CZYNNIKI WPŁYWAJĄCE NA WYBÓR ZAWODU LEKARZA W KONTEKŚCIE REFORM OCHRONY ZDROWIA ZACHODZĄCYCH NA UKRAINIE
Lesia Lymar, Sergii Omelchuk
NATIONAL MEDICAL UNIVERSITY NAMED AFTER O. BOGOMOLETS, KYIV, UKRAINE
Introduction: The article is dedicated to the motives of medical career choice studied by Ukrainian and foreign scientists, and by the authors themselves. The authors define the main motives, grouped into the pragmatic, social, scientific and professional ones, paying particular attention to the proposed reforms of the Healthcare of Ukraine “Health 2020”.
The aim: The study has been aimed at detection of the medical career choice factor groups and their possible correction during the medical training, defining possible influence of the Ukrainian Healthcare reformation onto alterations of the medical career choice.
Materials and methods: This article is based on bibliosemantic, dialectical, comparative, analytic, synthetic and comprehensive research methods.
Review and conclusion: The authors have analyzed medical career motives according to the A. Maslow hierarchy of needs, comparing the present motives with the motives to be changed after reforming the Ukrainian healthcare. The authors conclude that according to the Maslow’s hierarchy of needs, the medical career choice corresponding to the first, second and third needs level would be directly related to the pragmatic, social and scientific motives, further disappointment in career, low professional performance and professional “burnout”. The career choice corresponding to the last levels of the needs hierarchy is related to the professional motives and self-actualization, but, due to the applicants’ age and financial status of medical specialists in Ukraine, is not likely to occur. Positive changes in medical specialists’ salary rise, social protection offered by the State and state support of the profession will provide for correction of motives onto the higher level, in this way, benefiting the patients.
Wiad Lek 2018, 71, 1 cz. II, -216
There are many factors which provide for high competitive performance of the Ukrainian medical specialists on the world medical market, including professional knowledge, skills and effective “physician-patient” interaction abilities aimed at recovery of the last and practically implemented. The successful interaction of a physician and a patient is closely related to the professional activity motives, which, in turn, are related to the career choice motives. The aims of the “physician-patient” interaction stipulate for the effectiveness of the interaction, aimed at the patient’s recovery. Medical career choice motives may be classified into the primary and secondary ones. The primary motives are represented with the motives of the career choice when a person chooses the university to apply for, while the secondary motives may alter throughout the training and practice. So, it is extremely important to detect the primary motivation during the student’s training in a medical school, and, if necessary, to correct the motives before one starts his career. The Health care system of Ukraine is undergoing reformation changes, with the claimed-to-be high social position of the medical specialists, high salary and social protection of doctors as well as general transformation of the “physician-patient” interaction structure . The expected changes could affect medical career choice motives. As the issue of the medical career choice is particularly urgent in Ukraine in 2017, regarding the medical social position changes and the State guarantees, promised by new reforms, we have made up our mind to study this topic throughout.
The study has been aimed at detection of the medical career choice factor groups and their possible correction during the medical training, defining possible influence of the Ukrainian Healthcare reformation onto alterations of the medical career choice.
Materials and methods
This article is based on bibliosemantic, dialectical, comparative, analytic, synthetic and comprehensive research methods.
Review and discussion
The issue of medical career choice motives and medical interaction motives has been studied by many Ukrainian and world healthcare specialists: K. Mikhno , I. Vitenko , L. Lymar  , S. Omel’chuk , І. Pasichnyk, К. Pivtorak , Т. Rumiantseva , М. Morgan , D. Sobral , R. Tyssen  and others. The career choice by the school graduates issue has been investigated by R. Ovcharova , Ya. Tsekhmister, R. Kuzurkar . The career choice motives of the nurses are the topic of studies by Ye. Kadnikova , V. Ruban . L. Crossley and A. Mubarik compared the career choice motives of the medical students and dental students . L. Lymar, K. Pivtorak and T. Rumiantseva have studied transformation of the medical career choice motives during the medical students’ training. І. Pasichnik , М. Morgan and I.Wang  emphasized general medical image structure and related to this the medical career motivation. Some authors regard career choice motivation as a component of professional self-identification, while others consider it as a component of the emotions and will of a personality. According to A. Perepelytsa, the professional self-identification and career choice motives represent combination of moral values of the person, attitude to the career, plans of the person regarding the career and their correction according to the career image . K. Pivtorak stresses upon the direct relation of the medical career choice motives and the person’s moral and ethical values. V. Ruban notes that the professional “burnout” is a main factor which may alter the person’s career choice motives. L. Lymar claims that the medical students’ career choice motives guarantee the effectiveness and productivity of the “physician-patient” interaction and the treatment outcome. І. Pasichnyk correlates the career choice motives to the general medical career image. Regarding all the studies, the authors have decided to analyze the present medical career choice motives according to the personality structure by Freud, and classify the motives according to the A. Maslow pyramid.
The professional’s performance depends on his readiness for the professional interaction. The previous analysis performed by L. Lymar, established the following components of the professional interaction readiness: motives, cognition, operation and regulation. Motives take up priority position as the professional interaction motives stipulate for all other components as their causing factor. The motives of the medical specialist for the professional interaction comprise the sub-components, such as: medical career choice motives, motives of professional growth and motives of professional interaction. The career choice motives represent the primary component of the professional interaction motives, which defines general motives for the professional activity. According to the performed review of the literature data and the personal medical school teaching experience of the authors, the career choice motivation has been defined as a group of motives which caused the person the choose the desired career path and try hard to acquire the appropriate qualification.
Combination of the medical career choice motives represents the system of attitudes of the person to the chosen career, professional activity and interaction with the others (both medical specialists and non-medical people) during execution of the professional duties as well as the system of attitude of the friends, relatives and other people. Due to the authors’ personal teaching experience in the Medical school, the following medical career choice motives have been established: the forced choice “against the will of a student” (when the parents want their child to become a doctor, but the person doesn’t want it) ; forced choice, the student willingly accepting it; career prestige; possibility to earn good money; way to receive the respect of the others; possibility to save the other’s lives; nice portrayal of the career in mass media; student’s personal interest in medicine as a subject; possibility to become world famous as a genius physician; person’s admiration of his physicians he knows; unconscious career choice, the choice “due to the circumstances”( explained as :it simply happened so…”), etc. Generally, the all career choice motives may be classified into the internal ones (direct motives of a certain person, with the defined influential factors) and the external ones, which may be conscious (the career chosen on the parents’ decision, when the person wants to choose another profession) and non-conscious( choosing the career because “it is well portrayed”, “the friends or parents advised me”, without certain self-realization of its necessity).
The medical career choice motives may be grouped as follows:
– pragmatic motives: obtaining any material benefits (“profitable career”), career ladder possibilities, social assertion through the fame; taking up the authority position in medicine, running a clinic, etc. The student chooses medical profession for the high medical salary (choosing in Ukraine specialties like gynecology or plastic surgery, with which one can be employed in a private clinic and be paid better than the state physicians, receiving about 100 American dollars a month). The other career choice motives are one’s possibility to step up the career ladder and take up the administrative authority positions (which is quite often in Ukraine observed in medical dynasties, with parents and children engaged in one field of the medicine, or when the parents manage the private clinic and their son or daughter, upon graduating from the University, will run the clinic). Another motive from this group is one’s desire to become world famous through being a good specialist, being able to perform operations no one else can do or discovering a new treatment method. If this motive group predominates, the students, upon their University graduation, will try to avoid being “directed by University to their first workplace” to the suburbs regions, which could bring them neither money nor fame; neglecting the non-prestigious specialties, which don’t provide for any additional benefits (like a career of a family physician, being nowadays very demanding but little paid). With this motive group prevailing the students try to neglect their employment on the distant regions of the country (which results in lack of medical specialists in rural regions, which is an urgent problem for Ukraine) and avoid non-prestigious specializations.
– social motives, including possibility of direct communication with patients and their relatives, self-representation before the their patients and their relatives, etc. The students claim to have chosen the career because they “like helping others”, “love children” (pediatric students), “love communication”, or “This is going to be a funny and interesting career”. The medical career here is perceived as an entertainment method, the way to avoid the life boredom, quite often chosen by the extraverted people to provide for broad communication possibilities, by people with low self-esteem or high self-esteem, when the professional activity of a physician provides for personal self-representation.
– professional motives, including providing good patient’s health, improving his health (though, there are some hidden benefits in these motives, such as self-representation of a talented physician, which is confirmed by a patient’s recovery, that is, healing the patient to prove doctor’s professional qualities, heal the patient to become known and famous, etc.. In this case the submotives of the career choice need to be regarded carefully).
– scientific motives including career choice in order to contribute to the science and become respected in it. This excludes the patient from the professional interaction chain, which may be beneficial for the laboratory specialties (specialties of a microbiologist, virologist, etc.), with which the medical specialist doesn’t have to communicate with the patient. The danger of such choice may be manifested in neglecting patient’s welfare for the sake of one’s scientific reputation. This group is quite interesting as such motives may express one’s interest in the whole medical science or be the pragmatic motives (discovering a new method provides a basis for becoming world famous and rich), or represent the way to rationalize the choice caused by other conscious or unconscious factors.
– motives of personal self-actualization, including professional self-actualization, learning new methods of managing the medical tasks and interaction. These motives may be stipulated for the person’s interest in the specialty or both pragmatic and social motives, though being the most appropriate when defining doctor’s motivation.
The medical career choice is usually based on many motives, and this combination of motives defines this choice, although one or two motives predominate. When a certain motives group prevails ( e.g., tendency to receive certain materials benefits, or acquiring new knowledge and skills after the practice), this may substantially limit the physician’s activity scope. At the same time, it is extremely important for the specialist to realize the importance of his own career choice motives.
In this article we have tried to consider the psychological essence of the career choice motives, particularly in Ukraine. Defining motives due to the personal structure according to Z. Freud, the following observations are offered: positive and nice mass media portrayal of medical professions provides for such motives of medical career choice, according to the unreal “ideal ego” structure, with high expectations from it, that a person tries to compensate for his own imperfectness, trying to be the best, saving others’ lives and, in this way, substituting the God. Considering the average age of the medical schools applicants, which in Ukraine is 17-18 years (after finishing secondary schools usually), with prolonged teenager crisis and immature moral values, undergoing separation from the parents (and trying to prove them something or at least be equal with them), combines with the youth black-and-white thinking( tendency to be the best and save the world), it is possible to deduce that the medical career choice in this age is well grounded as the choice of the “best career” in the world or possibility to “change the world”. Though, in a few years period the psychic structure of the personality may change, with motives changing as well. If the person hasn’t shaped his “ego” concept, not realizing one’s own wishes, both internal and external needs, he may become severely frustrated in the profession, while meeting with practice. In addition, practice and emotional “burnout” change the career choice motives as well. So, to improve doctor’s professional performance, during the Medical School training it is necessary to define one’s motivation, structure of “ego real” and “ego ideal”, and shape the “ego professional” which will be based upon the “ego real”. The tasks of the Psychological Department of the Medical School and Educational Department include defining the motives and general psychic structure of the future specialists, with its subsequent correction during the medical studies.
Motivation of any activity originates in the needs. In the article we relate medical career choice motives to the A. Maslow hierarchy of needs (which is a universal reflection of the human needs) . The first stage of the hierarchy is represented with basic physical needs: satisfying the thirst, hunger, etc. the second stage is represented with the need of safety, which are relatively “higher” needs: safety provided though provided accommodation, occupation, safety around, regular income and social guarantees, etc. If both two stages are provided to a person, he develops needs of the third stage: the need to belong to the community, to be well received by the others, etc. The next stage is the need for respect and fame, recognition. The last stage is manifested with the need for self-actualization, searching for one’s position in life and aims of life. Hereafter we are going to consider the medical career choice motives according to the A. Maslow hierarchy of needs.
A person, whose actual needs are those of the first hierarchy stage, will choose the medical career with only pragmatic motives, e.g. choose the profession to earn a living, decide the accommodation problem( living in a hostel for doctors or obtain the social accommodation), etc. So, if the problem of accommodation is urgent, or a person’s family belongs to the low income group, he will choose medical career only with pragmatic motives. Standardly, physiological needs of the 1st stage must be provided for at least 85%, otherwise all activity of a person is aimed just at surviving. This is the primary factor, not regarding some unpleasant profession peculiarities( like deaths of the patients and responsibility of a doctor). For those, choosing the medical career only with the pragmatic motives, having encountered with the state medical salaries for those who start practice( which in 2017 range from 100 to 150 American dollars, according to the currency exchange), frustration in the career is inevitable, which may result either in changing the profession ( and giving up medicine at all), or just pragmatic attitude to professional duties, when all the person’s activities are aimed at earning money. No motivation correction measures will be effective, unless the physiological needs of a specialist (provided with clothes, food and accommodation) are satisfied. Here Medical School may raise a person’s motives for studying though the grants and scholarships, though with insufficiently provided material needs other motives can be slowly shaped. If, according to the scheme of reforms, medical specialists will be provided with accommodation and appropriate salaries , Medical School Psychological Department, Medical School Educational Department and Medical Institutions Administration may cooperate to alter secondary career choice motivation, shifting it from the pragmatic motives only. If, according to the reforms scheme, medical specialists salaries will increase, compared to the nowadays, and the specialist’s basic needs are provided (or a medical student realizes that upon his graduation all his basic needs will be covered by a state salary), motives of the career choice and professional interaction may “shift” onto the second stage of the needs hierarchy, to the personal self-representation, receiving the respect and self-realization, which would be more productive for the professional performance.
The second stage of the needs, needs for safety, are represented with the permanent job place, social guarantees, sick leave, social accommodation, related to the pragmatic and social motives of the career choice. A person choose medical career as the reliable one, which will provide him with certain social benefits. One may choose the career for treating himself or his own family, which may be related to unsuccessful history of treatment on the family, or due to a personal fear of being ill. The safety is realized through provision of physiological needs and certain social guarantees of the employer. So, in Ukraine, graduates often choose to work as medical representatives of large pharmaceutical companies (not as medical specialists!), due to high social guarantees (insurance, provision with private transport, compensations, financial support of the employees, credit line). If state supports graduates with the same on state positions, particularly family doctors (which is a specialty avoided by most graduates due to high responsibility, absent specialization and low social protection), the problem of specialists insufficiency will be solved.
The career choice with the second stage of motives is a more conscious choice than the previous one, but it is still far from dedication to medicine. According to the standard, safety needs must be provided for 70%, otherwise a person will experience fear and tension, and all decisions made by a person will be affected by the fear. I.e., if a person understands, that practice with the ambulance brigade won’t support his financial needs, ambulance system may be terminated (according to the reforms, medical specialists in the ambulance vehicles to be changed by paramedics without medical education), or that his educational certificate can’t guarantee him employment in the wished field, on this stage he will leave the medical career, deciding on the both first (pragmatic) and second stages of the needs. Apart from this, military actions on the territory of Ukraine provide for another anxiety reason, conscious or unconscious, leading to the medical career choice for protection of oneself. It is necessary to support the students during their medical training, explain them the standards and laws concerning their employment combined with psychological consultations on the student’s anxiety level, to correct the need for safety, so the profession career choice will be aimed at the patient’s welfare. Health care reforms and social support of medical specialists will provide for the altered career choice motives from this stage, but the state support will fulfill the second stage needs, leading to the more high stage of the career choice motives.
After the basic issues of accommodation, food and permanent job, the next need stage of a person is the need for socialization. This is manifested in “belonging” to the certain medical society or working in a definite group. These needs stipulate for the social motives of choice: interaction with patients; and the social-pragmatic ones: being employed in a prestigious clinic, choosing the profession due to its mass media image, meeting new people, etc. These motives aren’t related to the patient’s welfare, but to the doctor’s self-representation. Poor social acceptance of a person, absence of friends, low social background of the person’s family lead to the shifted motives, in order to “prove”, “step up on the higher social ladder stage”, “realize oneself through the career”, forgetting about the main task of the physician –interaction and treatment of the patient. E.g., a person may be so greatly overwhelmed with a doctor’s role, medical interaction with patients and their relatives and being in the medical society, that he forgets about his main tasks. Another motive of the medical career choice from this stage is substituting one’s personal family with a professional “family” (which occurs in case of problems in family and absent communication with the parents). What Medical School Service can do in the situation is to detect psychological peculiarities of a student and correct them (managing problems of introverted and extroverted students, family relations, etc.). According to the U. Suprun’s, acting as a Minister of Health Care of Ukraine, interview to the Ukrainian medical Bulletin, Ukrainian medical specialists must be respected the same as in the other countries of Europe and world , which will be achieved through reforming the healthcare system. Implementing the reforms will shift the main needs focus onto the upper stage, appropriate not to the pragmatic motives, but social, scientific and practical ones.
The next hierarchy level is the need for fame and recognition. The motives of this stage are the pragmatic, scientific and social, with the specialist striving to be recognized by the others, sometimes neglecting human factor in his interaction with patients. These motives prevail in some cases: with unsatisfied first and second stages of the pyramid, a person covers for the unsatisfied physiological needs and safety needs, trying to get “most from the job”. Or this may be observed in medical dynasties, when a person is used to the positive image of his surname (as the parents are well-recognized specialists), or when the parents since early childhood say to a person that he will be a famous doctor. Unfortunately, the patient’s welfare is neglected here, as this is not the main career and professional activity choice factor. Educational Department of Medical School is responsible for defining students’ needs of this stage and correct motives through active professional practice, participation in the students’ self-organization, etc. During 6 years of medical studies in Ukraine each student has an opportunity to fulfill his primary needs in recognition or alter the career choice motives in respect to the need, otherwise, continuing his practice to be recognized by the others.
The last stage of the Maslow hierarchy is the need for self-actualization, searching for one’s destination, life position, which almost coincides with the altruistic career choice. This may be realized with the previously developed and satisfied lower stages of needs, e.g. when a person is provided with finances, his family receives social support from the state, a person is well respected by the background, etc. As for the functions of the Medical School regarding last stage of the hierarchy, choosing medicine as a career from the last stage of needs is the direct task of Medical School, provided by permanent and continuous follow-up of the student throughout all 6 years of medical studies ( and the subsequent years of internship and specialization). What provides for the career choice from the last needs stage is: educational and professional mobility of the students and medical specialists, high competitiveness of Ukrainian specialists in the world market of medical services, possibility to engage in one’s own private practice (starting with the private family doctor practice and finishing with a private clinic), supported by the state credit lines. And such career choice is the most productive for the physician’s self-actualization, on both personal and professional levels, providing for high professional performance.
So, theoretically the morally mature medical career choice is possible to be made by an adult person, who isn’t undergoing the age crisis, having realized oneself in certain life spheres (which is possible is a person is financially and socially supported by the state), and all this corresponds to the claimed by the state reform trends. As the average age of the medical career choice in Ukraine makes up 17-18 years (after finishing secondary school) and at this age many personal characteristics of the applicants aren’t shaped yet, the career choice can’t be stipulated for the last stages of the hierarchy, but may correspond to the 1st or 2nd stages or be externally forced. So, the educational aims of the Medical schools and Medical Institutions include defining the person’s motives of the career choice, their needs, correcting the motives and satisfying the needs, which is only possible with close interaction of the medical schools and healthcare system. The educational measures will be effective only if the specialist’s needs are supported by the healthcare system, being the main employer in Ukraine. So, the tasks of the state and Ministry of healthcare of Ukraine include total financial, social and spiritual support of the medical specialists, raising the respect for medical profession, and increasing the competitiveness of the Ukrainian specialists on the world labour market, which will provide for higher medical career motivation.
Medical career motivation is represented with a group of motives which caused a person to choose a certain medical specialty and try to obtain the qualification. Personal experience of the authors provided for classifying career choice motives into the internal (conscious career choice) and external ones (both conscious and non-conscious career choice, forced from outside). Analysis of the main medical career choice factors provided for the following classification into pragmatic, social, scientific and self-actualization motives, with the most beneficial for the profession motivation – professional and self-actualization motives, while the pragmatic, social and scientific motives may lead to negative outcomes of treatment, due to the specialist’s concentration on external factors, not the treatment itself. The mature medical career choice motives are possible when the person’s “ego” structure is well shaped, with the “real ego” corresponding to the “ideal ego”, which is almost improbable at 17-18years. According to the A. Maslow hierarchy of needs, the career choice from the first, second and third need stages may correspond to the pragmatic, social and scientific motives, disappointment in the career, low medical performance due to their concentration on finances and other factors, not the patient’s benefit, to add to the professional “burnout”. The career choice from the last need stages correspond to the professional motives and personal self-actualization, but, considering the average age of the applicants and financial status of the doctors in Ukraine nowadays, this is unlikely in case of the primary choice. The task of the Education Service Department of a Medical School is detecting motives of a medical student career choice and its gradual correction during the students’ training in a medical school. At the same time, regarding the basic directions of the Healthcare reforming in Ukraine, future possible changes in medical labour financing, providing social protection by the state and state support of the medical career will provide for correction of the career choice, with prevailing social and professional motives instead of the pragmatic ones.
Motives of the medical career choice are grouped into the pragmatic, social, scientific and professional. The task of the Educational Department of Medical Schools is to detect and correct the prevailing motive groups. The changes of the motives are possible under the performed reforms of Healthcare, which will raise the doctor’s role and protect medical specialists by the State guarantees.
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