How and why do medical students choose the specialty of Infectious and Tropical Diseases? A national cross-sectional study

Background Infectious diseases (ID) physicians are more needed than ever to tackle existing and emerging global threats. However, in the US approximately one quarter of the ID fellowship programs are unfilled every year. The creation of the ID residency in 2017 in France offers the opportunity to know how and why the specialty is chosen by medical students. Methods We first analyzed the choice of specialty of all French medical students in 2017 and 2018 according to their rank at the national exam that ends medical studies. A web questionnaire was then sent on January 2019 to all ID residents in France (n=100) to assess their professional project and the factors influencing their choice of specialty. Results We analyzed the choice of 17,087 medical students. ID was the first-chosen specialty with a median national rank of 526/8539, followed by plastic surgery and ophthalmology. The questionnaire was completed by 90% of the French ID residents. The most encouraging factors to choose ID were the multi-system approach of the specialty, the importance of diagnostic medicine and having done an internship in ID during medical school. The most dissuading factors were the work-life balance, the workload and the salary. express working and

Only 3 medical specialties among the 68 specialties evaluated had a higher number of unfilled positions than ID (geriatric medicine, nephrology and ultrasound medicine).(6) Canada has also described difficulties in finding ID residents and fellows.(7) , (8) Studies in the USA have identified dissuading factors from choosing the ID specialty and potential targets for action, such as a low salary or an unsatisfying work-life balance. However, we do not know if these factors are similar across countries. (9,10) In 2017, France undertook a reform of the residency that created new qualifying specialties such as infectious and tropical diseases. From 2017 onward, a fixed number of positions in ID are opened every year in each city of France. At the end of medical school, French students take a national ranking exam and the medical and surgical specialties are chosen according to their rank: from the first ranked to the last, each medical student chooses a city and a specialty. Before this reform, ID was a subspecialty that could only be chosen after completing another residency (usually internal medicine or family medicine).
The creation of the ID residency represents an interesting opportunity to know how the specialty is chosen by French medical students and to explore their expectations, motivations and reservations when choosing ID.

Choice of ID specialty
The national ranking, the choice of city and the choice of specialty of each medical student is published every year in the French ministry of Health official journal. (11) We used the publication of the medical students' choice of specialty in 2017 and 2018 to analyze the median rank in each specialty. We included every medical student entering residency in 2017 and 2018 in France.

Questionnaire development and population
A web questionnaire to explore the factors influencing the choice of ID residency was developed using SurveyMonkey® by a working group of 15 ID specialists. The working group included one professor, two hospital practitioners, six fellows and six residents. The questionnaire took into account previous questionnaires on the topic(9,10) and was adapted for the French curriculum. The questionnaire was reviewed and tested by two first-year ID residents to check for simplicity and comprehensiveness and was modified according to comments. The survey was anonymous and received approval from the French data protection authority (CNIL, registration number: 2213137).
The questionnaire was split into three parts (supplementary material). The first part collected information about demographics, medical school curriculum, professional project and expectations of ID residency. The second part focused on the motivations and reservations of ID residents when choosing the specialty. To explore this, we chose 36 factors relative to ID ( Figure 2) and asked the participants to use a slider to decide if it discouraged them or encouraged them to choose ID.
The following legend was shown at the top of the slider for each factor: "strongly discouraged me to choose ID" at the far left, "did not influence my choice" in the middle and "strongly encouraged me to choose ID" at the far right. The slider position was then linked to a number between 0 ("strongly discouraged me to choose ID") and 10 ("strongly encouraged me to choose ID") to do the statistics and

Statistical analysis
Data from the survey were imported into R software (version 3.2.4). Numerical data are presented as absolute numbers, proportion, median ± interquartile range (IQR).
To represent the choice of medical and surgical specialties by the medical students, we drew a ridgeline plot which represents a superposition of density curves by choice of specialty according to the ranking of medical students in 2017 and 2018.
We used the R packages "ggridges" and "ggplot2" for the ridgeline plot.

Choice of ID specialty
We analyzed the choice of medical or surgical specialty of 17,078 medical students: 8372 who took the French national ranking exam in 2017 and 8706 in 2018 (Table   1)

Survey participants
The survey was sent by email to all the ID residents in France (n = 100). The response rate to the survey was 90%: 46 women and 44 men, median age of 25 years (IQR, 24-25.25) completed the survey (Table 2). Students from every residency program of ID in France participated (supplementary material).

Project and expectations
Seventy-one participants (79%) did an internship in an ID department during medical school and 27 participants (30%) had a working experience abroad in a hospital or a non-governmental organization (NGO) during medical school (Table 2).
Thirty-nine participants (43%) decided to choose the ID specialty during medical

Measures to increase the attractiveness of ID
Improving the quality of life of ID physicians was judged very likely or likely to increase the attractiveness of the specialty by 86% of participants, increasing the salary by 81%, developing the international network by 81%, developing private practice in ID by 78%, decreasing the workload by 75%, increasing the availability of hospital non-academic positions by 71% and increasing the availability of academic positions by 71% (Figure 3). Overall, the 12 measures evaluated were judged very likely or likely to increase the attractiveness of the ID specialty by more than half the participants. discussion This study brings interesting results for the choice of the ID specialty at a national level. The two most motivating factors to choose ID were the multi-system approach of the specialty and its diagnostic activity. These results indicate that ID should keep its strong internal medicine roots with a diversity of activities instead of moving toward overspecialization. The quality of the teaching of ID as well as an internship in ID during medical school encouraged the choice of the specialty. These results are similar to other studies in which ID education and early ID rotation were associated with a career interest in ID. (12,13) The international and global reach of ID specialty have been consistently cited as motivating and more than 80% of the participants thought that the international network should be strengthened.
International collaborations are important assets of the specialty and we should increase our effort to build bridges between national and continental societies of ID.
The decision to include a mandatory semester abroad in the French ID residency is a step toward this aim and was deemed motivating by most of the participants.
The fact that ID is currently the most popular specialty in France differs from what happens in other countries such as the USA.(6) Yet the dissuading factors that we identified in our study are really close to the ones identified in previous studies: concern about salary, the work-life balance and limited job availability.(9) While trainees in the USA are probably not more driven by money than in France, the impact of salary on the choice of specialty is probably lower in France than in the USA. Indeed, >86% of medical students in the US graduate with debt (approximately $120 000/student), (14) whereas French medical education is supported by the government and costs around 500$ per year. As ID physicians are among the lowest paid physicians,(15) student debts have a high potential to influence medical students. Nonetheless, an increase of the salary of ID physicians was still described in our survey as one of the likeliest measures to increase the attractiveness of ID.
Recommendations for working toward appropriate compensation for ID physicians include recommendations such as awarding financial compensation for ID who work in the public service or ensuring that the compensation of ID physicians reflect the added value to public health. (2) Studies have reported high rates of burnout symptoms among ID physicians (16,17)  (18) Increasing early research opportunities in ID has been cited as a potential measure toward a reinvigorated interest in the specialty. (19,20) Tropical medicine and antimicrobial stewardship were the topics that interested the most the participants showing the need for a strong and sustained support for international collaboration and antimicrobial stewardships programs, (19) but only 16% of the participants in our study expressed an interest in vaccination. This finding is worrying, especially with the rise of vaccine hesitancy globally and particularly in France. (21,22) In this study, we did not contact residents in other specialties and thus cannot analyze the reasons why other students did not choose ID. Moreover, this is a study done in France in a specific healthcare context and only 2 years after the recognition of ID as a qualifying specialty. Our results may not reflect the situation in other countries, especially countries in which medical studies are expensive or countries in which the healthcare system is mainly private. However, this study validates most of the potential measures that have been suggested in previous studies in order to increase the attractiveness of ID, suggesting that our results are not limited to France. (9,10,19) conclusions The recognition of ID as a qualifying specialty in France can be considered a success insofar as the specialty reached the first place among all medical and surgical specialties. Individuals who choose ID residency are attracted by the prospect of intellectual stimulation inherent in the specialty (multi-system approach, diagnostic challenges), its global reach and its variety of activities but have reservations regarding the salary, the workload and the availability of positions mainly in university hospitals. According to this national survey, the decision to make ID a qualifying specialty in France strongly encouraged the students to choose ID. These results enable us to be optimistic about the future of this essential specialty and may encourage some countries to recognize ID as a qualifying specialty. *Only the specialties cited by more than 5 participants are reported