The early determinants of career choices for medical students following an obstetrics and gynaecology placement: Mixed methods study

To explore the impact of attending a clinical placement in considering a career in obstetrics and gynaecology.

2][3][4] In 2022, 5.7% of graduates were considering O&G as a career, in comparison to 19.5% for general surgery. 5,6But interest does not necessarily equate to application and recruitment.With the expansion of a consultant-led maternity service, changes following the Ockenden report and an increase in doctors working less than full time (LTFT), there will in fact be an increase in demand for O&G doctors.Alongside the high attrition rate seen (30% in 2018), there will be a need to over-recruit O&G doctors to manage the demand and increasing UK service requirements. 7actors affecting career choice positively include a positive experience attending clinical placements as a student and influence from a teacher or clinician. 8,9Workforce planning and obstetric litigation are important negative considerations. 1 More recently, UK studies 8,10 have highlighted student concerns over a lack of work-life balance in O&G. 11K medical students attend a clinical placement in O&G, often during the penultimate year of their studies, for 6 to 8 weeks.Studies have shown that the length of time spent in speciality clinical placements does not appear to impact recruitment; 12 rather, it is the quality of and support during the clinical placement that appears to encourage interest. 3tudents are exposed to childbirth which can include adverse or traumatic birth events.These experiences are often the only exposure students will have prior to making decisions over a career choice.
Medical students, driven in their learning towards summative examinations, often overlook the additional benefits of clinical placements in the consideration of their future career choices.This can be partly attributed to the change in undergraduate curricula.A survey of UK medical schools in 2006 highlighted the change in undergraduate curriculum over recent years, commenting on the decrease in delivery suite experience. 13At our medical school, there is no longer the requirement to observe a set number of births and this may be limiting the students' exposure to the speciality and may have an impact on their career choices.
The aim of this study was to explore the experiences of medical students on a clinical placement in O&G at one London university, including the impact of exposure to labour ward and impact on a career choice in O&G.

| Clinical placement
At our institution, fifth year medical students attend an O&G department in a hospital in North West London for 6 weeks.They attend all clinical areas within obstetrics, including the labour ward, elective caesarean section operating lists, antenatal clinics, maternity triage and the postnatal ward.They are provided with a clinical timetable and work a variety of work patterns including out-of-hours (evening shifts, weekend shifts and night shifts).The focus of this study was to explore experiences on the labour ward, which included out-of-hours work.Students worked with all members of the multi-disciplinary team including all grades of obstetric doctors as well as the midwifery team.

| Study design
A mixed methods study comprising online questionnaires and subsequent focus groups was conducted.

| Participants
Purposive sampling was conducted.Fifth year students attending a clinical placement in O&G at a London medical school, between January 2021 and January 2022, were invited to complete online pre-placement and post-placement questionnaires and then subsequently invited to attend a focus group in the 2 weeks after the end of their clinical placement.

| Questionnaires
A pre-placement and post-placement questionnaire were developed using the current literature, expert consensus and piloting, to answer the research questions for the study, to explore the impact of the clinical placement and involvement in traumatic birth events on the student's career choices.The questionnaires were completed online via the Qualtrics platform and took between 5 and 7 minutes to complete (Appendix S1).

| Focus groups
The students were provided with a participant information sheet and had the opportunity to ask questions about the study, before providing electronic written consent.Focus groups were conducted on Microsoft Teams following a validated interview topic guide, which had been developed by the authors based on knowledge of the specialty, a literature review and suggestions from medical students following a pilot study.Each focus group session was conducted by the author ES following training she was given in conducting focus groups by the author AB and lasted between 45 and 90 minutes.AB was present for the first focus group.No other individuals were present for the remaining focus groups.Focus groups continued until data saturation was achieved and no further focus groups or repeat focus groups were conducted.Reflective notes were made during each focus group by the author ES to aid analysis.

| Data analysis
The quantitative data from all completed questionnaires were entered and analysed using IBM SPSS version 27.Both descriptive and inferential statistics were used.A framework analysis was performed on the qualitative elements of the questionnaire.
The focus groups were audio-recorded and transcribed verbatim.The transcripts were analysed using a framework analysis to identify themes.The transcriptions were reviewed by the author (ES) and themes developed.All researchers reviewed the transcripts to refine the analysis further and define a final model of organised themes.

| Patient and public involvement
We did not engage patients or the public in our study.

| Surveys
A total of 247 questionnaires were completed, 126 preplacement questionnaires and 121 post-placement questionnaires, resulting in a 40% and 39% response rate, respectively.The demographics of the participants are available in Appendix S1.
A total of 30 (24%) students answered yes to considering a career in obstetrics and gynaecology in the pre-placement questionnaires, 40 (32%) did not want to pursue a career in obstetrics and gynaecology and 56 (44%) were unsure.A total of 41 (34%) of the students answered yes to considering a career in obstetrics and gynaecology in the post-placement questionnaire, 42 (35%) answered no and 38 (31%) were unsure (Table 1).The pre-placement and post-placement questionnaires were not paired, so a direct comparison cannot be made.
Students were asked whether they were looking forward to the placement and whether they enjoyed the placement.A total of 95 (75%) students were looking forward in the placement, 7 (6%) were not and 24 (19%) were unsure.A total of 114 (94%) enjoyed the placement, 1 (1%) did not and 6 (5%) were unsure (Table 2).
Cochran's Q test for paired data (n = 58) was used for career choice and enjoyment of the placement (P-value < 0.05).We do not reject the null hypothesis that the proportions of student responses of choosing a career in O+G is the same before and after the placement (p = 0.317).We do reject the null hypothesis that the proportions of students looking forward to and enjoying the placement is the same before and after the placement (P = 0.0001).The data suggest that students enjoyed the placement more than they were looking forward to it, but the likelihood of a student considering a career in O&G may not have changed following the clinical placement (Figure 1).
All students had witnessed a birth during the clinical placement with variation in the type of birth seen.Only 99 (82%) had witnessed a spontaneous vaginal birth, 100 (82%) had witnessed an elective caesarean section and 82 (68%) had witnessed an emergency caesarean section.A similar number of students had witnessed an assisted vaginal delivery, 66 (55%) seeing a forceps and 63 (52%) seeing a ventouse.A total of 82 (68%) had witnessed an episiotomy, 80 (66%) had witnessed a postpartum haemorrhage and 18 (15%) had witnessed a shoulder dystocia.A total of 63 (52%) had witnessed a manual removal of placenta and 39 (32%) had witnessed the repair of a third-degree tear.
A total of 104 (86%) students had witnessed a complex or complication during labour, delivery or the immediate puerperium and 102 students described the events.The top three complications that were described were an assisted delivery (30, 25%), followed by an emergency caesarean section (28, 23%) and a postpartum haemorrhage (24, 20%).

| Focus groups
Seven focus groups were conducted with four to seven students in each group, giving a total of 39 medical students.Data saturation was achieved following the seventh focus group.Students had attended three different hospital sites and almost three-quarters of the students identified as female (28/39 female, 11/39 male and 0/35 other).Six main themes were identified from the framework analysis, three positively and three negatively contributing to considering a career in obstetrics (Figure 2).

| Considering a career in obstetrics and gynaecology
Following qualitative analysis of the focus groups, a total of three themes emerged in relation to students considering a career in O&G.

| Theme 1: 'pregnancy is not an illness'
The students described pregnancy as a physiological phenomenon rather than a pathological condition.This is in comparison with the illness that is seen in other specialties, which was the only student experience prior to this placement.Pregnant women represent a healthy patient population who make an active choice to become pregnant, highlighting the socially acceptable and often relatable situation of childbirth.This was a desirable attribute for students considering a career in obstetrics, in contrast to the illness seen in other specialties.
Like these patients are more or less generally healthy, like you're on a cardio or resp ward where they are quite unwell and you are trying to help them get better.Here, most people are fine and hoping for like a normal, like an uncomplicated delivery.
(FG1 F2) The students described the subtheme of labour ward being a 'happy environment', demonstrating this somewhat unique element of obstetrics, where patients are optimistic and expect to leave with a healthy baby.
It is really nice to have a specialty where like the majority of it is really positive.And people are happy and you are kind of there for one of the best moment of their life.(FG2 F4)

| Theme 2: 'extraordinary experience of observing childbirth'
The students discussed the privilege of being part of a team who facilitate safe childbirth and the positive impact this has on the woman as a reason to consider a career in obstetrics and gynaecology

I think it's just seeing how medical or healthcare professionals can turn this really potentially stressful event [childbirth] into something that isn't as stressful or maybe it was as enjoyable for the patient…the way you talk to a patient and the way can interact what their memory is of the experience [of childbirth] and I think that is something that is something that is quite special to the specialty. (FG2 F6)
This highlights the satisfaction that can come from working in the specialty, through facilitating safe childbirth and empowering women during this time, providing fulfilment to clinicians working in obstetrics.

| Theme 3: 'variable specialty'
Students attended all areas of obstetrics including outpatient (antenatal clinic) and inpatient services (antenatal ward, postnatal ward, maternity triage and the labour ward) during the clinical placement.The students attributed how varied and exciting the specialty is, as a reason to want to pursue a career in O&G, but also why they enjoyed the placement, highlighting the mix of both medicine and surgery, and the practical exposure the specialty provides.

I actually enjoyed it [the placement] a lot more than I thought I was going to. And what I like about it, is that it is so varied, you have the obstetrics side, you have the gynae side and it's like even though medicine in general, there is always going to be different things going on, I think obs and gynae is like on another level. Because no 2 days will ever be the same. (FG5 F13) O+G is probably the most varied in terms of the number of things that could be going on. There are so many different disciplines working together in time, whereas usually on a ward you have a ward round and then jobs. And that's it then until the afternoon, so it's a lot more simple. (FG5 M8)
The labour ward is a fast-paced environment that relies on multi-disciplinary team working, providing clinicians with a varied and often adrenaline-fuelled role that this study has demonstrated was a consideration in students' choice of career.
As a result students were also exposed to the multidisciplinary team highlighting the community of practice that exists within obstetrics.

I really liked the action and excitement in labour ward…and just seeing everyone else working with each other. Whilst working on labour ward you see everyone working together, antenatal, postnatal or c section list. So that
[is] really good to see the multi-disciplinary aspect of it.

| Not considering a career in obstetrics and gynaecology
Following qualitative analysis of the focus groups, a total of three themes emerged in relation to students not considering a career in O&G.

| Theme 1: 'lack of work-life balance'
The students described a desire for a work-life balance and that this may be difficult to achieve in a career in O&G.The students developed this fear following the clinical placement, working shift patterns, which included out-of-hours working and night shifts, observing and working with staff, but also following conversations with healthcare professionals (predominantly junior doctors).One student discussed their views on career choice, explaining a preference for general practice as a future career choice:  The students commented on the responsibility involved in looking after women in labour discussing the situations where they had observed a bad outcome for either the woman or baby.The perceived high levels of responsibility, accountability and resulting stress were also mentioned.
I really like it as a placement but as a student…I don't know if I could deal with the level of stress and be responsible for this and if something goes wrong, you are the person they look to.(FG6 F17) When asked how this compares with other specialties, students discussed the differences seen in medical and surgical specialties, including the significance of looking after two patients, the woman and their baby: yes, because they are healthy when they come through the door and then they leave either not healthy or without their baby.The stakes are high.(FG6 F24)

| Theme 3: 'emotional toll'
Following on from theme 2, the students discussed the emotional toll of working in a high stakes specialty, particularly if there was a bad outcome for either the woman or their baby, emphasising the heightened emotional burden that comes with the responsibility of working in obstetrics.

I don't like the responsibility of having to take care of the baby as well, um coz if things so wrong, in terms of during labour, if things go wrong, because things should not go wrong. If things go wrong it's bad. I can't imagine how guilty one must feel if something um goes wrong in labour and the baby suffers. (FG6 F20)
Student fears of observing poor outcomes and experiences of upsetting birth were cited as traumatic, demonstrating the weight of the emotions that students and clinicians are expected to manage in obstetrics.

I was really scared about seeing a stillbirth. That was my biggest fear going into the placement like I was like I don't know how I am going to cope. I've seen the baby come out at c section really floppy… I was just scared in the corner like I don't want to be in the way. I think for me it was really difficult. (FG6 F18)
The terminology used in the quote above demonstrates the impact that exposure to traumatic birth events can have on the mental health of medical students during the clinical placement and should be considered regardless of impact on career choice.

| Main findings
Career selection in medical students is a complex and dynamic process. 146][17] This study has demonstrated student interest in O&G both before and after attending a clinical placement.Although small numbers, we have not found a statistically significant change in the proportions of students considering a career in O&G following the clinical placement.
The qualitative results from this study have demonstrated competing themes.Participants viewed O&G as a unique specialty that involves a healthy patient population during the major life event of childbirth, but this was offset by the risk of involvement in adverse or traumatic birth events and the resulting psychological impact of working in such a high stakes speciality.
The student experiences during the clinical placement highlight a somewhat medicalised experience of childbirth.Only 82% participants witnessed a spontaneous vaginal birth.High numbers of complications were seen; 15% witnessed a shoulder dystocia, despite only occurring in less than 1% of vaginal births in the UK. 18This suggests students are being exposed to a medicalised representation of childbirth.Students are driven by the need to pass summative assessments which are heavily focused on the medical aspects of obstetrics.In addition, the previous requirement by many medical schools to 'witness a certain number of vaginal births' has been removed from many medical school curricula, which may contribute to the reduction in exposure to low risk vaginal births. 13Students may not be getting a representative experience of childbirth, with the clinical placement being the only exposure students have to obstetrics before choosing a specialist career path and starting their own family.
The qualitative results from this study have highlighted additional concerns over the psychological impact of student exposure to traumatic birth events.Adverse or traumatic birth events are not uncommon.Students on clinical placements may be exposed to negative or traumatic experiences, including maternal death, stillbirth or neonatal death.The theme of the 'emotional toll' applies not only to a career in obstetrics but also to students on clinical placement.This is an important consideration for university faculties as well as healthcare professionals responsible for students during their clinical placement in obstetrics.Studies have shown that healthcare professionals can act as role models.Junior doctors should be considered in providing mentorship, to encourage interest but also maintain enthusiasm in already interested students.The role of clinical teaching fellows should also be considered to encourage students to pursue quality improvement (QI) projects and audits to allow them to gain a better understanding of the speciality.Healthcare professionals and faculty responsible for students on clinical placements should also be available to provide support if students experience traumatic birth events, to protect from negative psychological sequelae, in a cohort who is inexperienced and more vulnerable to stress.
Studies have shown contradicting results of student worries over work-life balance in O&G 3 but this study demonstrated concerns from this cohort of students.Despite the introduction of the European Working Time Directive, which has sought to reduce the undesirable impact of working long hours, some still find the current practice of out-ofhours and shift work off-putting.With almost a quarter of O&G trainees working less than full time (LTFT), this could provide a solution to the much needed work-life balance in obstetrics and gynaecology 19 and should be promoted by doctors working with students during their clinical placement in O&G.

| Strengths and limitations
The results from this qualitative research study are from one London medical school.Although from one school, there is nothing to suggest that student experiences in the UK vary significantly and certainly not within London, as labour wards are similar across the UK.The response rates for the questionnaires were 37% and 40%, which is deemed an appropriate response rate and focus groups were conducted until data saturation and showed good internal consistency.There may have been selection bias in the students who completed the questionnaires and participated in both the focus groups, as students with an interest in obstetrics and gynaecology may show more interest in participating, although the results of the paired data suggest a reduced interest following the clinical placement.

| CONCLUSION
The findings from this study suggest that student experiences on the labour ward have an impact on the consideration of career choice.Although considering only one university, student experience of childbirth on labour wards across the UK are likely to be similar.Regarding elements of obstetrics, the unique environment of facilitating a healthy patient population through childbirth and how variable O&G is, were positive, whereas concerns over a lack of work-life balance and the emotional toll of adverse or traumatic birth events were negative.
Considering the high levels of burnout and high attrition rates seen in O&G junior doctors in the UK, recruitment of enthusiastic but realistic graduates is of paramount importance.Medical schools and healthcare professionals responsible for students during clinical placements in O&G should consider the role of junior doctors as mentors, to promote career discussions in order to encourage recruitment into the speciality and to safeguard the future of the workforce.

| Practical and research recommendations
Future research should include the qualitative exploration of the experiences of a mentorship programme led by junior doctors during the clinical placement in providing support and career discussions.This small-scale study should be followed up, looking at a larger group of students across multiple institutions in the UK and a cohort study looking at the impact of foundation year jobs in O&G on career choice.been omitted; and that any discrepancies from the study as planned have been explained.

F I G U R E 1 F I G U R E 2
Student responses to considering a career in O&G and enjoyment of the placement before and after the placement.Themes relating to career choice.

forward to and enjoying the placement Pre-placement questionnaire Post-placement questionnaire
Medical students considering a career in O&G before and after the clinical placement.
T A B L E 1T A B L E 2 Medical students looking forward to and enjoying the placement.Looking[Correction added on 26 January 2024, after first online publication: In Table1and Results section, the percentages listed under Post-placement questionnaire were incorrect and have been corrected in this version.]