Impact of ophthalmology posting on the attitude and perception of senior medical students in a Nigerian medical school to ophthalmology as a specialty and a career choice
Kareem Olatunbosun Musa1, Olufisayo Temitayo Aribaba1, Adetunji Olusesan Adenekan1, Olubanke Theodora Ilo1, Monsurah Olabimpe Salami2, Adeola Olukorede Onakoya1
1 Department of Ophthalmology, Guinness Eye Centre, Lagos University Teaching Hospital, College of Medicine of the University of Lagos, Idi-Araba, Lagos, Nigeria
2 Department of Ophthalmology, Hotel Dieu Hospital, Kingston, Ontario, Canada
Date of Web Publication 14-Feb-2019
Dr. Kareem Olatunbosun Musa
Department of Ophthalmology, Guinness Eye Centre, Lagos University Teaching Hospital, College of Medicine of the University of Lagos, Idi-Araba, Lagos
DOI: 10.4103/jcls.jcls_84_18
Background: Ophthalmology posting/clerkship is an integral part of the curriculum of medical schools globally. This provides ophthalmic educators an excellent opportunity to positively influence the medical students undergoing the posting. Materials and Methods: A pretest–posttest, noncontrolled, nonrandomized experimental study was conducted among 5th year medical students of the College of Medicine of the University of Lagos who underwent ophthalmology posting between November 2015 and February 2016. All respondents were requested to fill a semistructured questionnaire on the first and the last day of the posting. Information on sociodemographic data, perception and attitude toward ophthalmology, future practice plan, and a possibility of taking up a career in ophthalmology were obtained using a semistructured questionnaire. The data were analyzed using IBM Statistical Package for the Social Sciences version 20. Results: A total of 210 out of the 228 students participated in this study constituting a response rate of 92.1%. The mean age was 23.0 ± 2.3 years, and the male-to-female ratio was 1:1.1. There was a statistically significant improvement in the overall mean attitudinal scores after posting compared to the scores before posting (P < 0.01). Furthermore, there was a statistically significant improvement in the overall mean perception scores after posting compared to the scores before posting (P < 0.01). Although there was an increase in the mean score of disposition of respondents to ophthalmology as a future career from 2.18 before posting to 2.30 after posting, this was not statistically significant (P = 0.06). Conclusion: The 4-week ophthalmology posting impacted positively on the perception and attitude of respondents to ophthalmology as a discipline, but did not translate to a significant improvement in the consideration of ophthalmology as a future career.
Keywords: Attitude, impact, Nigeria, ophthalmology, perception
Musa KO, Aribaba OT, Adenekan AO, Ilo OT, Salami MO, Onakoya AO. Impact of ophthalmology posting on the attitude and perception of senior medical students in a Nigerian medical school to ophthalmology as a specialty and a career choice. J Clin Sci 2019;16:26-32
Musa KO, Aribaba OT, Adenekan AO, Ilo OT, Salami MO, Onakoya AO. Impact of ophthalmology posting on the attitude and perception of senior medical students in a Nigerian medical school to ophthalmology as a specialty and a career choice. J Clin Sci [serial online] 2019 [cited 2020 Jan 22];16:26-32. Available from: http://www.jcsjournal.org/text.asp?2019/16/1/26/252277
Medical students are potential specialists in any of the medical or surgical specialties. They are the pool from which medical and surgical specialties are going to derive their future specialists. During undergraduate medical training, medical students are expected to rotate through all medical and surgical specialties. These rotations (postings/clerkship) present a good opportunity for medical educators in various specialties to positively influence the medical students concerning career choice. Several factors have been attributed to the career preferences of medical students in the literature. These factors include lifestyle consideration, perceived financial reward, role model influence, personal interest, societal perception, and the intellectual content of the specialties.[1],[2],[3],[4] However, the perception and attitude of medical students toward a specialty could be influenced positively or negatively by their experiences during the posting and could be a pointer to the possibility of such discipline being considered as a future career.
Several studies have been conducted on the impact of clerkship on the attitude of medical students toward several specialties,[5],[6],[7],[8] but little is known of the impact of ophthalmology posting on the attitude and perception of medical students toward ophthalmology as a discipline and as a prospective career. This is particularly important in Sub-Saharan Africa where ophthalmologists are inadequate taking into cognizance the fact that future specialists are going to evolve from present medical students. In Nigeria, there are three ophthalmologists per 1 million population which fall short of the minimum of one ophthalmologist per 250,000 people going by the Action Plan of Vision 2020 for 2006–2011.[9],[10]
Therefore, this study sought to determine the impact of ophthalmology posting on the attitude and perception of 5th year medical students of the College of Medicine of our university to ophthalmology as a discipline and career choice.
This research was a pretest–posttest, noncontrolled, nonrandomized experimental study involving 5th year medical students of the College of Medicine of the University of Lagos who underwent ophthalmology posting between November 2015 and February 2016. The posting was for a period of 4 weeks per batch, and there were three batches of medical students. During the posting, medical students were exposed to didactic lectures, seminars, teachings during ward rounds and outpatient clinics, and theater-based teachings. Ethical approval was obtained from the Health Research Ethics Committee of our institution (ADM/DCST/HREC/APP/630). Written informed consent was obtained from each respondent, and the study adhered strictly to the Declaration of Helsinki for human research.
All respondents were requested to fill a semistructured questionnaire on the first and the last day of the posting. The questionnaire sought to obtain information on sociodemographic data, perception and attitude toward ophthalmology, future practice plan, and a possibility of taking up a career in ophthalmology. To ensure anonymity, the respondents were requested to use a code/username (not real name) that they could easily remember when filling the second questionnaire on the last day of the posting. The responses to the statements on attitude (six) and perception (ten) were in a five-point Likert scale format – strongly agree, agree, not sure, disagree, and strongly disagree. A combination of positive and negative statements was used to reduce response bias with respect to the participants. Responses to positively worded statements concerning attitude and perception were scored as follows: strongly agree = 5, agree = 4, not sure = 3, disagree = 2, and strongly disagree = 1. Responses to negatively worded statements were scored in a reverse manner as follows: "strongly agree" = 1, "agree" = 2, "not sure" = 3, "disagree" = 4, and "strongly disagree" = 5. The disposition of the respondents to ophthalmology as a future career was also in a five-point Likert scale format, namely "definitely yes" = 5, "likely" = 4, "not sure" = 3, "unlikely" = 2, and "definitely no" = 1. The score of each respondent was converted to percentage for the purpose of grading. Respondents who scored 61% and above in the attitudinal and perception rating were considered to have a positive attitude and perception toward ophthalmology while scores of 60% and below were regarded as negative attitude. The questionnaire was pretested by administering it on twenty 4th year medical students after which some statements were modified to ensure clarity.
The data were analyzed using IBM Statistical Package for the Social Sciences version 20 (IBM Corp., Armonk, NY). The scores for the responses to statements on attitude, perception, and disposition to ophthalmology were found not to be normally distributed using Shapiro–Wilk test (P < 0.001). Therefore, Wilcoxon signed-rank test was used to determine any significant changes between "before posting" score and "after posting" score for each item. Furthermore, the respondents' disposition toward ophthalmology as a future career was dichotomized into "favorable" ("definitely yes" and "likely") and "unfavorable" ("not sure," "unlikely," and "definitely no") and its association with gender was analyzed using Chi-square. Similarly, the association between gender and respondents' future practice plan was analyzed using Chi-square. The significance level for all statistical tests was set at P < 0.05. Fisher's exact P value was calculated as appropriate.
A total of 210 of the 228 5th year medical students participated in this study (completing both "before posting" and "after posting" questionnaires) constituting a response rate of 92.1%. Their ages ranged from 20 to 35 years with a mean age of 23.0 ± 2.3 years. One hundred and forty-six (69.5%) respondents were within the 20–23 years age group, being the majority. There were 109 (51.9%) females with a male-to-female ratio of 1:1.1. Two hundred and three (96.7%) participants were single while 172 (81.9%) were Christians [Table 1].
Table 1: Sociodemographic characteristics of respondents
The respondents' attitude and perception of ophthalmology as a specialty were largely positive both before and after the posting. Two hundred and nine (99.5%) respondents had a positive attitude toward ophthalmology before posting, which improved to 100.0% after the posting. Similarly, 194 (92.4%) respondents had a positive perception of ophthalmology before posting while 205 (97.6%) had a positive perception after the posting.
The results of the comparison of the mean scores of the items assessing the respondents' attitude toward ophthalmology as a specialty before and after posting are shown in [Table 2]. There were statistically significant increases in the mean scores for all the items (P < 0.01), except for "ophthalmology posting is not necessary and should be removed from medical students' postings" whose P = 0.443. Furthermore, there was a statistically significant improvement in the overall mean attitudinal scores after posting compared to the scores before posting (P < 0.01). Similarly, there were statistically significant increases in the mean scores for all the items assessing the respondents' perception of ophthalmology as a specialty before and after posting (P < 0.01), except for "ophthalmology will adversely affect my lifestyle" whose P = 0.459 [Table 3]. Furthermore, there was a statistically significant improvement in the overall mean perception scores after posting compared to the scores before posting (P < 0.01).
Table 2: Attitude of respondents to ophthalmology before and after posting
Table 3: Perception of respondents to ophthalmology before and after posting
One hundred and seventy-seven (84.3%) respondents planned to undergo postgraduate specialty (residency) training, 21 (10.0%) were undecided, and 12 (5.7%) respondents were not interested in residency training. Of the 12 (5.7%) respondents who were not planning to undergo residency, 2 (0.9%) respondents felt residency is boring and a waste of time; 3 (1.4%) were not just interested; 1 (0.5%) felt the remuneration was not encouraging; and 2 (0.9%) respondents gave no reason. In addition, 4 (2.0%) respondents were considering careers outside medicine postgraduation (law, music, biomedical engineering, and an unstated career).
[Table 4] shows the result of the mean scores for the disposition of the respondents to ophthalmology as a future career before and after the posting. Although there was an increase in the mean score from 2.18 before posting to 2.30 after posting, this was not statistically significant (P = 0.06). Eighteen (10.2%) respondents were favorably disposed toward pursuing a career in ophthalmology before posting while 26 (14.7%) respondents were interested in pursuing a career in ophthalmology after the posting. There were no statistically significant associations between the respondents' gender and the disposition toward pursuing a career in ophthalmology before and after the posting [Table 5].
Table 4: Disposition of respondents to ophthalmology as a career choice before and after posting
Table 5: Test of association
One hundred and fifty-one (85.3%) respondents were not interested in pursuing a career in ophthalmology after the posting. Among this category of respondents, surgery and internal medicine were the two most popular specialties among the males documented among 19 (27.5%) and 10 (14.5%) male respondents, respectively [Table 6]. Conversely, obstetrics and gynecology and pediatrics were the two most popular specialties among female respondents documented among 14 (17.1%) and 11 (13.5%) female respondents, respectively. Overall, surgery, obstetrics and gynecology, internal medicine, and pediatrics were the four most popular specialties among respondents who were not interested in pursuing a career in ophthalmology.
Table 6: Distribution of specialty choices of 151 respondents not favorably disposed to career in ophthalmology by gender
[Table 7] shows the reasons for the specialty choices among 177 respondents who were interested on residency training. Personal interest was the most important reason documented in 116 (65.5%) respondents. This was followed by lucrativeness and "less busy specialty" documented among 66 (37.3%) and 65 (36.7%) respondents, respectively.
Table 7: Reasons for the specialty choice among 177 respondents interested in residency
Concerning the future practice plan of the respondents, 70 (33.3%) respondents planned to practice in Nigeria after graduation; 41 (19.6%) planned to practice outside Nigeria; and 99 (47.1%) respondents were undecided. Furthermore, only 12 (5.7%) respondents were considering practice in the rural areas; 117 (55.7%) will not/never practice in the rural areas; and 81 (38.6%) were undecided. There were no statistically significant associations between the respondents' gender and their future practice plan [Table 5].
With respect to the experience of the respondents, 138 (65.7%) reportedly enjoyed the posting, 37 (17.6%) respondents were unsure, and 35 (16.7%) did not enjoy the posting. The reasons given by the respondents who were unsure and those who did not enjoy the posting are summarized in [Table 8]. Concerning the 138 respondents who enjoyed the posting, 88 (63.7%) respondents found the clinic-based teaching most enjoyable whereas the most enjoyable component of the posting was found to be didactic lectures, theater-based teaching, bedside teaching during ward round, and seminars in 25 (18.1%), 11 (8.0%), 7 (5.1%), and 7 (5.1%) respondents, respectively. However, there was no statistically significant association between the posting component most enjoyed and a disposition to pursue a career in ophthalmology as shown in [Table 5].
Table 8: Reasons for negative/indeterminate posting experience
In this study, the respondents had an overall positive perception and attitude toward ophthalmology at the beginning of the posting. This may be due to their prior exposure to the rudiments of ophthalmology during their 4th year as part of the basic clinical skills course. Similar observation of possible influence of introductory posting was reported by Adebowale et al.[8] who conducted a similar impact study on medical students undergoing psychiatry posting. There was a statistically significant improvement in the overall perception (P < 0.01) and attitudinal (P < 0.01) scores of the respondents after the posting compared to the overall scores at the beginning of the posting. There is unanimity in the literature concerning the positive impact of specialty posting on the attitude and perception of the medical students undergoing such posting.[5],[6],[7],[8],[11],[12],[13] However, the impact of such positive posting experience on the choice of future careers of medical students is mixed. In this study, the positive impact did not translate to a significant increase in preference for ophthalmology as a future career (P = 0.06). Similar findings were reported by Lyons,[7] Adebowale et al.,[8] and Amini et al.[13] This suggests the possibility of involvement of other factors in the determination of career preference which may be a subject for further studies. On the contrary, Al-Heeti et al.,[5] Kaplowitz et al.,[6] Xavier and Almeida,[11] and Lyons and Janca[12] reported a significant impact of positive posting experience of medical students on their career choice. Although the attitude to a particular posting is said to dwindle as the students' progress in their studies and undergo other postings,[14] a favorable posting experience could have a lasting effect if identified interested students get continuous encouragement from medical educators in such discipline as they complete the remaining aspect of their training.[15]
Surgery, obstetrics and gynecology, internal medicine, and pediatrics were the four most popular career choices of respondents who were not interested in ophthalmology. The popularity of these specialties as career preference of medical students has been reported in previous studies from Nigeria[2],[16],[17] and Kenya.[18],[19] This is not surprising because medical students usually have longer exposure to these core clinical specialties during clinical rotation. Personal interest, lucrativeness, and "less busy specialty" were the three main reasons that influenced career choice among respondents in this study. Two of these also featured in the top three reasons reported by Akinsola et al.,[16] namely regular work hours, monetary income, and benefit to the society. However, Oche et al.[2] reported flexibility of specialty, interest in research, and reputation of the specialty whereas Maseghe Mwachaka et al.[19] reported the presence of role model in specialty, job opportunities, and financial rewards as the determinants of career choice.
Only one-third (33.3%) of the respondents planned to practice in Nigeria while 19.6% planned to practice outside Nigeria. Nearly half (47.1%) of the respondents were undecided at the time of the study. However, going by the recent economic downturn of Nigeria with dwindling economic fortune, there is a possibility of more undecided respondents switching to the group of respondents who planned to practice outside Nigeria. This could further worsen the shortage of doctors currently being experienced in Nigeria as there are 4 doctors per 10,000 population.[17] In the light of the foregoing, government needs to provide enabling environment that will encourage young medical graduates to stay back and practice in Nigeria.
Only 5.7% of the respondents considered practice in the rural areas after graduation while over half (55.7%) will not/never practice in the rural areas. This might be due to the inadequacy or lack of social amenities in the rural areas. This could further tilt the balance of physician task force against the rural areas. Furthermore, the location of the medical school involved in this study in a cosmopolitan city of Lagos may make rural environment less attractive to these respondents. Therefore, there is a need for government to provide incentives to make rural practice more attractive to fresh medical graduates to ensure equitable distribution of physician task force between rural and urban areas.
Although almost two-third (65.7%) of the respondents enjoyed their posting with the clinic-based teaching being the most enjoyable, the remaining 34.3% were either unsure or did not enjoy the posting. Therefore, there is a need for the ophthalmic educators to make the other components of the posting to be more enjoyable. Furthermore, all staff involved in the posting need to be friendlier to these students without compromising discipline.
This study is limited by the lack of similar study on ophthalmology discipline with which to compare the findings of this study. This has necessitated a comparison with similar studies in other specialties. Furthermore, the assessment of student immediately after the posting may not reflect a lasting perception and attitude toward ophthalmology as the positive change could be transient. A study design with long-term follow-up of these respondents may be able to determine the enduring effect of such an impact. Finally, the noncontrolled and nonrandomized nature of the study makes it a weaker experimental study design. However, it could be argued that the nonoptional nature of ophthalmology posting makes 5th year students without ophthalmology exposure that could be used as a control group unavailable.
The 4-week ophthalmology posting impacted positively on the perception and attitude of respondents to ophthalmology discipline but did not translate to a significant improvement in consideration of ophthalmology as a future career. Furthermore, only one-third of the respondents planned to practice in Nigeria after graduation while only 5.7% considered a practice in the rural areas postgraduation.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]
Musa KO
Aribaba OT
Adenekan AO
Ilo OT
Salami MO
Onakoya AO