Why Ophthalmology: A Cross-Sectional Study of the Motivating Factors Influencing the Choice of Ophthalmology as a Career Among Medical Students in Saudi Arabia

Background: Choosing a future career is a frightening and anxious decision for medical students; understanding any factor that influences making such a decision will be helpful for the medical students to reach it with satisfaction. Aim: The aim of this study was to determine the factors that would influence the choice of ophthalmology as a future career among medical students in multi-medical colleges in Saudi Arabia. Methods: This cross-sectional study was conducted for pre-clinical and clinical medical students from February 2021 to May 2021 in multi-medical colleges in Saudi Arabia. The questionnaire used was from previously published research, and it was modified and validated by a board-certified ophthalmologist. Results: A total of 6.1% of all medical students considered ophthalmology as their first choice as a future career; factors that influenced choosing ophthalmology were personal interest, satisfaction from improving patient quality of vision, good patient prognosis, and the appeal of being an ophthalmologist; these factors showed a highly significant difference in comparison to other factors. Conclusion: Several factors are explored for choosing ophthalmology as a future specialty; understanding these factors can help medical students determine their choices for a future career.


Introduction
One of the most important decisions a medical student has to make is choosing a future specialty that perfectly matches his/her abilities and preferences. Medical students usually face this dilemma during or before their internship [1]. Multiple factors would influence the choice of medical specialties, which can be classified into two main domains: (1) personal-related such as gender, type of personality, and preferences and (2) work-related such as the environment of the specialty, specialty income, and affection on lifestyle and the workload [2][3][4][5][6]. In the United States, the most influencing factor considered when choosing a medical specialty as a future career was the perception of the others toward the job, followed by having more days off work [7].
According to a previous study done in Jordan, the most significant factors influencing the preference of future specialty among medical students were "intellectual content of the specialty," "individual's competencies," and "reputation of the specialty" [3]. Locally, a study done in Al-Madinah Al-Munawwarah concluded that the most important predictors for the selection of medical career were personality preferences and specialty characters [8]. Another study done in Riyadh revealed that the choice of the future medical specialty depends mainly on "anticipated income," "specialty interest," and "specialty flexibility" [9].
Ophthalmology is an interesting specialty that gives the opportunity of using surgical skills and the knowledge to diagnose and treat with medicine. The choice of the Saudi residents who were matched into the ophthalmology residency program was made depending mainly on the ability to combine surgery and medicine [10]. In Saudi Arabia, ophthalmology is considered a highly competitive specialty due to the limited number of seats. Therefore, knowing the factors that push medical students toward ophthalmology is critical to understanding the challenges that prevent graduates from choosing this specialty and thus directing the efforts to solve these challenges.
Looking at the literature locally, a study on medical students at King Saud bin Abdulaziz University for Health Sciences in Riyadh revealed that the most important factors for the students to consider ophthalmology as a future career were high income, private sector opportunities, and part-time opportunities, respectively [11]. Although there is a study done before exploring why medical students prefer ophthalmology as a future career in one university, there are rare studies on locally addressing this issue across all regions in Saudi Arabia at many universities. Therefore, the authors conducted this study to determine factors that would influence the choice of ophthalmology as a future career among medical students at different universities in Saudi Arabia. This study might lead to a better understanding of why ophthalmology is a highly competitive field among graduated medical students. In addition, it is interesting to consider which factors contribute the most to choosing ophthalmology as a future specialty during college years among medical graduates.

Materials And Methods
A cross-sectional study was conducted in Saudi Arabia between February 2021 to May 2021; a structured and self-administrated electronic questionnaire was distributed among medical students of multiple health faculties in Saudi Arabia, and data were collected using an online platform. Arabic version of the questionnaire that was used in previously published research was used; it was modified and validated by a board-certified ophthalmologist [11]. Male and female medical students in both pre-clinical and clinical phases, with the majority of participants in the clinical phase, were included in the study. The exclusion criteria in our study comprised of those who did not accept the consent or graduated medical students and interns.
The questionnaire was divided into three sections: The first section was about the demographic features of the study subjects. While the second section mainly focused on influential factors that led to choosing or rejecting ophthalmology as a future specialty. The third section was concentrated on academic performance and opportunities.
The total number of participants was 465, with more than 65% of studied subjects who were active in the clinical phase in the period between February 2021 and May 2021.
In our study, we used Statistical Package for Social Sciences (SPSS) program (version 27.0, IBM corp. Armonk, NY, USA) for data analysis and management. Results were expressed as categorical data using frequencies and percentages for each variable. Chi-square was used to compare these data. All tests were two-sided. The significance level was expressed as highly significant, significant, and non-significant according to the P-value, P < 0.001, P < 0.05, P > 0.05, respectively.
The agreement of individuals to fill the questionnaire was considered as a consent of participation. The data are highly confidential, and it is only accessible by the primary investigator and co-investigators. All of them participated voluntarily, and they were able to withdraw from the study. In addition, the data did not include any identification. The ethical approval for this study was received from the Scientific Research Ethics Committee of College of Medicine at Taibah University, Al-Madinah Al-Munawwarah, Saudi Arabia (STU-20-023). Table 1 shows some basic information about the sample population, which included the total number of 865 participants that was almost divided by half between the two genders (413 males and 452 females   Figure 2 shows the factors that attracted our participants toward ophthalmology and other factors that pushed them away, respectively.    Upon asking participants if they have ever been exposed to ophthalmology, 66.2% were exposed in different ways and times. On the other hand, 33.6% were never exposed to ophthalmology ( Table 3).   Table 4 includes some questions that were answered by yes or no by our participants. The first question was "Are you interested in ophthalmology as a future career?": 44.4% of participants answered "yes," and 55.3% were not interested. Another question was "Is ophthalmology on top of your list for a future career?": 28% of participants answered "yes" to this question, while 71.7% said "no." The next question was "Have you ever been exposed to an ophthalmic procedure?": 28.5% said "yes," while 71.2% answered "no." The last question was "Have you ever observed an ophthalmic procedure?": 32.4% answered "yes," while 67.3% said "no."

Questions Frequency Percent (%) P-value
Have you ever been exposed to an ophthalmic procedure?  Table 5 includes the questions to assess the participants' interest in different ophthalmology activities. Upon asking them if they have ever attended an ophthalmology conference, only 7.6% answered "yes," whereas 30.6% did not attend but were interested in attending in the future. On the other hand, 46.8% and 14.6% answered "no" and "not my priority," respectively. When asking participants, "Have you ever participated in an ophthalmology research?", 7.9% said "yes," and 17.2% were not involved in research at the moment but showed interest. However, 66.2% did not participate, and 8.3% were never interested in participating. Finally, when they were asked, "Have you ever participated in any community service activity related to ophthalmology?", 10% said they have participated in at least one community service, whereas 15.2% did not participate but showed interest. On the other hand, 68.1% had no experience, and 6.3% had no plans to participate.

Questions Frequency Percent (%)
Have you ever attended a conference in ophthalmology?

Discussion
Choosing a future career has been always a dilemma for medical students. The process consumes a long time and is affected by many influences. Students need to review what are the advantages and disadvantages of each medical field, explore the options for their professional and academic advancement, cope with the specialty with their lifestyle preferences, try their favorable specialty in their elective courses, and consider the income and benefit. However, certain specialties have developed a reputation for being a high demand over time; one of these top specialties is ophthalmology, which has become harder to get in because of the limited seats in the training facilities and the competitiveness of this specialty [2,3,12,13].
The purpose of this research was to investigate the causes and factors that influence medical students on their decision to choose ophthalmology as a future career.
The study was done on 865 medical students, which showed that general surgery and internal medicine were the highest preferred specialties (10.5%) followed by neurology (6.2%) and ophthalmology (6.1%). However, most students (31.1%) have not chosen their preferred specialty yet. These findings match what was previously published in King Saud bin Abdulaziz University for Health Sciences, except that ophthalmology was the second most preferable specialty and pediatric was the third [11].
Surprisingly, personal interest was the highest influencing factor in choosing ophthalmology as a future career, whereas 96% of the study participants chose it as their most important determining factor. This came opposing to two research published in King Saud bin Abdulaziz University for Health Sciences and Alfaisal University, which showed that high income was the most significant factor influencing the choice of ophthalmology as a future career [9,11].
Vision is considered one of the most important senses in human lives, so losing this sense could present a significant effect on patients. Therefore, 91% of participants chose personal satisfaction from helping people to see better as their second most important factor in choosing ophthalmology. Notably, good patient prognosis came in third with 79% giving it credit that goes together with personal satisfaction from helping people to see better. Also, influencing patients' lives was one of the most significant factors, with as much as 79% for choosing ophthalmology as a future career. This aspect has been addressed in King Saud bin Abdulaziz University for Health Sciences, which affected the choice of 28% of participants. Patino et al. showed that vision can cause clinically substantial changes in vision-specific health-related standard of living, implying that the ophthalmologist can help patients' lives indirectly [14].
Students have acknowledged the value of lifestyle over time and have made it an intrinsic element of their decision-making factors [4,6,7]. Ophthalmology is one of the recognized specialties that have a satisfying lifestyle that attracts medical students toward it. A satisfying lifestyle is mostly recognized as having sufficient free time off work, which gives the ability to have more time spent with family members, friends, or hobbies. Our study showed that ophthalmology drew 77% of participants because of the satisfying lifestyle and flexible work schedule. Ophthalmology drew 74% of students because of the little contact with emergencies and small range of medical problems.
Comparing this study with a study done in King Saud bin Abdulaziz University for Health Sciences showed that a lesser degree of stress attracted 24% of their participants toward ophthalmology [11]. Our study showed that 75% were drawn to ophthalmology due to a great selling feature.
The variables that drive people away from a highly competitive specialty like ophthalmology are a fascinating specialty to investigate; we discovered that ophthalmology was avoided by 30% of students due to the chance of having unsatisfied patients and 28% due to the difficulty of getting into the ophthalmology residency program.
Furthermore, the reliance of ophthalmology on clinical diagnostic skills, the appeal of being an ophthalmologist, and the opportunity to perform procedures were among the aspects that drew our participants in. All of these aspects are supported by independent studies in which students who chose surgical specialties, in general, justified their decision based on the capacity to execute practical procedures and operations, scientific knowledge application, and the prestige of surgery inside the medical field [15,16].
At last, a long-lasting dilemma for medical students remains to be choosing their future career. This may lead to poor decision-making regarding this dilemma. Upon reviewing different studies regarding this issue, we found that most studies do not accommodate a specific specialty, but they approach it in a general manner. Therefore, in our study, we chose to focus on choosing ophthalmology per se as a future career among medical students in different medical schools across all regions of Saudi Arabia.

Conclusions
There are many factors that would influence or hold medical students from pursuing ophthalmology as a future career, which would be made clearer with this type of study. Our study is focused on ophthalmology, the factors influencing the choice of ophthalmology, and why it is a competitive field in Saudi Arabia. This research provides a proper insight into what drives students in Saudi Arabia toward and against ophthalmology as future career.