Abstract

Background: In this study, we aimed to investigate the current interest of Turkish medical students to pursue a career in cardiovascular surgery and to identify possible factors which positively or negatively affected their decisions.

Methods: Between January 2022 and August 2022, a cross-sectional survey of 34 questions was created using the Google Forms online survey platform. Questions were directed to participants to evaluate demographic features, interest level in cardiovascular surgery, interest in other specialty programs, and interest in residency abroad using fivepoint Likert scales.

Results: A total of 5338 Medical Students were reached who were balanced to 7 geographical regions across Türkiye and 1233 (23%) medical students participated in the questionnaire. Of the respondents, 544 were males and 689 were females with a mean age of 21.2±0.5 (range, 17 to 28) years. More than half of the students (56.2%) considered residency training programs in Türkiye. Cardiology had the highest preference rate for residency training (8.3%), followed by cardiovascular surgery (7.5%). More than one-third of students (36.5%) who were interested in pursuing a career in cardiovascular surgery decided to be trained abroad. Achieving a prestigious job, motivation for life saving, prioritizing innovations, and high academic studies were the main factors that positively affected the perspective of students on cardiovascular surgery, while stressful surgeries, intense and tiring night shifts, and a relatively poor social life/work balance were the main deterrent factors. Attendance to cardiovascular surgeries positively affected the decisions of students (p=0.008).

Conclusion: Although it is thought that the interest in pursuing a career in cardiovascular surgery has reduced in recent years all over the world, our study shows that cardiovascular surgery still continues to be a popular specialty among Turkish medical students. Therefore, we believe that guiding medical students by using their current potential and encouraging the students to attend cardiovascular surgeries more frequently throughout their education life are essential in choosing cardiovascular surgery as a future career option.

In recent years, there has been a decline among medical students to become cardiovascular/thoracic surgeons as a future career plan.[1] In particular, in the United States (USA), United Kingdom (UK), European countries, and other parts of the world, there is a significant decline in the preference for cardiovascular surgery specialization among newly graduated physicians. The increased number of cardiac and vascular cases which are performed percutaneously by cardiologists and interventional radiologists, the decreased number of surgeries despite the increase in population, significant advances in technology, limited job opportunities after graduation, and the burden of patients with high comorbidities can be considered as responsible reasons.[1-6]

Since 2003, the widespread use of drug-eluting stents for the treatment of coronary artery disease leading to a decrease in coronary artery bypass grafting (CABG) have greatly affected the preference of students. In the near future, non-CABG surgeries such as arrhythmia surgeries, cardiac remodeling, and other open or minimally invasive procedures may increase. Declining interest in cardiovascular surgery may lead to a shortage of cardiovascular surgeons in the upcoming decades. Since the number of cardiovascular surgeons has dropped for the first time over the past two decades, there is a significant future concern about the number of surgeons. In addition, more than half of active surgeons are older than 55 years and are about to retire.[7]

In the present study, we aimed to investigate the current interest of Turkish medical students to pursue a career in cardiovascular surgery and to identify possible factors which positively or negatively affected their decisions, motivations, satisfaction, and ambitions.

Methods

Study population
This nationwide, cross-sectional study was conducted at 20 medical schools across Türkiye, between January 2022 and August 2022. As of 2022, there were 96,935 medical students in 107 Medical Faculties in Türkiye. Using a type 1 error of 0.05 and a study power of 95%, the number of medical students required to be recruited was determined as 1,226. Invitations were sent to a total of 5,538 students, divided into seven geographical regions in Türkiye. A self-administered online survey specifically designed in web-based Google form. Voluntary and anonymous participation was taken into account. No specific exclusion criteria were applied, except for incomplete responses.

The questionnaire was consisted of 34 questions and directed to the participants including demographic features, future career expectations, willingness to be specialized, residency abroad, thoughts about cardiovascular surgery residency, and factors affecting students' decision to choose cardiovascular surgery as a future career option were investigated via multiple choice questions and Likert scale. Demographic data including age and sex, current career intentions, previous cardiovascular surgery exposure, experiences, and perspective of cardiovascular surgery were analyzed.

Study endpoints
Twenty-one multiple choice questions were designed to deter and encourage according to the Likert scale specific to cardiovascular surgery. The Likert ranking scale was scored as follows: (i) strongly deterring (ii) deterring (iii) neither deterring nor attractive (iv) attractive (v) strongly attractive.[1] A factor was determined whether to be either attractive or deterring in case of more than 60% of the cohort reported in favor.

In addition to entire cohort analyses, a distinct subgroup analysis was performed regarding final-grade medical students, first-grade medical students, male and female students, students having a physician family member, and those having a cardiovascular surgery mentor or ever attended a surgery.

Statistical analysis
Statistical analysis was performed using the IBM SPSS for macOS version 28.0 software (IBM Corp., Armonk, NY, USA). The Kolmogorov-Smirnov test was used to analyze normally distributed continuous variables. Continuous variables were presented in mean ± standard deviation (SD), while categorical variables were presented in number and frequency. Continuous data were compared using the t-test and the Mann-Whitney U test. Categorical data were analyzed using the chi-square test or Fisher exact test. A p value of <0.05 was considered statistically significant.

Results

Sample sizes, demographics
Of 5,538 medical students, 1,233 (23%) from 20 medical schools across Türkiye completed the survey. Of the respondents, 544 were males and 689 were females with a mean age of 21.2±0.5 (range, 17 to 28) years. Most of the participants (96.7%) considered a post-graduate residency program and 25.3% of the participants had a physician family member.

Outcomes in total
Most of the medical students (57.5%) considered residency training programs in Türkiye. In addition, the USA, Germany, and UK were the most preferred countries among medical students who desired to go abroad for residency training programs (Figure 1).

Figure 1. Participants" answers to questions about cardiovascular surgery and future plans.

When we compared the first- and sixth-grade medical students in terms of residency training programs abroad, a statistically significant difference was revealed in favor of the first-grade students (56.5% vs. 21.4%, respectively; p=0.001). In other words, there was a significant tendency among the first-grade students in terms of training residency abroad rather than the sixth-grade medical students (Figures 2-4).

Figure 2. Future career plan of medical students for residency training.

Figure 3. Overall future career plans for residency of medical students.

Figure 4. Distribution of female and male medical students according to residency training preference.

Outcomes related to cardiovascular surgery
Cardiology was the most considered residency training program (8.3%), followed by cardiovascular surgery (7.5%). Furthermore, cardiovascular surgery was most considered by the second-grade (31.2%), followed by the fourth-grade (26.9%), and the lowest by the fifth-grade (7.5%) medical students. When we compared the results of the second- and fifth-grade medical students, a statistically significant difference was identified (p=0.014), while no significant difference was observed between the second- and sixth-grade students (p=0.082). In addition, among the pre-clinical and clinical students, no significant difference was seen (p=0.13). More than one-third of medical students decided to choose cardiovascular surgery training programs abroad (51.4% female). Germany, the USA, and UK were the most preferred countries, respectively. Almost half of the students (48.9%) attended any surgery, whilst only 17.8% of the students previously participated in cardiovascular surgery before. Almost half of the participants (44.7%) had a cardiovascular surgery mentor, while one-third of the participants attended a cardiovascular surgery congress or seminar before. Participation in cardiovascular surgeries anytime during medical education positively affected the decisions of students (11.8% vs. 6.6%, respectively; p=0.008).

The main factors that positively influenced students to choose cardiovascular surgery were detected as achieving a prestigious job, saving a life, prioritizing innovations, and high academic studies while stressful surgeries, intense and tiring night shifts, and the relatively poor social life/work balance were the main deterrent factors (Figures 5-7).

Figure 5. Factors affecting medical students" preference for cardiovascular surgery training.

Figure 6. Factors Affecting Medical Students" Preference For Cardiovascular Surgery Training cont".

Figure 7. Factors affecting medical students" preference for cardiovascular surgery training cont".

Overall outcomes for preferring specialty
Plastic surgery, neurosurgery, ophthalmology, and cardiovascular surgery were most considered by the first-, second, third- and fourth-grade students, respectively. Furthermore, cardiology was most considered by the fifth- and sixth-grade students.

According to specialties, pediatrics, obstetrics and gynecology, psychiatry, and pathology were more considered by females (p=0.03, p=0.001, p=0.001, and p=0.001, respectively), while cardiology, plastic surgery, and internal medicine were most considered by male students (p=0.002, p=0.018, and p=0.02, respectively). Interestingly, cardiovascular surgery was more considered by females without a statistically significant difference (57 females, 34 males; p=0.21).

Discussion

In this study, we evaluated the perception of medical students about cardiovascular surgery and other specialties all over Türkiye. This cross-sectional survey revealed that cardiovascular surgery is still the second most preferred specialty after cardiology among medical students, while more than one-third of these students decided to pursue residency training programs abroad. In addition, cardiovascular surgery was more preferred by female students rather than male students. Achieving a prestigious job, motivation for of life saving, and prioritizing innovations were considered as the main factors, while stressfulness, exhausting night shifts, and poor work/life balance were considered the main deterring factors for considering cardiovascular surgery residency training programs. Attendance to cardiovascular surgery was found to be a significant factor for preference. The current interest in cardiovascular surgery was higher among the secondand fourth-grade medical students.

In total, 42.5% of the medical students (more than half of first-grade students) decided to pursue residency training abroad, and Germany, the USA, and UK were the most preferred countries. Pediatrics, psychiatry, and pathology were more considered by females, while cardiology, plastic surgery, and internal medicine were more considered by males. Furthermore, one-fourth of students had a physician family member.

Cardiovascular surgery, which has started to ascend since the 1950s, reduced its former popularity among newly graduated physicians.[3,8-10] Physicians over the age of 65 years have a mortality rate of 80% and, in the next decade, most elderly cardiovascular surgeons are expected to be retired. In addition, aging population and increasing cardiovascular diseases have arisen the demand for cardiovascular surgeons.[11] Therefore, a shortage of cardiovascular surgeons is expected in the next decades.[7] The improvement of interventional cardiology and radiology increase the perception of a dying specialty for cardiovascular surgery.[12,13]

Lebastchi and Yuh[14] and Ghannam et al.[6] previously reported that exposure and mentoring to cardiovascular surgery were the main determinants by respondents (98% and 89%, respectively). Mentoring and more exposure to cardiovascular surgery are considered to be encouraging factors for newly graduated physicians for preference. Furthermore, heavy working conditions should be improved and the importance of this unique specialty should be emphasized by national/international associations and medical faculties.[5] Otherwise, it seems to be inevitable that there would be no qualified cardiovascular surgeons in the future at all.[7]

Algethami et al.,[1] Vaporciyan et al.,[3] Kesieme et al.,[15] Preece et al.,[5] and Coyan et al.[11] and reported that 4.5%, 6%, 8.4%, 10.8%, and 13% of medical students decided to choose cardiovascular/thoracic surgery training programs, respectively. Our study revealed that cardiovascular surgery was the second most considered specialty among medical students with a rate of 7.5%.

In their study, Coyan et al.[11] reported that no sex difference among medical students who considered cardiovascular surgery, in contrast to male sex-weighted previous studies.[3,6,16] In addition, females constituted less than 5% of cardiothoracic surgeons in previous studies. Family planning and motherhood are reported to be seen as obstacles to being a cardiothoracic surgeon.[8,16,17] On the contrary, our results showed that female medical students were more interested in being a cardiovascular surgeon.

Additionally, Preece et al.[5] investigated the tendency of interest in a future career in cardiothoracic surgery among 352 medical students from 32 medical schools. The main factor that affected students' choice was the enthusiasm for saving lives; however, high competition levels were negatively affected. Our results are similar in that achieving a prestigious job, saving a life, prioritizing innovations and academic studies were the encouraging factors, despite poor work/life balance being the main deterring factor. In addition, 75% of students did not attend cardiothoracic surgery adequately, and only 13% of students attended a cardiothoracic conference before.[5] Our results are similar; as such, only 12.5% of the students attended a cardiovascular conference before, and 20% of the medical students attended cardiovascular surgery before.

Vaporciyan et al.[3] conducted a study in the USA among 2,153 general surgery residents and investigated the factors and interests for cardiothoracic surgery residency. The authors reported that 71% of the students had a cardiothoracic surgery mentor. Longterm training was regarded as an important deterring factor and mentoring was thought to be a stimulant for choosing cardiothoracic surgery residency training programs.[1] Foote et al.[16] and Coyan et al.[11] reported that 25.3% and 31% of medical students had a physician family member, respectively, and our results (25.2%) were similar to previous studies.

Nonetheless, there are some limitations to our study. First, previous surveys mostly investigated the current interest in cardiothoracic surgery, while we conducted a survey about the interest in cardiovascular surgery due to the medical structure of our country. Second, the low response rate of about 23% could have been improved among medical students. Third, due to the nature of this cross-sectional survey, decisions and interests of the students can change over time

In conclusion, our study demonstrates that cardiovascular surgery is still the second most considered specialty among medical students in Türkiye, despite a decline in interest all over the world. More attendance to cardiovascular surgery and mentorship are essential to increase the preference of students. Therefore, we believe that potential and motivation of medical students should be well handled, and it is crucial to be a role model for newly graduated physicians. Correctly directing this potential in Türkiye would prevent the potential shortage of qualified cardiovascular surgeons in the future other countries would experience.

Study Author and Centers: 1Institute of Cardiology, Istanbul University-Cerrahpaşa, Istanbul, Türkiye: Serkan Burc Deser and Dilara Durak; 2Medicine Faculty of Ondokuz Mayıs University, Samsun, Türkiye: Metin Altin; 3Bursa City Hospital, Bursa, Türkiye: Ahmet Yuksel; 4Medicine Faculty of Yıldırım Beyazıt University, Ankara, Türkiye: Muhammed Arif Dogan; 5Medicine Faculty of Bülent Ecevit University, Zonguldak, Türkiye: Gaye Taskin; 6Medicine Faculty of Necmettin Erbakan University, Konya, Türkiye: Elem Sener;7Medicine Faculty of Aydın University, Istanbul, Türkiye: Zubeyde Kagitci; 8Medicine Faculty of Giresun University, Giresun, Türkiye: Elif Nur Yerlikaya; 9Medicine Faculty of Gazi University, Ankara, Türkiye: Semanur Dogan; 10Medicine Faculty of Harran University, Şanlıurfa, Türkiye: İrem Caglayan; 11Medicine Faculty of Ordu University, Ordu, Türkiye: Yigit Gökberk Sahin; 12Medicine Faculty of Hacettepe University, Ankara, Türkiye: Ahmet Bugrahan Yildiz; 13Medicine Faculty of Kocaeli University, Kocaeli, Türkiye: Aleyna Gazi; 14Medicine Faculty of Katip Çelebi University, Izmir, Türkiye: Özgem Uysal; 15Medicine Faculty of Adnan Menderes University, Aydın, Türkiye: Mizgin Siyahtas; 16Medicine Faculty of Atatürk University, Erzurum, Türkiye: Gülcin Ozer; 17Medicine Faculty of Mersin University, Mersin, Türkiye: Mehmet Emin Kayaalp; 18Medicine Faculty of University of Health Sciences, Ankara, Türkiye: Seyidahmed Hasanzade; 19Medicine Faculty of Sakarya University, Sakarya, Türkiye: Göktug Kuru; 20Medicine Faculty of Maltepe University, Istanbul, Türkiye: Melike Caglar.

Ethics Committee Approval: The study protocol was approved by the Ondokuz Mayıs University, Medical Faculty Training and Research Hospital Ethics Committee (date/no: 30.05.2022. OMÜ KAEK 2022/134). The study was conducted in accordance with the principles of the Declaration of Helsinki.

Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author Contributions: Idea/concept, data collection and/ or processing: S.B.D., D.D.; Design: S.B.D., D.D., A.Y.; Control/ supervision, materials: S.B.D.; Analysis and/or interpretation: S.B.D., M.A.; Literature review; writing the article: S.B.D.; Critical review, references and fundings: S.B.D., A.Y.

Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding: The authors received no financial support for the research and/or authorship of this article.

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