INTRODUCTION

“Postgraduate medical education (PME) is defined as the phase of medical training where doctors, after having obtained a formal medical qualification, can develop additional competencies in a defined area of their choice” (1). In particular, the undergraduate period is a stage at which medical students begin to know themselves professionally, and thus they are directed to the specialty branch corresponding to their temperament and personality traits. A significant number of physicians who complete basic medical education choose to continue postgraduate medical training and specialize in a specific field. The rates of participation in the specialty examination in medicine, which is decisive in PME, indicate that physicians’ preference for PME is directed towards receiving a specialist education. The most important motivation for PME in Turkey is the desire for professional satisfaction and specialization; the ability to plan a career after graduation is another important factor (2,3).

In recent years, a significant change in the choice of specialty exams in medicine has led to a noticeable variation in the minimum scores required for individual specialty branches. It is noteworthy that ratings for some basic science specialties, such as medical biochemistry and medical microbiology, are rising (4,5). Professional ideals and career plans, working conditions, shift duty, medical responsibility, malpractice concerns, financial rewards, and the effects of workload on doctors’ private lives are some of the factors affecting post-graduate specialty selection. However, nowadays factors such as financial return and comfort come to the forefront in the choice of specialty (6-8). Furthermore, it is reported that students’ experiences in medical faculties have an effect on their preferences. The choice of specialty is determined by environmental factors as well as the predisposition of the person, gender, temperament, and character traits (9,10).

Cloninger defines personality with two primary components: temperament and character (11). The temperament dimensions persistence, novelty seeking (NS), reward dependence (RD), and harm avoidance (HA) are essential characteristics that affect an individual’s life plans and decisions. Temperament reflects the hereditary aspect of individual behavioral differences and preferences. Self-directedness (SD), cooperation, and self-transcendence (ST) define the dimensions of character. The character aspect of personality matures through personal, environmental, and socio-cultural processes (12). The analysis of personality traits that characterize students may elucidate a generalizable relationship with their specialty preferences. Using the Temperament and Character Inventory (TCI) could lead to the description of personality traits that characterize particular medical students and predict their success in performing the tasks entailed by different specialties (13).

Career psychologists have argued that career choice and personality interfere with each other. There is limited knowledge of personality profiles and how they are related to specialty choice (14). According to cognitive theory, anxiety can be explained as the tendency to overestimate the potential for danger. Persons with anxiety disorders tend to imagine the worst possible scenario and avoid supposedly dangerous situations, such as crowds, heights, or social interaction (15). It was suggested that temperament traits may be related with adaptive roles, such as depressive traits increasing the sensitivity to suffering, cyclothymic traits being relevant to creativity, and hyperthymic traits being implicated in generally more active pursuits (16). The effects of anxiety on choosing specialties have not been examined.

Clarifying the factors that underlie the choice of specialties may provide a better understanding of students’ preferences for a given specialty and may be helpful in the development of health education. Among these factors, the personality traits of medical students are important elements that cannot be ignored. We hypothesized that there could be an association of the temperament and characters of the candidates for specialty-training and the selected specialties.

This study aimed to investigate the effects of anxiety, temperament, and character dimensions on final-year medical students’ preferences for postgraduate education. The results are expected to provide objective data that will increase the satisfaction of medical students in their specialty choice.

METHOD

Study Design

The study with a cross-sectional analytical design was conducted at Canakkale Onsekiz Mart University Faculty of Medicine between July 2018 and March 2019. Study reporting was done as per the STROBE guidelines (17). The study protocol was approved by the local ethics committee at Canakkale Onsekiz Mart University (No: 15-07-Date: July 25, 2018). Each participant signed an informed consent form in conformity with the Declaration of Helsinki.

Setting

Canakkale Onsekiz Mart University is located in the northwest of Turkey. It operates a tertiary-level hospital serving a population of around 750.000 people. Medical students receive three years of pre-clinical education, followed by two years of clinical clerkships and a one-year internship training. During the study, there were 161 students in the internship year and in total nearly 900 students enrolled in the medical school. In the internship year, most of the training was carried out uninterrupted in the hospital environment for 52 weeks.

Participants

Participating students were members of the sixth-year medical class, defined as the internship year at Canakkale Onsekiz Mart University Faculty of Medicine. The intern trainees were visited in their workplaces, and all 161 students were invited to answer the study questions in an empty and silent room. Under the supervision of the project leader and researchers, the students completed the self-report research questionnaire. Five students refused to join, and two were excluded due to insufficient and unreliable data. The results for 151 participants were analyzed (Figure 1). The participation rate was 93.8% (151/161).

Measures

The data collection tool consisted of three parts: the Personal Data Form, State-Trait Anxiety Inventory (STAI), and the TCI. The primary outcome variables of the study were the preferred main specialty area, the favorite specialty branch, and reasons to choose a particular specialty. Independent study variables were age (years), gender, perception of the economic situation, place of birth, STAI scores, and TCI dimension scores.

State-Trait Anxiety Inventory: Developed by Spielberger et al. (18), it was designed to measure overall anxiety in adults on a four-point Likert-type scale (STAI Form X). In 1983, the STAI was revised to reduce the overlap with depression and emphasize better-described factors of state and trait anxiety (STAI Form Y) (19). The STAI is a psychological self-report inventory consisting of 40 questions. The STAI measures two types of anxiety – state anxiety, or anxiety about an event, and trait anxiety, or anxiety level as a personal characteristic. The scores obtained from both scales can range between 20 and 80. Higher ratings indicate higher anxiety levels. The scores received from the scale were categorized as 1) <37 minimal anxiety, 2) 37-41 slight anxiety, and 3) >41 high anxiety. The scale was adapted and validated for the Turkish language by Oner and LeCompte (20). The values for reliability coefficients ranged between 0.26 and 0.68 for state anxiety and between 0.76 and 0.86 for trait anxiety.

Temperament and Character Inventory: Developed by Cloninger et al. (11), the TCI was designed to provide a comprehensive evaluation of normal personality and all its dimensions. The TCI includes statements for which the subject should select ‘true’ or ‘false.’ The TCI is a 240-item self-administered questionnaire constructed to assess personality in seven dimensions, divided into “temperament” and “character.” Temperament is identified through the following four aspects: NS, HA, RD, and persistence (PS), while character is identified through the following three dimensions: SD, cooperativeness (C), and ST. The scale was adapted and validated for Turkish language by Kose et al. (12). Cronbach’s alpha coefficients for the Turkish version of the TCI were reported to be between 0.60 and 0.85 in the temperament dimensions and between 0.82 and 0.83 in the character dimensions. Except for PS, all dimensions were subdivided into 3 to 5 subdimensions. In the temperament dimension, NS (Exploratory excitability [NS1], Impulsiveness [NS2], Extravagance [NS3], Disorderliness [NS4]), and HA (Anticipatory worry [HA1], Fear of uncertainty [HA2], Shyness [HA3], Fatigability [HA4]) have 4 subscales, and RD (Sentimentality [RD1], Attachment [RD2], Dependence [RD3]) has 3 subscales. In the character dimension, SD (Responsibility [SD1], Purposefulness [SD2], Resourcefulness [SD3], Self-acceptance [SD4], Enlightened second nature [SD5]), and C (Social acceptance [C1], Empathy [C2], Helpfulness [C3], Compassion [C4 ], Pure-hearted conscience [C5]) have 5 subscales and ST (Self-forgetful [ST1], Transpersonal identification [ST2], Spiritual acceptance [ST3]) has 3 subscales. The scale scores consist of the sum of the subscale scores. For example, the T total NS score is calculated as (NS1+NS2+NS3+NS4).

Bias

The questionnaire included brief information about the research to ensure that the study data were obtained correctly, and participants were asked not to record their identities on the questionnaire form. To prevent bias, data collection was done by anonymous self-reporting, and error checking and debugging were made after entering the data into the computer.

Statistical Analysis

Data were digitized and analyzed using SPSS Statistics version 25.0 (Armonk, NY: IBM Corp.). The results were presented as frequencies, percentages, means, and standard deviations (SD). Normal distribution of the numerical data was analyzed using the Kolmogorov-Smirnov test. Homogeneity of variance was examined by Levene’s test. For the comparison of the preferred main specialty sections, which were internal medicine and surgery, independent samples Student’s t-test was used for TCI dimensions and sub-dimensions, as well as the mean STAI scores. All hypotheses were two-sided, and a p value of <0.05 was considered statistically significant.

RESULTS

Participants

The study included 151 intern trainees. The mean (±SD) age of the participants was 23.66±1.18 years, and 57.6% (n=87) were females. The participants were born mostly in Turkey’s most populous cities such as Istanbul (16.7%, n=24), Bursa (9.7, n=14), and Ankara (7.6%, n=11), or locally in Canakkale and surroundings (4.2%, n=7). Nearly half of the intern trainees (49.7%, n=74) did not have economic problems, 18.8% (n=28) had slight livelihood difficulties. Sociodemographic variables of the intern trainees are presented in Table 1.

Descriptive Data

The majority of the intern trainees (88.1%, n=133) wanted to continue PME, and more than half felt that PME was necessary. The most common reasons for requesting specialty training were occupational satisfaction (43.6%, n=41) and career opportunities (31.9%, n=30), respectively (Table 2).

The majority of participants stated that they would choose internal (64.2%, n=97) and surgical (35.1%, n=53) disciplines, while the basic sciences (0.7%, n=1) were the least popular choice. The most requested specialties were psychiatry (9.9%, n=15), orthopedics and traumatology (8.6%, n=13), and physical therapy and rehabilitation (8.6%, n=13). In case they could not be allocated to their favorite specialties, the participants’ most common second choices were physical therapy and rehabilitation (12.0%, n=16), ear, nose, and throat diseases (9.0%, n=12), or internal medicine (8.3%, n=11) (Table 3).

The first three among the main reason for choosing a specialty were compliance with temperament and character (29.2%, n=42), lifestyle suitability (18.1%, n=26), and working conditions (14.6%, n=21), respectively. The second and third reasons for specialty choice were similar (Table 4).

The mean (±SD) STAI state and trait scores of the participants were 38.01±8.79 and 42.28±8.84. The intern trainees’ high state and trait anxieties were 31.1% (n=47) and 57.6% (n=87) according to the STAI.

For the temperament dimensions of TCI, the mean (±SD) values were as follows: NS (19.35±5.09), HA (18.77±7.03), RD (13.88±3.68), and PS (4.90±2.14). Character dimensions were as follows: SD (29.88±6.93), C (29.09±6.23), and ST (15.60±6.14). The intern trainees’ TCI dimension and sub-dimension scores are given in Table 5.

Outcome Data

Although 27 different specialty preferences were mentioned, the categories were merged into internal medicine and surgical disciplines during comparisons.

Using the STAI anxiety categories as dependent variable, the mean state and trait anxiety scores were compared using the independent samples t-test, which showed no significant difference between the groups. State anxiety scores for internal (n=95) and surgical (n=52) disciplines were 38.55±8.98 and 36.87±8.39, respectively (t=1.110, p=0.269). On the other hand, trait anxiety scores for internal (n=93) and surgical (n=49) areas were 43.05±9.01 and 40.61±8.33, respectively (t=1.574, p=0.118).

Using the different mean TCI subscale scores as dependent variables, independent samples t-test was performed to compare between study preferences. HA (19.95±6.89 & 16.36±6.84), HA2 (4.69±1.77 & 3.62±2.03), HA3 (4.6±2.14 & 3.67±2.08), HA4 (4.72±2.26 & 3.92±2.17) and RD1 (6.65±1.85 & 5.92±1.85) scores of internal medicine were statistically higher than surgery scores (p<0.05). The SD3 (3.23±1.28 & 4.08±1.04) scores for internal medicine were statistically lower than scores for surgery (p<0.05). There was no statistical difference between the other TCI scale dimension and sub-dimension scores concerning the main medical specialty categories (p>0.05) (Table 6).

DISCUSSION

The majority of intern trainees wanted to continue PME, and more than half felt that PME was necessary. The most common reasons for requesting specialty training were occupational satisfaction and career opportunities. On the other hand, only one participant (0.7%) opted for basic medical sciences; all the other students chose internal or surgical disciplines. The most popular specialties were psychiatry, orthopedics and traumatology, and physical therapy and rehabilitation. The three most common answers to the question about the main reason for selecting a particular specialty were compliance with temperament and character, lifestyle suitability, and working conditions.

There was no statistically significant difference between state and trait anxiety levels and the selection of the specialty fields. However, HA and RD1 scores for internal medicine were statistically higher than scores for surgical disciplines. The SD3 scores for internal medicine were statistically lower than those for surgery. There were no significant differences in the other TCI scale dimension and sub-dimension scores regarding the main medical specialty areas.

In our study, both trait and state anxiety levels were high (especially trait anxiety). In a systematic review, anxiety levels were reported to be higher among US and Canadian medical students than in the general population (21). In a study conducted in Egypt, the prevalence of anxiety among medical students was 73% (22). The prevalence of anxiety was reported to be 32.9% in a systematic review and meta-analysis examining mental health problems among medical students in Brazil (23). A multicenter study using the STAI scale in medical students reported state-anxiety to be 81.7% and trait-anxiety to be 85.6% (24).

One of the reasons why intern trainees want to specialize in internal medicine departments rather than in surgical departments may be the high level of anxiety among residents who choose surgical disciplines (25). We could not find any Turkish or English publications examining the effect of anxiety on specialty selection. Our study showed that the levels of state and trait anxiety did not affect the choice of the main areas of specialty.

Vaidya et al. (26) used the TCI scale to examine the relationship between the temperament and characteristics of medical students and the choice of specialty, finding students choosing surgery, emergency medicine, and obstetrics and gynecology to be higher in NS than the other students. The potential future surgeons were lower in HA and RD than the others. Students choosing primary care specialties, emergency medicine, and obstetrics and gynecology were all high in RD, with students aiming at entering pediatrics having the highest scores.

Many studies have reported that the personality trait is a common intrinsic factor in the specialty choice (27-29). Our findings suggest that temperament (HA and RD1) and character (SD3) influence specialty choice. HA, associated with the neurotransmitter serotonin, is the tendency to avoid or give up certain behaviors as an intense response to aversive stimuli manifesting itself as fear of uncertainty, shyness of strangers, quick fatigability, and pessimistic worry of future problems. RD, which is associated with the neurotransmitter noradrenaline, is a tendency towards intense response to reward, seen as sentimentality, social attachment, and dependence on approval of others. SD refers to self-determination, being able to control, regulate, and adapt behavior per own goals and values, to be self-sufficient, self-acceptant, responsible, reliable, and effective (30). In our study, students choosing surgery were as cooperative as the other students. However, Schwartz et al. (31) found surgeons to be especially high in C and SD. There may indeed be a surgical personality characterized by extraversion, C, and SD. 

Some limitations of this study deserve mention. First, research was conducted in only one class of final-year students at a single medical school during one academic year in Turkey. Therefore, it is difficult to generalize the findings. Second, this research did not closely examine other motivational factors such as lifestyles, beliefs, competitiveness, and duration of the residency program. Third, the data collection method bears the limitations of questionnaire studies. Finally, our sample is not large enough to analyze each specialty in detail. Since this was not a sampling study, a sample size calculation was not performed; the whole population was invited to join.

In conclusion, the present results suggest that temperament and character have some influence on specialty choice, whereas anxiety did not demonstrate such an impact. These findings may be beneficial to medical educators or career counselors for the specialty choice of medical students. Despite its limitations, this study may be helpful to medical students, professors, and medical educators in the process of specialty choice. Further research with larger sample sizes, including other grades of students, will be required to evaluate the more intricate factors associated with specialty choice.

Ethics Committee Approval: The study protocol was approved by the local ethics committee at Çanakkale Onsekiz Mart University (No: 15-07-Date: 25.07.2018).

Informed Consent: Each participant signed an informed consent form following the Declaration of Helsinki.

Peer-review: Externally peer-reviewed.

Conflict of Interest: No conflict of interest.

Financial Disclosure: This study was not funded by any organization.

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