- College of Medicine, King Saud Bin Abdulaziz University for Health Science, Jeddah, Saudi Arabia.
- Department of Surgery, Section of Neurosurgery, King Abdulaziz Medical City National Guard Health Affairs, Jeddah, Saudi Arabia.
Khalid Talal Alghamdi, College of Medicine, King Saud Bin Abdulaziz University for Health Science, Jeddah, Saudi Arabia.
DOI:10.25259/SNI_226_2022Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Khalid Talal Alghamdi1, Ahmad Abdullah Alamoudi1, Mohammed Abdullah Bomonther1, Haitham Ali Alasmari1, Kenan Hatem Nejaim1, Afnan Mahfouz Samman2, Moajeb Turki Alzahrani2, Abdulhadi Y. Algahtani2. Factors affecting the choice of becoming a neurosurgeon in the western region of Saudi Arabia. 16-Sep-2022;13:424
How to cite this URL: Khalid Talal Alghamdi1, Ahmad Abdullah Alamoudi1, Mohammed Abdullah Bomonther1, Haitham Ali Alasmari1, Kenan Hatem Nejaim1, Afnan Mahfouz Samman2, Moajeb Turki Alzahrani2, Abdulhadi Y. Algahtani2. Factors affecting the choice of becoming a neurosurgeon in the western region of Saudi Arabia. 16-Sep-2022;13:424. Available from: https://surgicalneurologyint.com/surgicalint-articles/11866/
Background: The preference of medical specialty for students can start even before enrollment into medical school, or as late as following their graduation. During their senior years, students often get a prospective on the working environment and the difficulties faced in the field. This, along with other factors, can strongly alter their career choice. This study aims to explore the degree of interest in neurosurgical specialty among medical students and the factors influencing their choice of becoming a neurosurgeon in the western region of Saudi Arabia.
Methods: This is a cross-sectional study which was done across three universities of the western region of Saudi Arabia including King Saud bin Abdulaziz University for Health Sciences, Umm Al Qura University, and King Abdulaziz University.
Results: A sample of 1023 students from the second medical year up to the internship was conducted, and out of them, 585 (57.2%) were males and 438 (42.8%) were females. Three hundred and fifty-nine (35.1%) of the students were interested in neurosurgery, while 664 (64.9%) were not. The data show that females have more interest (40.8% of females) compared to males (35.1% of males). Furthermore, there was a general trend toward a decrease in the interest in neurosurgery with time. The impact on patients “rewarding feeling” was the most reported attraction to the specialty, followed by income. Stress was the most reported deterring factor among students. Neurosurgery is one of the most challenging specialties, yet it is still considered one of the most competitive ones.
Conclusion: Many factors have been found to influence medical students’ choices to apply for neurosurgical training as we described. Interestingly, we noted higher interest among female students, and among college freshmen compared to their counterparts. Further studies should be conducted on a larger scale to analyze these findings.
Keywords: Neurosurgery, Neurosurgery’s attractive, Neurosurgery’s students, Students interest
The preference of medical specialty for students can start even before enrollment into medical school, or as late as following their graduation. During their senior years, students often get a prospective on the working environment and the difficulties faced in the field. This along with other factors, can strongly alter their career choice. By clinical years, medical students have a better idea about the working environment, nature of work, and difficulties faced in those fields. In neurosurgery, its interesting that although it is one of the most competitive specialties in medicine, many students avoid and keep away from it. [
Choosing a specialty is considered one of the most stressful and critical choices in the life of medical students, for students are faced with numerous possibilities with little exposure to them.[
Previous efforts on the subject are scarce; in addition, we could not find any study that covered the whole kingdom, and no study asked about both positives and negatives. In our study, we want to get a comprehensive perspective on medical students’ perception of neurosurgery as a career path and the reasons that make them choose or avoid it. We hope that we can also get a geographical representation of the results; thus, we may see some correlation between students’ regions and their beliefs and feelings toward neurosurgery.
This cross-sectional study was done across three universities of the western region of Saudi Arabia including King Saud bin Abdulaziz University for Health Sciences, Umm Al Qura University, and King Abdulaziz University. A sample of 1023 students was conducted using Google sheets and was randomly sent by two assigned students from each university to students from the second medical year up to internship equally both male and female across the three universities. We excluded nonmedical students and 1st-year medical students; also an incomplete questionnaire was excluded from the study. A pilot study was applied before the start of the study on 35 students (they were not included in the study sample) to check for readability, comprehension, question design, and length of the questionnaire. The questionnaire consisted of three main sections. The first part is regarding demographic characteristics such as age, gender, medical year, and GPA. Second part regarding the knowledge of neurosurgery as a career and what is required of the student to be accepted in the residency program and to see the interest of the participant toward the specialty whether he or she attended a course, conference, or project related to neurosurgery. The last part is regarding what makes them attracted or deterred in neurosurgery specialty. Many factors were asked to see what attracts the students toward the specialty such as competitiveness, research opportunities, technology advance in the field, and prestige of the specialty. Factors that make students deter from the specialty also were asked such as long working hours, poor social life, and few training centers.
The study was approved by the Institutional Review Board (IRB) of the hospital with the number (NRJ21J/213/09). Written consent was obtained from each participant and a summary of the research was discussed before distribution of the questionnaire. Coding sheets were used to protect the names of the students. Data were stored in a workplace PC protected by a password.
In this study, we received 1023 valid responses from medical students studying in King Saud bin Abdulaziz University for Health Sciences, Umm Al Qura University, and King Abdulaziz University, which are the biggest universities in the western region of Saudi Arabia. Out of these medical students, 585 (57.2%) were males and 438 (42.8%) were females. Regarding their interest in neurosurgery, 359 (35.1%) of them were interested, while 664 (64.9%) were not. Using a Chi-square test of independence, we tested the null hypothesis that males and females are not equally interested in neurosurgery with high significance (P < 0.001). The result shows that females have more interest (40.8%) compared to males (30.7%). The respondents’ education level in the university starting with 2nd-year 237 (23.2%), 3rd-year 174 (17%), 4th-year 96 (9.38%), 5th-year 260 (25.4%), 6th-year 211 (20.6%), and internship 45 (4.4%). In addition to that, education level was significantly affecting the interest in neurosurgery, in which there was a decreased level of interest with an increase in the education level (P < 0.001). In the 2nd year, 55.70% were interested while in the internship only (11.11%) were interested in neurosurgery. Students who are fully understanding the specialty by attending conferences 69 (6.7%) or had done projects 67 (6.5%) are interested in comparison to those who did not attend a conference or have a project in the field (P < 0.001) [
Even though more students (64.9%) were not interested in neurosurgery, there were multiple attractors that have been listed from all students regardless of their interest. The top 3 attracting factors were: positive impact on patients “rewarding” 576 (56.3%), income 557 (54.4%), and interest in neuroscience 387 (37.8%). However, interest in neuroscience was significantly higher in students who were interested (77%) in comparison to those who were not (17%). Regarding the income, the students (56%) who are not interested consider it more attractive than those (51%) who are, and the females appear less attracted by the income in comparison to males (P < 0.001). Other factors including, competitive field, research opportunities, innovation/ technology, Impact on patients, interest in neuroscience, variety of cases, and having role-model were reported as attractive factors in students who were interested more than others (P < 0.001). In contrast, academic field preference, the prestige associated with the specialty, geographic location of the training center, number of on-calls, and successful placement of recent graduates into desired subspecialty fellowship were reported comparably in both interested and not interested students [
Multiple deterring factors have been reported from the students. The most-reported three deterring factors were as follow: (i) stress (66.1%), (ii), difficulty/neurophobia (55%), (iii) and the specialty risk (54.8%). The long training period was considered as deterring factor for interested students (43%) lower than those who are not interested (54%) (P < 0.001). Similarly, practical aspect, long surgeries were also reported more in not interested students (52%) in comparison to interested students (45%) (P > 0.001). However, many deterring factors are surprisingly comparable between both groups of students including competitive field, risk, difficulty/neurophobia, income, lifestyle, work-life balance, stress, gender diversity, complex patients, few trainings centers, and limited job opportunities [
The choice of a future career in medical practice can be a daunting experience for medical students and interns, as there are many factors to consider. It is a complex decision, strongly influenced by personal preferences and contact with the work environment. Medical students frequently tend to give consideration to a program’s academic accomplishments, reputation, patient volume, and diversity, flexible working hours, the influence of consultants/mentors, to a lesser extent, and salary and research opportunities.[
Neurosurgery enjoys a distinct position among the medical specialties as a constantly evolving field with rapid innovations in surgical operations and management. Approximately 5 million essential neurosurgical cases are unmet in low- and middle-income countries every year. On a local level, a report was published in 2019, estimating the density of neurosurgeons in the Kingdom of Saudi Arabia to be approximately 1/250,000 population.[
It is worth mentioning that an exception to the current literature has been reported by two studies from Ireland and Oman, the percentages of medical student who considered neurosurgery to be their ultimate career in those reports were 78% and 72 %, respectively.[
Medical students’ exposure to any clinical specialty is, indeed, of an important influential power in students career choice. Specifically, exposure to the work culture typical of the specialty, as well as the type of cases and the special challenges of each specialty.[
The interest in neurosurgery can be traced to numerous factors. Studies comparing students who desire a career in surgery suggest that predictors of surgical interest include enthusiasm for the procedures and impacts, desire for intellectual challenge, positive interactions with surgeons, perceptions of prestige, and minimal discouragement by lifestyle concerns and work hours.[
It is difficult, on the other hand, to know with certainty the reasons for the relatively low neurosurgical residency applications, which appear to be multifactorial.[
Neurological surgery being a high-risk specialty, and a likely target for malpractice claims, makes it even less appealing specialty. Studies show that approximately 60% of neurosurgeons consider medical malpractice premiums an extreme burden, causing many working neurosurgeons to eliminate high-risk procedures from their practices.[
Neurophobia, a phenomenon described by Ralph Jozefowicz, defined by fear of the basic and clinical neuroscience and is thought to be due to the students’ inability to apply their knowledge of basic sciences to clinical situations.[
Several additional factors such as the lack of controllable lifestyle, length of residency program, job opportunities, and the long duration of training years in neurosurgery residency program have also been linked to this deviation away from the specialty.[
In the reported literature, work and life balance alone play an important influencing factor in career choice for medical students. Numerous studies have demonstrated an increased desire for work-life balance among medical students and a trend toward greater interest in more lifestyle-friendly specialties including radiology, ophthalmology, anesthesiology, and dermatology.[
It is fair to say that individuals who value a balanced lifestyle, time-appropriate residency, and a predictable work schedule are not good candidates for a demanding specialty such as neurosurgery. Nonetheless, lifestyle plays a major role in the career decisions of women in particular, as societal norms not only grant women a larger proportion of caregiving duties but also hold women to a higher standard within these roles.[
In a report published 2018, women represented only 12% of neurosurgeons in the United States and Canada. A slight but steady increase has been noted in women pursuing neurosurgical residency in the United States from 10% in the 1990s 7–17.5% in 2018.[
It is well established that an earlier organized involvement in medical student education can result in an improved understanding of the specialty challenges among students, resulting in a greater number of well-qualified residency applicants enrolling into neurosurgery. That mentioned, such exposure may aid in waving the frequently overestimated negative assumptions on neurosurgical specialty, especially in institutes which were primary care and nonsurgical specialties are being emphasized on during the medical students’ early clinical years.[
Different previous studies highlighted factors that may increase the interest of medical students toward the surgical specialties including neurosurgery. Resident involvement in medical student education, faculty-student interaction, the mentorship programs, the inclusion of didactic lectures by clinical surgeons, and early exposure to surgical clerkships was all important influential factors.[
As a technology-intensive surgical discipline, it is essential that medical students with an interest in pursuing neurosurgery receive early, regular exposure to clinical vignettes, and neuroanatomy. In light of the demanding career and lifestyle of neurosurgeons, it is important to provide a basis, on which medical students make an informed decision for themselves rather than on the highly competitive nature of the specialty. This, however, is particularly challenging as the level of knowledge and skills in neurosurgery field often makes it difficult to get a closer hands-on experience by medical students.[
The medical student interest level in neurosurgery, a competitive and highly demanding field, in the western region of Saudi Arabia compares to international statistics. Interestingly, we found a general trend toward reduced interest in neurosurgery among senior medical students when compared to freshmen. We also found higher interest among female students. Further studies done on a larger scale should be done to analyze these findings.
Institutional Review Board (IRB) permission obtained for the study.
There are no conflicts of interest.
1. Agarwal N, Norrmén-Smith IO, Tomei KL, Prestigiacomo CJ, Gandhi CD. Improving medical student recruitment into neurological surgery: A single institution’s experience. World Neurosurg. 2013. 80: 745-50
2. Akhigbe T, Sattar M. Attitudes and perceptions of medical students toward neurosurgery. World Neurosurg. 2014. 81: 226-8
3. Algahtani AY, Jamjoom AB, Al Rabie A, Jamjoom ZA. Attrition and success rates in the Saudi board of neurosurgery: Analysis of 115 consecutive residents who started training from 2001 to 2014. Cureus. 2021. 13: e18235
4. Alhejaili MA, Alrashedi MH, Alatawi AN, Alenezi MF, Albalawi KA, Albalawi MF. Assessment of attitude and perception toward neurology and neurosurgery specialties among medical students and interns attending college of medicine at university of Tabuk in Tabuk City, Saudi Arabia. Egypt J Hosp Med. 2018. 71: 2960-2
5. Ali AS, Tariq AS. Attitudes and perceptions of Omani medical students and interns toward neurosurgery: A cross-sectional study. Am J Clin Neurol Neurosurg. 2018. p. 35-11
6. Alqahtani NG, Alhumaid T, Almazyad K, Almesned I, Almusalam A, Agha S. Attitudes and perceptions of medical students toward neurosurgery as a career, Riyadh, Saudi Arabia. Egypt J Hosp Med. 2018. p. 5935-9
7. Alshahrani M, Dhafery B, Al Mulhim M, Alkhadra F, Al Bagshi D, Bukhamsin N. Factors influencing Saudi medical students and interns’ choice of future specialty: A self-administered questionnaire. Adv Med Educ Pract. 2014. 5: 397-402
8. Chung RS. How much time do surgical residents need to learn operative surgery?. Am J Surg. 2005. 190: 351-3
9. Dada OE, Ooi SZ, Bukenya GW, Kenfack YJ, Le C, Ohonba E. Evaluating the impact of neurosurgical rotation experience in Africa on the interest and perception of medical students towards a career in neurosurgery: A continental, multi-centre, cross-sectional study. Front Surg. 2022. 9: 766325
10. Dixon A, Silva NA, Sotayo A, Mazzola CA. Female medical student retention in neurosurgery: A multifaceted approach. World Neurosurg. 2019. 122: 245-51
11. Harris MG, Gavel PH, Young JR. Factors influencing the choice of specialty of Australian medical graduates. Med J Aust. 2005. 183: 295-300
12. Iorio-Morin C, Ahmed SU, Bigder M, Dakson A, Elliott C, Guha D. Demographics, interests, and quality of life of Canadian neurosurgery residents. Can J Neurol Sci. 2018. 45: 214-20
13. Jozefowicz R. Neurophobia: The fear of neurology among medical students. Arch Neurol. 1994. 51: 328-9
14. Klimo P, DeCuypere M, Ragel BT, McCartney S, Couldwell WT, Boop FA. Career satisfaction and burnout among U.S. Neurosurgeons: A feasibility and pilot study. World Neurosurg. 2013. 80: e59-68
15. Marasa LH, Pittman TA. Factors neurosurgery candidates use when choosing a residency program. J Neurosurg. 2014. 120: 167-72
16. McNutt SE, Goss ML, Hallan DR, Bible JE. Factors in residency decision making for female neurosurgery applicants. World Neurosurg. 2020. 140: e105-11
17. Miller G, Bamboat ZM, Allen F, Biernacki P, Hopkins MA, Gouge TH. Impact of mandatory resident work hour limitations on medical student’s interest in surgery. J Am Coll Surg. 2004. 199: 615-9
18. Sansosti AA, Jacobs RC, Safonova A, Jani RH, Schumann J, Friedlander RM. Impact of a hands-on pre-clinical neurosurgery elective course on second-year medical student interest and attitudes. J Med Educ Curric Dev. 2020. 7: 2382120520964852
19. Wilson M, Pugh J. Increasing the appeal of neurosurgery to qualified medical students in Canada. Can J Neurol Sci. 2012. 39: 667-9
20. Zaed I, Jaaiddane Y, Chibbaro S, Tinterri B. Burnout among neurosurgeons and residents in neurosurgery: A systematic review and meta-analysis of the literature. World Neurosurg. 2020. 143: e529-34
21. Zuccato JA, Kulkarni AV. The impact of early medical school surgical exposure on interest in neurosurgery. Can J Neurol Sci. 2016. 43: 410-6