Factors Affecting Interests in CTS and Career Choice

Our current knowledge of CTS interests and attitudes of medical students can be summarised by two recent national surveys. They examined medical students’ attitude towards CTS and found that approximately 27-31% of the cohort was considering a career in surgery^[10,11]. However, the numbers may be as low as 14% among final-year students. The surveys also highlight the disparity between CTS experiences both between and within individual medical schools. The survey by Preece et al.^[10] revealed that 75% of students had inadequate to no exposure to CTS within the curriculum and only 13% have attended a cardiothoracic conference or careers day. Contrarily, the survey by Gasparini et al.^[11] found that 71% of the students surveyed have had CTS exposure within the curriculum, with many receiving CTS opportunities through surgery (45.1%), lectures (45.1%), and conferences (42.6%).

Additionally, other motivators and barriers may affect CTS engagement of students and junior doctors. A survey by Sutton et al.^[12] examined 482 students from 20 medical schools and identified the two most important factors as interests in the speciality and its work-life balance. The increased exposure during clinical attachments and dedicated careers lectures can facilitate these factors and can be beneficial to careers choices at the undergraduate level. These findings are also identified in other specialities and countries as suggested by the survey and review of plastic surgery application in Canada by Austin et al.^[13] They identified that more than 44% of students, who were not considering plastic surgery as a career, indicating that increased exposure to the speciality will increase their interests.

Mentorship

With similar trends in CTS observed in the United States of America, Allen et al.^[14] have studied the impact of mentorship and increased involvement of medical students in both laboratory research and surgery. Through increasing shadowing opportunities, involvement in animal-based operations, and clinical research projects, the majority of students applied for surgical subspecialities, with as many as 20% towards CTS. They identified that the presence of mentors greatly influences career decisions by providing insight into CTS — and surgery as a whole —, ultimately recommending the establishment of programmes to facilitate the engagement of medical students during medical school. This is also supported by the work of Woolf et al.^[3] in establishing the effects of undergraduate and postgraduate exposures on subsequent career choice. Implementation of outreach or mentorship programmes such as the academic mentoring programme trialled by Fricke et al.^[15] can also be beneficial as supported by the survey where respondents feel the best way to promote CTS is to directly observe CTS (46%) and meeting cardiothoracic surgeons (15%)^[11]. Similarly, to address the lack of knowledge regarding the nature and pathway of CTS training, basic introduction to the fundamentals for all specialities should be provided at medical school to help foster their interests and facilitate informed career decisions^[11].

Types of Exposure and Teaching

These findings highlight that interventions in both undergraduate curriculum and extracurricular activities are required to rectify the declining interest in CTS. In a recent systematic review of factors affecting choosing surgery as a career, 11 of the 21 studies indicated that clinical exposure improves both knowledge and interests in surgery^[16]. While exposure can change the perception of surgery and its lifestyle, a study on neurosurgery reported that it reduced interests. One of the concerns identified by Zuccato et al.^[17] was the need to make early career commitments which leaves other specialities unexplored, leading to reconsiderations. This phenomenon is likely also applicable to CTS as it also requires dedication in the speciality early on.

Regardless of its effects on career choices, the accessibility to CTS, like other smaller specialities, is often limited to large high-volume centres. Of those that are affiliated with medical schools, they may not offer enough placement opportunities to accommodate the number of students. This results in very limited opportunities for students to gain exposure and scrub in theatres. This is supported by data from our study, in which only 10.46% of students had a placement in CTS. While our finding may appear lower than those of Gasparini et al.^[11], it may be attributable to more extensive inclusion criteria than using clinical placement alone in this study. As such, most UK medical schools are unable to include compulsory CTS placements for all students, driving the majority of cardiothoracic teaching into non-clinical environments. These activities include lectures and small group teachings on cardiothoracic emergencies such as aortic dissection, in which all medical schools have covered as part of the curriculum, with lectures being the primary mode of delivery. Other methods may be considered to influence interests and education, such as the use of short workshops as studied by ElHawary et al.^[18]. Their study assessed the effect of a 60-minute suturing workshop for medical students on their confidence and interest in surgery. Of the 85 medical students that participated, 82% reported being more interested in surgery after the workshop, demonstrating that even short-lasting, practical experiences are also beneficial. Similarly, interactive sessions from one-day skills day are also effective at improving understanding of surgery and changing student perceptions of surgery^[19]. Furthermore, both surgical simulation and three-dimensional modelling are increasingly recognised methods that may also have a place in improving student surgical interests^[20-23]. Regardless, despite being highly valued and commonly utilised pedagogic methods, literature have emphasised the unique benefits of clinical attachments and the importance of students being part of a team^[24].

In short, it is difficult to foster interests in CTS through clinical exposure alone, and other alternatives should also be considered. The increasing demand for the ageing population must be met by attracting prospective cardiothoracic surgeons^[25,26]. Our findings are supported by similar studies across other specialities which identify exposure as an important factor towards surgical interests. This study has highlighted the need to implement various interventions at both undergraduate and postgraduate levels to anticipate and address the future demands of the speciality.

Limitations

The primary limitations of this study lie in its survey-based methodology, which provides an estimation of respondents who are interested in CTS. As such, respondents from only 16 medical schools have been captured and is not wholly representative of all medical students and foundation doctors in the UK, especially as there were no Scottish graduates who responded. The voluntary nature of surveys can also introduce response bias as doctors with interests in CTS or early exposure may be more likely to respond, producing an overestimate of CTS teaching and exposure. While conducting this survey online helps maximise respondents reached, this method prevents the calculation of response rates as it is not known how many this survey has reached. As this is a cross-sectional survey, it cannot account for the pre-existing interests in CTS which can affect whether the respondents choose to apply for CTS training. Additionally, as the curriculum of undergraduate study and postgraduate training are constantly changing to meet standards of the General Medical Council, reported experiences in this survey may not hold for later cohorts. Further studies should also consider including demographic information of participants’ gender, ethnicity, and socioeconomic status as these may also affect interests in surgical training^[16,27].