); 2023 > Article
AlNojaidi, Alaqil, AlQhtani, and Alhadlaq: What factors during elective rotations influence undergraduates to pursue plastic surgery as a career?

Abstract

Background

Plastic surgery is considered one of the most competitive specialties globally. In Saudi Arabia, it was established in 2001 in the central province (Riyadh) and then expanded in 2009 to include more eastern and western provinces. Previous research has identified several factors that impact pursuing a career in plastic surgery.

Methods

This cross-sectional study was conducted through a five-page, five-section questionnaire distributed among senior medical students and interns using online platforms between August 2021 and January 2022. The overall number of questions was 25, which tackled different aspects, including sociodemographic characteristics (i.e., age and gender); the duration of the elective rotation; supervisor during the elective; encouraging, discouraging, and influencing factors; and the rating of participants’ desire to become a plastic surgeon.

Results

After elective training, the most common factor that influenced medical students to choose a plastic surgery career was exposure to a variety of cases (favorable to agree: 80.4%), followed by involvement in clinical activities (i.e., rounding, clinics, and case presentations) (favorable to agree: 70.6%). On the contrary, the most common factor discouraging students from choosing a plastic surgery career after elective training was plastic surgery being a competitive specialty for matching (favorable to agree: 62.7%), followed by the intense workload (favorable to agree: 56.9%).

Conclusions

Medical students were more likely than medical interns to explore a career in plastic surgery. Exposure to a variety of cases, inspiring mentors, and a decent amount of time spent in the operating room were the most influential factors.

INTRODUCTION

Several factors impact medical students’ and interns’ interest in pursuing a career in plastic surgery [1]. Moreover, several studies have mentioned other influencing factors, such as the variety of career choices, the complexity of the field, future lifestyle, and enjoyable rotations in plastic surgery [2].
Extracurricular elective training is crucial to obtain a general idea of a specialty–plastic surgery or any other specialty–especially if the exposure is minimal in medical school and internship. A study stated that students and interns should obtain as much elective experience as possible to assist them in their career choices [2]. After taking a plastic surgery elective, students’ and interns’ perceptions can change, which is essential for future career decisions [3]. As previously mentioned, several factors influence the choice of plastic surgery as a specialty, such as, most importantly, the presence of a role model and previous exposure (e.g., elective training). According to another study, the difference between these two influencing factors is that having a role model can actually promote and encourage residents to become educators, whereas taking an elective can help candidates decide early on whether or not they want to pursue plastic surgery as a career [4]. When comparing these influencing factors, taking elective training is considered more influential for candidates [5].
Mentors have a significant impact on students and interns, during procedures, operations, simulation, or clinical teaching in general. Schmidt et al. [6] mentioned that surgical residents are outstanding mentors and role models; hence, students who are being taught usually choose a surgical specialty. However, students without a surgical resident mentor are less likely to choose a surgical specialty. The impact of elective training extends beyond selecting a specialty to deciding on the program in which students or interns want to continue their careers. A study conducted at the University of Toronto in Canada identified various factors affecting the selection of a plastic surgery residency program after elective training, such as impressions of the residents’ and staff’s collegiality, overall resident satisfaction, opportunities to undertake hands-on procedures like suturing, having a formal debrief and rotation-end evaluation with the supervising staff, and attending resident academic activities [7]. Directors usually encourage candidates to attend home or away rotations, which improve their likelihood of matching, to enhance the chance of acceptance into residency programs [8].

METHODS

This cross-sectional study was conducted through a five-page, five-section questionnaire distributed among senior medical students and interns using online platforms between August 2021 and January 2022. The overall number of questions was 25, which tackled different aspects, including sociodemographic characteristics (i.e., age and gender); duration of the elective rotation; supervisor during the elective; encouraging, discouraging, and influencing factors; and participants’ rating of their desire to become a plastic surgeon. Data were analyzed using the SPSS version 26 (IBM Corp.).

RESULTS

A total of 51 participants were involved, of which 64.7% were in the younger age group (age 20–25 years old), with female students dominating the sample (60.8% vs. 39.2%). Nearly half of them (45.1%) had attended plastic surgery electives only once, and the duration for the majority was more than 2–4 weeks (56.9%). Nearly 70% reported that a resident physician was their supervisor, and 56.9% took electives during medical school (Table 1).
Fig. 1 compares the factors that encouraged students to take plastic surgery electives. The top three factors were interest in plastic surgery, which was the major encouraging factor for taking an elective rotation (92.2%), followed by not having enough exposure in medical school (35.3%) and income (25.5%).
After elective training, the most common factor influencing medical students to choose a plastic surgery career was exposure to a variety of cases (favorable to agree: 80.4%), followed by involvement in clinical activities (i.e., rounding, clinics, and case presentations) (favorable to agree: 70.6%). However, the opportunities to participate in research and the environment were the least common factors (favorable to disagree: 31.4% and 43.2%, respectively) (Fig. 2).
On the contrary, the most common factor that discouraged students from choosing a plastic surgery career after elective training was the perception of plastic surgery as a competitive specialty for matching (favorable to agree: 62.7%), followed by the intense workload (favorable to agree: 56.9%), while “it is not the specialty I thought” was the least common discouraging factor (favorable to disagree: 49%) (Fig. 3).
Although the desire to pursue plastic surgery as a career after elective training was higher (mean: 7.39) than that before elective training (mean: 6.9), the overall results did not reach statistical significance (P=0.307) (Fig. 4). In measurements of the perceptions of taking elective plastic surgery between senior medical students and medical interns, it was observed that the number of senior medical students who took elective rotations during medical school was significantly higher (P<0.001). Moreover, significantly more senior medical students indicated that “not enough exposure” was an encouraging factor for taking a plastic surgery elective (P=0.006). Other variables included in the tests did not show significant differences between senior medical students and medical interns regarding other encouraging factors for taking a plastic surgery elective or the desired rating to become a plastic surgeon before and after elective training (all P>0.05) (Table 2).
Table 3 reveals that senior medical students scored higher on most of the important determinants for pursuing a career in plastic surgery, although the differences were not statistically significant (all P>0.05). Regarding the discouraging factors, the ratings of senior medical students were higher for “competitive specialty for matching” (mean: 4.00) and “too much reading” (mean: 2.78), while medical interns showed higher ratings for “media/public perception” (mean: 3.00), an undesirable specialty (mean: 2.94), and an intense workload (mean: 3.85). The differences in discouraging factors between senior medical students and medical interns were not statistically significant (all P>0.05).

DISCUSSION

Plastic surgery as a specialty can be very exhausting, as it is very competitive compared to other surgical specialties. However, because of the limited exposure in medical school, many students and interns are unaware of their interest or lack of interest unless they receive exposure to plastic surgery through extracurricular elective training. The results of this study agree with those in the literature. The growing interest in plastic surgery is multifaceted; nonetheless, the earlier students and interns received clinical exposure and interaction with plastic surgeons, the stronger their desire was to pursue a career in plastic surgery. According to the results of this study, senior medical students were more interested in pursuing a career in plastic surgery than medical interns. Based on our data, the desire of medical interns was higher before the elective rotation (before training, interns’ mean score: 7.45 vs. medical students’ mean score: 7.28); however, after the elective rotation, the desire of medical students became higher than medical interns (after training, medical students’ mean score: 7.67 vs. interns: 6.48). Furthermore, the most common factors that encouraged medical students to pursue the plastic surgery career path were exposure to a variety of cases, inspiring mentors, spending a reasonable amount of time in the operating room, and having better hands-on opportunities, whereas for medical interns, only being involved in clinical activities was a critical determinant (mean: 3.82) where they had better ratings than medical students (mean: 3.67). In a study by Tahiri et al. [2], various career choices have also been reported by both surgery residents and medical students as the driving force for interest in a plastic surgery career, followed by the complexity of the field and future lifestyle. They further added that despite similarities, the proportions of medical students and residents differed significantly in terms of perceptions regarding their future lifestyles and enjoyable rotations. In the USA [5] and the UK [9], exposure to the plastic surgery field was the common denominator underlying students’ choice to pursue a career in plastic surgery, followed by a better lifestyle [7]. The most prevalent reasons for selecting a career in plastic surgery were the general perceptions of resident and staff collegiality, resident happiness, and having a formal rotation-end debrief evaluation with the supervisory staff. Given all these results, the presence of a mentor had a more significant role in medical students’ and residents’ decisions for a career in plastic surgery. According to our results, having an inspiring mentor played an influential role in the decision-making of both medical students and interns. However, in the literature, mentors played a more significant role in medical students taking an interest in surgery [4,10].
Unlike encouraging factors, medical students and interns showed conflicting results in relation to discouraging factors. For instance, medical students indicated that they were discouraged from pursuing the plastic surgery specialty because it is highly competitive and will demand more time for reading, whereas medical interns cited media or public perceptions, misperceptions about plastic surgery, and the intense workload as the most common discouraging factors. In a study published by Jabaiti et al. [3], medical students’ reasons for not choosing a career in plastic surgery were that “it is a demanding specialty,” “could be delicate and risky,” and is “boring or not interesting.” The authors added that medical students’ misconceptions about plastic surgery were due to a greater dependence on obtaining information from media/television and disregarding more appropriate sources such as medical curricula or plastic surgeons during elective rotations. Despite several barriers, plastic surgery mentors should value their presence and make a concerted effort to be available [11].
Taking plastic surgery elective training is necessary to increase exposure, confidence, and interest in this field. As mentioned by Drolet et al. [4], students who enrolled in elective rotations were mostly driven by their interest in the specialty, which has also been observed in our study. Accordingly, the most dominant encouraging factor of both medical students and interns to take on a plastic surgery elective rotation was interest (92.2%), followed by lack of exposure in medical school (35.3%) and income (25.5%). Greene and May [5] highlighted that in medical schools with plastic surgery training programs and those providing exposure to this field, a higher rate of graduates applied for the plastic surgery residency, which, however, did not coincide with the results in the article by Dean et al. [9]. According to their reports, most medical students (82%) did not consider taking on plastic surgery elective rotations, which corroborated the findings of Al Qurashi et al. [1].
Moreover, the number of medical students who took elective rotations during their medical school was significantly higher (P<0.001) and they were more likely than medical interns to cite the lack of exposure to plastic surgery as the reason for taking elective plastic surgery rotations (P=0.006). In Canada, research indicated that the numbers of residents and medical students who had chosen plastic surgery based on future lifestyles and enjoyable rotations were statistically significantly different [2]. These results emphasize that interested applicants should be encouraged to gain more relevant experience in elective training for guidance to help them decide on a career path.
In conclusion, medical students were more likely than medical interns to explore a career in plastic surgery. Exposure to a variety of cases, inspiring mentors, and a decent amount of time spent in the operating room were the most influential factors for medical students to pursue a plastic surgery career. Elective rotations had a positive influence on medical students’ decisions when choosing a career path, as they were able to determine early on whether they wanted to pursue a career in plastic surgery. Mentors should aid future candidates in the field of plastic surgery by establishing their goals and encouraging them to participate in research activities in order to advance their careers in the field.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

Notes

Ethical approval

The study was approved by the Institutional Review Board of Imam Mohammad Ibn Saud Islamic University (IRB No. 105-2021) and performed in accordance with the principles of the Declaration of Helsinki. Informed consent was waived.

Fig. 1.
Encouraging factors for taking elective plastic surgery.
aaps-2022-00430f1.jpg
Fig. 2.
Influencing factor from choosing a plastic surgery career after elective training.
aaps-2022-00430f2.jpg
Fig. 3.
Discouraging factor from choosing a plastic surgery career after elective training.
aaps-2022-00430f3.jpg
Fig. 4.
Rate your desire to become a plastic surgeon before and after elective.
aaps-2022-00430f4.jpg
Table 1.
Sociodemographic characteristics of medical students (n=51)
Variable No. (%)
Age group
 20–25 yr 33 (64.7)
 > 25 yr 18 (35.3)
Sex
 Male 20 (39.2)
 Female 31 (60.8)
No. of plastic surgery electives taken
 One 23 (45.1)
 Two 13 (25.5)
 Three 3 (5.9)
 More than three 12 (23.5)
Total duration of electives
 2–4 wk 29 (56.9)
 4–8 wk 9 (17.6)
 > 8 wk 13 (25.5)
Main supervisor during elective
 Consultant 10 (19.6)
 Specialist 3 (5.9)
 Resident 35 (68.6)
 Intern 3 (5.9)
When did you take your elective?
 Medical school 29 (56.9)
 Internship 22 (43.1)
Table 2.
Perceptions of taking plastic surgery electives among senior medical students and interns during medical school (n=51)
Factor Senior (n = 18) Interns (n = 33) P-valueb)
When did you take your elective? < 0.001
Medical school 17 (94.4) 12 (36.4)
Internship 1 (5.6) 21 (63.6)
Encouraging factors for taking a plastic surgery electivea)
Interest 17 (94.4) 30 (90.9) 1.000
Not enough exposure in medical school 11 (61.1) 7 (21.2) 0.006
Income 6 (33.3) 7 (21.2) 0.502
Obtaining recommendations and conducting research 5 (27.8) 5 (15.2) 0.296
Reputation and lifestyle 5 (27.8) 5 (15.2) 0.296
Inspiring mentor 3 (16.7) 4 (12.1) 0.686
Media influenced 3 (16.7) 1 (3.0) 0.120
Grades 2 (11.1) 4 (12.1) 1.000
A plastic surgeon relative or family friend 1 (5.6) 1 (3.0) 1.000
Others 0 1 (3.0) 1.000
Rate your desire to become a plastic surgeon before the elective 7.28 ± 2.58 7.45 ± 2.11 0.952c)
Rate your desire to become a plastic surgeon after the elective 7.67 ± 2.97 6.48 ± 3.29 0.228c)

Values are presented as number (%) or mean±SD.

a) Variable with a multiple-response answer;

b) P-value calculated using the Fisher exact test;

c) P-value calculated using the Mann-Whitney test. Significant at P<0.05.

Table 3.
Influencing and discouraging factors from pursuing a plastic surgery career after receiving elective training between senior medical students and interns during medical school (n=51)
Factor Senior Intern P-valuea)
Influencing factor
The team and the environment were attractive 3.00 ± 1.68 2.79 ± 1.56 0.615
You had hands-on opportunities in (minor, major, operating room) 3.33 ± 1.75 2.97 ± 1.40 0.276
You were involved in clinical activities (e.g., rounding, clinics, and case presentations) 3.67 ± 1.61 3.82 ± 1.16 0.836
You had inspiring seniors/mentors 3.78 ± 1.52 3.09 ± 1.70 0.141
You were exposed to a variety of different cases 4.11 ± 1.67 3.97 ± 1.29 0.471
You were given research opportunities 3.06 ± 1.76 2.79 ± 1.65 0.568
A decent amount of time was spent in the operating room duration compared to other surgical specialties 3.50 ± 1.79 3.42 ± 1.35 0.478
Discouraging factor
Competitive specialty for matching 4.00 ± 1.08 3.61 ± 1.41 0.399
Media/public perceptions (solely cosmetic) 2.94 ± 1.21 3.00 ± 1.32 0.814
Too much reading 2.78 ± 1.06 2.67 ± 1.36 0.700
Not the specialty I thought 2.72 ± 1.36 2.94 ± 1.37 0.584
Intense workload (overwhelming specialty) 3.22 ± 1.26 3.85 ± 1.28 0.068

Values are presented as mean±SD. Scores taken from a weighted average response with a range from “strongly disagree” coded as 1 to “strongly agree” coded as 5 (max score).

a) P-value calculated using Mann-Whitney test. Significant at P<0.05.

REFERENCES

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2. Tahiri Y, Lee J, Kanevsky J, et al. The differing perceptions of plastic surgery between potential applicants and current trainees: the importance of clinical exposure and electives for medical students. Can J Plast Surg 2013;21:178-80.
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3. Jabaiti S, Hamdan-Mansour AM, Isleem UN, et al. Impact of plastic surgery medical training on medical students’ knowledge, attitudes, preferences, and perceived benefits: comparative study. J Public Health Res 2021;10:1927.
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4. Drolet BC, Sangisetty S, Mulvaney PM, et al. A mentorship-based preclinical elective increases exposure, confidence, and interest in surgery. Am J Surg 2014;207:179-86.
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9. Dean S, Javed M, Jones N. Factors influencing a career choice in plastic surgery as a UK medical student. PMFA J 2016;3:1-5.

10. Sanfey HA, Saalwachter-Schulman AR, Nyhof-Young JM, et al. Influences on medical student career choice: gender or generation? Arch Surg 2006;141:1086-94.
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11. Silvestre J, So AL, Lee BT. Accessibility of academic plastic surgeons as mentors to medical students. Ann Plast Surg 2015;74:85-8.
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