Our survey has demonstrated that applicants highly value "variety of clinical experiences" but nonetheless often distinguish between top programs based on social/geographic factors. There were no major differences based on gender, but there were several differences between family medicine and specialty applicant priorities. Most of these results are novel in this area of research as well as in this population and shed some light on CaRMS applicant decision making.
From the results of the Maxdiff section (Table 2), the top three factors overall were the variety of clinical experiences, resident morale, and distance to relatives. Conversely, most lifestyle factors such as financial incentives, work schedule, and parental leave were not considered important. It would seem that applicants favour program quality and social factors over lifestyle factors. These general trends are consistent with other studies [3, 6, 10, 12].
There were very few differences between male and female applicants, except that males tended to put greater emphasis on academic reputation and research (Table 3). While females placed more emphasis on parental leave attitudes, both groups ranked that factor last. Thus, overall, male and female medical students have similar priorities when selecting a residency program, which is consistent with other studies [2, 3].
Family medicine and specialty applicants do display several statistically significant differences (Table 3). Family physicians certainly require a broad range of knowledge and thus it is not surprising that family medicine applicants put greater emphasis on the variety of clinical experiences. The greater emphasis by specialty applicants on resident morale may reflect the fact that they spend considerably more time on-service and usually have longer residency programs. There is a disproportionate ratio of specialists to family physicians with appointments at academic centers as staff physicians . Our results were consistent with this work environment preference, as specialty residents on average placed greater emphasis on academic factors such as quality of faculty, research opportunities and academic reputation. Specialty applicants also gave the interview experience a lower priority. It is plausible that applicants to more competitive specialties may have felt content to get into their chosen specialty regardless of location or program; thus leading to less emphasis on the interview experience.
Table 4 displays respondent selections of the principal reason why they didn't choose their second ranked program, also known as the distinguishing factor. Given that most people match to their first choice program, the choice to rank a program second causes the greatest statistical drop in match probability. It is interesting to note that the frequency of the distinguishing factors has a different order than their overall priorities. For instance, while variety of clinical experiences was ranked first overall, it was the distinguishing factor only 9.33% of the time. Most applicants chose factors that were entirely outside the control of the program, such as social and geographical factors. This discrepancy suggests that while respondents highly valued factors such as variety of experiences and positive resident morale, many programs fulfilled their expectations in these areas. Thus, when it came down to a decision between their top choices, most chose the program that better suited their social and geographical situations. It may seem discouraging to program directors that they appear to have limited control over this final decision. Nonetheless, the high overall values placed on many controllable factors indicate that programs need to meet those criteria to be seriously considered. Some studies on resident burnout, work hours, and morale have found positive benefits from options such as hiring physician assistants and the limitation of resident work hours [26, 27]. In Canada, not all provincial regulatory bodies have set maximum duty hours and programs do have some influence in the work schedules and hours of their residents. Clinical variety is a more difficult factor to modify, as some centers are simply limited by the patient volumes they see. However, innovations such as use of simulations and the creation of dedicated "medical procedure rotations", have been demonstrated to increase resident confidence in scenarios they otherwise seldom encounter [28, 29].
There are limitations to our study that affect the way the results may be interpreted. Our sample was drawn from the most populous province in Canada; thus geographic factors may become more of an issue when considering a national sample. Quantitative and qualitative differences in the application process, post-graduate training programs, and the health care system make international comparisons difficult. For instance, students in the United States would have a greater number of residency programs to choose from, including programs outside of their national matching service. This can certainly affect the factors that influence their decisions. Our response rate of 41% is another limitation, but this is comparable to other published student surveys on this topic of similar scale [2–5, 9–11]. Also, the demographic similarity of our sample to that of the CaRMS applicant pool indicates that the survey respondents were representative of the population of interest (Table 1). Lastly, our survey focused on 13 factors, while certainly other issues may influence applicants. However, as previously mentioned we chose a range of factors found to be of potential importance by previous literature and excluded those previously found to be of very low priority. We aimed to create a comprehensive questionnaire while at the same time avoiding low yield questions that may increase participant fatigue and drop-out.
The strengths of our study include its novel methodology as well as several unique findings. Maxdiff methodology leads to a standardized numerical scale with results that disperse across the full spectrum of the scale. This eliminates the systematic level and dispersion biases that affect the Likert style rating scales used in almost all other studies . Maxdiff also forces respondents to make decisions between a set of factors, thus providing better differentiation between factors when compared to rating scales [10, 14]. To our knowledge, this is the only survey to date on this topic which asks how applicants distinguish between their top programs. Moreover, this study provides unique insights into the different values of family medicine and specialty applicants.