Masood Ali Shaikh  ( Independent Consultant )
Samar Ikram  ( Ziauddin Medical College, Ziauddin University )
Ramsha Zaheer  ( Graduate Class of 2014, Dow Medical College, Dow University of Health Sciences, Karachi )

There is a growing perception in Pakistan that comparatively more women are gaining admissions and graduating from medical colleges; however these graduates are not practicing medicine. This pilot study provides perspectives on the influences on medical career choice and plans regarding future medical practice among female final-year students and house-officers in Karachi. Using convenience sampling, a study was conducted in August and September 2016, wherein out of 141 women, 95 (67.4%) were final-year medical students and 46 (32.6%) were house-officers. Most of the women (n=101; 71.6%) made their own choice to become doctors, while only 18 (12.8%) were compelled by their parents. An overwhelming majority (n=131; 92.9%) planned to do house job upon graduation or complete their ongoing one. Regarding post-graduation, 124 (87.9%) participants intended to acquire post-graduate qualification. Results indicate the need for representative studies to quantify the determinants and correlates of women\\\'s choice to study and practice medicine.
Keywords: Career choice, Medical school, Health services, Women, Pakistan.

Introduction

Women had been allocated limited seats in the public sector medical colleges of Pakistan for decades. Consequently, they had to face tough competition for admission into medical colleges. However, in 1990, the Pakistan Supreme Court put an end to this practice in its landmark decision of \\\'Shirin Munir v. Government of Punjab\\\' and instituted an open merit system, where both men and women competed on merit alone.¹ An extensive search on Medline did not reveal any study on the impact of \\\'Shrin Munir\\\' in medical college admissions in Pakistan. However, there is a growing perception fuelled by national and international media that more women than men are getting admissions, and graduating from medical colleges; but rather than practicing medicine, they end up as housewives.^2-5 Often these media reports insinuate that women become physicians to improve their prospects for finding better husbands. According to the Pakistan Medical and Dental Council (PMDC), of the total 159,074 doctors (general practitioners (GP) with basic degree only) registered till December 2016, 52.7% (n=83815) were male, while 47.3% (n=75259) were female.⁶ Furthermore, of the total 37, 573 doctors registered as specialists till December 2016, 69.6% (n=26163) were male while 30.4% (n=11,410) were female. Only in Sindh did the number of female registered GPs outnumber the males, but only by 1.2% (49.4% vs. 50.6%, males and females respectively). While these figures do not accurately represent the number of admissions by gender, they might be used as an extension to consider that females do not outnumber males in all medical colleges of the country.
Several studies have been published on the career migratory intentions and medical specialty choice among medical students in the country.^7,8 However, to the best of our knowledge, no studies have been conducted inquiring into and quantifying the role of personal and familial factors including those of current or prospective in-laws, influencing the female students\\\' and interns\\\' decision for acquiring medical degrees and their plans for pursuing postgraduate qualifications and practicing medicine. This pilot study attempts to address this gap, and provide perspective on the influences on medical career choice and future medical practice plans by assessing the intentions of female final year medical students and house officers in Karachi.

Methods and Results

A cross-sectional pilot survey was conducted using convenience sampling among the female final year medical students and house officers in various libraries, medical schools and hospitals in Karachi using a self-administered questionnaire with both open- and close-ended questions. The pretested questionnaire inquired about influences of family and friends on pursuing medicine and going to medical college; the current marital status; decision about choice of fiancé/husband; plans of doing/completing house job; intentions of pursuing post-graduate education; plans regarding children; perception of potential influence of current/future spouse on practicing medicine in future; and opinions about having made it to the final year/becoming a physician. The questionnaire was administered in August and September 2016, and information was collected after obtaining verbal informed consent and ensuring complete confidentiality. Data were analysed using open-source statistical software package R 3.3.1 for frequencies and percentages.
Cumulatively, 141 individuals completed the questionnaire out of which 95 (67.4%) were final year medical students and 46 (32.6%) were house officers. Records on those individuals who were approached but refused to participate were not kept. However, they were less than 30, and primary reason provided for non-participation was being busy and not having time to complete the questionnaire. 



Table-1 shows the respondents\\\' plans regarding marriage, having children in the future, and the importance of current or future husband\\\'s opinions regarding plans to pursue a professional career. Over half of the participants (n=76; 53.9%) were either currently married, engaged, or reportedly going to be engaged within next twelve months. Out of these, 15 (19.7%) participants reportedly made this decision alone, while another 33 (43.4%) made this decision along with their parents. Regarding the decision of having children in the next one to five years, 62 (44.0%) females were equivocal about their plans, in terms of either having or not having children. Around three-fourths of the individuals (n=108; 76.6%) reported that their current or future spouse\\\'s opinions and wishes on their future professional career plans would be either "very important" or "important" to them.



Table-2 reports on the respondent\\\'s influences on the choice of medical career, and future professional career plans. Most of the respondents (n=101; 71.6%) themselves wanted to become doctors, while only 18 (12.8%) females reported that their parents forced them to become a doctor. An overwhelming majority (n=131; 92.9%) planned to do their house job upon graduation or complete their ongoing house job. Regarding post-graduation, 124 (87.9%) respondents replied affirmatively to having plans for acquiring post-graduate qualification. Out of these 124 respondents, 52 (41.9%) individuals reported having plans to take MCPS or FCPS i.e. the membership and fellowship qualifications from the College of Physicians and Surgeons of Pakistan with nearly half the females (n=60; 48.4%)wanting to pursue post-graduation in either general medicine or sub-specialties of medicine. There was also an interest in pursuing the qualifications from abroad with 37 (29.8%) participants; however, there was a considerable overlap with 23 (18.5%) respondents opting for more than one postgraduate training option.
Almost all respondents (n=135; 95.7%) reported foreseeing themselves as practicing doctors in the next five years. However, only 84 (59.6%) participants reported to be either "happy" or "very happy" at having made it to the final year of medical college or upon graduating from it.

Discussion

To the best of our knowledge, this is the first study in Pakistan inquiring into and quantifying the role of personal and familial factors influencing the choice of female medical students and house officers regarding their career in medicine, including pursual of postgraduate qualifications. Despite popular perceptions perpetuated by the media, most female final year medical students and house officers in our pilot study felt happy at having made it to the final year of medical college or graduating from it and had primarily decided to pursue medical education at their own behest with the overwhelming majority planning to do or complete their ongoing house jobs and pursue post-graduate qualifications.
Corroborating these assertions, 135 (95.7%) women reported foreseeing themselves working as physicians in the next five years. Out of the 124 women who were affirmative on acquiring post-graduate qualifications, 24 (19.4%) respondents wanted to acquire post-graduate qualifications in the areas of either general surgery or surgical sub-specialties. These findings are all the more important and encouraging against the backdrop of 76 (53.9%) respondents who were either currently married, engaged, or were reportedly going to be engaged in the next twelve months. This may demonstrate the limited role, if any, of their present or prospective in-laws or spouses on their career plans regarding practicing medicine and acquiring post-graduate qualifications. This is despite the fact that 108 (76.6%) respondents reported that the opinions and wishes of their fiancé, husband, or future husband on their future professional career plans were either "very important" or "important" to them.
The current study is comparable with findings from other studies which note the interest of pursuing post-graduate qualification from abroad. In 2012, a study conducted in Dow Medical College of Dow University of Health Sciences, Karachi, reported that 97 (61.4%) out of 158 Pakistani female medical students intended to pursue careers abroad, while 64 (50.4%) out of 127 male Pakistani students reported similar intentions.7 Another study conducted in 2015 at the Department of Obstetrics & Gynaecology Unit II, Civil Hospital, Dow Medical College, Karachi, reported that out of 181 female medical students and interns, 90 (51.7%) intended to migrate, compared to 37 (62.7%) out of 59 males, with the primary reason being better post-graduate education options and better economic prospects abroad.⁸ This response is not limited to Karachi as a study conducted in Islamabad and Rawalpindi noted that out of 210 female medical students, 175 (83.3%) wanted to acquire postgraduate qualifications, compared to 148 (88.1%) out of 168 male medical students.⁹ These studies report comparable plans for acquiring postgraduate medical qualifications and career migratory intentions among male and female students and interns. In our study, 29.8% of the respondents planned to pursue postgraduate qualification from abroad.
There are five public and eleven private medical colleges in Karachi recognised by PMDC, with 1200 new admission seats allocated to each sector.¹⁰ Hence, this pilot study does not purport to debunk the perception of women pursuing medicine as a means to an end, rather than an end in itself for personal fulfilment in life. However, it does provide a perspective that perhaps not all female medical students and house officers are uncomfortably marooned between familial pressures to pursue medical education for better beau prospects and their plans to fulfil their personal professional aspirations for career in medicine. Findings from our pilot study need to be interpreted with the caveat that these results are merely exploratory in nature, as the basic premise of our report was to ascertain the intentions of the female medical students and house officers. Larger representative studies are needed to quantify the determinants and correlates of women\\\'s choice to study and practice medicine in our country. These phenomena have to be better understood which would help choreograph public health policy for realising full economic potential of half of the country\\\'s population for spurring economic growth, development, and well-being.

Disclaimer:  None to declare.
Conflict of Interest:  None to declare.
Funding Disclosure:  None to declare.

References

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