The Influencing Factors of the Career Pathway for Health Professions’ Education

Objective: This study has been designed to identify and explore the factors that influence medical and dental graduates to opt for Health Professions Education (HPE) as a sole career. Main Design: A qualitative study Sub-type: Phenomenological (exploratory) design was used to find out the factors that influenced medical and dental graduates to choose HPE as a full-time career. Setting: It was conducted at Riphah International University, Islamabad.


Introduction
Career selection is a vital stage and determines his/her path in life. 1 Due to easy access, there are abundant options available. After assessing multiple factors, individuals make informed career decisions. 2 Previously, the career path used to be predetermined, whereas now there is a career planning process. 3 The factors that contribute to this decision may broadly be grouped under intrinsic, extrinsic, vacations, finances, and prestige. 4 The rapidly increasing numbers of medical colleges in Pakistan, asks for faculty training for having core knowledge, and competency to apply teaching methodologies based on adult learning principles. which demands the need for Health Professions Education (HPE) Programs to be readily available accepting the innovations and inculcation of excellence in teaching and learning, and implementation of these strategies to develop an effective framework that can meet international standards. 5,6 Professional institutions are now acknowledging the value of medical education and Doctors are choosing HPE as a Career to teach, assess health-care policy and economics, and quality management, creating practical solutions for institutions in various clinical disciplines. 7 With the backdrop of the introduction and pressing issues develops a niche on which this research is based. There has been a surge in HPE Programs, (Certificates, Diplomas, and Masters) across Pakistan as well as a presumable rise in Doctors and Dentists opting for HPE Programs. 8 Objectives: In this study, our objective was to identify and explore the factors that influenced the choice of those Medical and Dental Graduates who chose HPE as a sole career, as to our knowledge there is yet to be an attempt to explore the factors influencing the choice of HPE as a sole career. Significance of Study: Doctors and dentists have a wide variety of specialties. One such specialty is HPE which revolves around all three divisions, undergraduate, postgraduate, and the continuing professional development, of a Medical and Dental Practitioner. In Pakistan, there is a varied perception of this specialty despite it encompassing the very essence of the journey of a medical and dental graduate, aiming to produce a population of ethical, knowledgeable, skilled, and up-to-date professionals. [9][10][11] To address these, a formal process of training is required with enrollment in an HPE Program. This study has been designed to identify and explore the choice of those Graduates who have opted for HPE as a sole career.

Materials and Methods
Study Design: A qualitative study to explore the factors through individual's lived experiences that can influence career choices for health professions' education as a career pathway. Study Setting and Duration: The study was conducted at Islamic International Medical College, Riphah International University, Islamabad. Data was collected over four months, February to May, and the total duration of the study was from February to June 2018. Study Population: All medical and dental graduates who had completed a post-graduate HPE qualification and had at least five years' experience. Population size: A semi-structured one-to-one interview was carried out on 6 participants who reached the saturation point and fulfilled the inclusion criteria. Inclusion Criteria: Medical and Dental graduates that had opted for health professions' education as a sole career with post-graduate HPE qualification and worked for at least 5 years in the field. Exclusion Criteria:  Graduates that had opted for HPE as a parttime career  Graduates that had less than five years of experience after HPE qualification. Data Collection tool and Analysis: Study tools Semi-structured one-on-one interviews were used for data collection. Thirteen questions were developed; were divided into four parts. The first part was used as an 'ice-breaker' to assess the awareness of Health Profession Education. 13 The second part was to explore the factors. The next part documented the differences between full-time and part-time faculty. The last part was framed to evaluate any challenges and participants' recommendations. Data analysis: All interviews were audio recorded and then transcribed. The participants were subsequently sent a copy of the transcript to assess it, for the purpose of credibility and triangulation. [14][15][16] After transcription, the documents were imported into © QSR International's NVivo Software v.11 for formulation and analysis. Data Analysis was done using the word, -search, and -frequency queries. The documentation of results was based on the results from © QSR International's NVivo Software v.11 NVivo output according to the above-mentioned queries, supported by relevant quotations from the transcribed interviews. Pilot Testing: A Pilot test was performed for validation, following which the questions were slightly modified and finalized, based on the feedback from the pilot study. Ethical consideration: After the ethical approval, Informed Consent was obtained from all participants by informing them that their participation was voluntary. The participants were given assurance of their anonymity and confidentiality. No reward or payment was given to any of the participants. Results 6 participants were recruited for the study based on inclusion criteria and the saturation point of the data. There were 4 females and 2 males. The mean age of the participants was 44 years. After analyzing the data 4 main 'areas of focus could be interpreted from the questions, namely;  Influence  Differences between full-time and part-time HPE facilitators  Challenges faced and  Recommendations for the career Text lines related to different Areas/Nodes were coded in one or more than one Theme accordingly. The most important Area/Node was 'Influence' from which ten themes were recognized which have been mentioned below. "I wouldn't take the credit of planning my career (smiles), but would like to acknowledge the contribution of my role models and mentors" Oversaturation of other specialties "Saturation in the other disciplines led me to choose HPE" Involvement in running projects "Running projects, being committee members and bringing about innovations. Shaped my career without any actual planning" Priorities "If Medical Education(ME) is your priority then demographics, or even anything else will not affect you, and you'll manage your routine accordingly" Opportunities for advancements and future relevance "I aim to lead the ME department, am in pursuit of creating a community of learned trainers all over Pakistan, and then the world, starting with other developing countries as well eventually directing the DME.it is my area of interest in my PhD.
There are very few doctorates in ME, so it's easier to climb up the ladder" Satisfaction All the respondents had mentioned that they were satisfied, and this satisfaction and motivation had an interdependent relationship. But to assess what played the most part in their satisfaction, there were numerous subcategories were derived.

Scholarship activities'
and 'Intellectual challenge' From the analysis, the degree of intellectual challenge, which was dependent on the professional environment as well, was closely related to the extent of scholarship activities.
"The choice has given me opportunities to fuel my research. The working environment is conducive to learning as well as intellectually challenging. I have been fortunate enough to have these opportunities to complete my doctorate and then the FHEA fellowship and now the Fellowship from the US, all these add to my satisfaction" Training the trainer "Huge amount of reform is needed in Pakistan, and maybe I can be one of those who can train the trainers. Working with students, teachers, decision-makers and educational leaders, I feel confident and enjoy this" Career ladder This sub-theme had reference to the career progression ladder.

Demographics
For specialty choice, demographics is documented to be an important factor. This theme included the effects of Gender Marital status on specialty choice.
Gender "It is more feasible for a lady to work in discipline of HPE, as we do not have those circumstances to pursue that passion which are very demanding" "It is not about an individual's marital status or gender. If ME is your priority; anything else will not affect you, and you'll manage accordingly" Marital status "Having a family was an influence, I thought that I should join a discipline that would allow me to be at home with the children. "So yes, everything related to curriculum, and to some extent, assessment as well Curriculum development in general" Faculty development "I like to read and write about conceptual models and ideas, rather than collecting and interpreting data. Overall, that is my liking and preference, but specifically, professionalism, faculty development and assessment" Leadership "Leadership! There is a lot of vacuum. It motivated Me" Professionalism "I like to read and write about conceptual models and ideas, rather than collecting and interpreting data. Yet, specifically, professionalism, faculty development and assessment" Role model or mentor "I would ask myself, why inspiring teachers are remembered and quoted. I really admire those pioneers who constructed this discipline from scratch" "The Professors, my Supervisors, and Course Director; and colleagues all are nurturing and Inspirational. This helps and leads me wanting to be like them" Personality type There have been numerous studies that have documented influences of Personality on Specialty preference. As personality is attributed to the overall behavior and interests of an Individual, it was interdependent with lifestyle and nature of work.
"It naturally matched with my personality. Because I tend to lean towards academics, it Suits my personality"

PART TIME OR FULL TIME PROFESSION
Full-time educationists "HPE is a full-time job. Full-time professionals working in the DME have their own level of expertise and components of Medical Education that have to be addressed, formulating a centralized approach, enhancing co-ordination and linking everything. THIS emphasizes the importance of a full-time HP Educator, whom can fulfil the responsibilities required, Medical education needs full-timers that are wise enough and innovative" Part time educationists "Usually older individuals want to opt for HPE to improve their teaching skills and contribute in curriculum development. Parttimers give first-hand experiences all the way from the lecture hall to the clinics, helping us improve both the facilitators and students" "Their knowledge is very superficial, because they can hardly get any time, as they do not invest in this specialty & had a more pragmatic and practical approach, not going deep into the theoretical frameworks" Difference between full time and part time educationists "Educationists are change agents, who will lead, manage and drive all the stakeholders to one goal, and are usually those who are eligible for being the Director of the DME. They can be categorized as part-time and full-time" "Work is delegated to those individuals working as part-time, those having Masters in addition to their basic qualification i.e. surgeons and physicians, to work in various committee's and even head them" 3. CHALLENGES This area includes the themes/factors that broadly encompassed the 'challenges' that individuals Faced once they had chosen HPE as a specialty. The most responses recorded from participants were 'Taunts', followed by 'Faculty resistance' and 'Effects on family' numerous other categories were noted 1. Taunts "I also faced taunts -"How 'I' could change the system?"; "This is the 'western' mode of teaching, how can you implement it here?" "are we not competent enough having studied from the same system" "you will face many hurdles and cannot achieve anything" 2. Family resistance "I had a lot of pressure from my family to quit working altogether as it Was taking up a lot of my time and I face the challenge of finding a balance between my personal and professional" 3. Faculty resistance "Orienting the faculty about HPE I faced a lot of resistance. Senior colleagues were not ready for change, you need to make them understand and walk them through. Making right decisions within the given resources was an uphill task" 4. RECOMMENDATIONS AND SUGGESTIONS FOR FUTURE PROFESSIONALS This area of focus emerged from a question that was presented to the participants. This had a twofold advantage; with a possibility to help make an inference about the satisfaction of the Participants and to whom would they recommend this specialty. Five participants gave a positive response and recommended opting for HPE as a specialty; one of them (Participant 2) even suggested that everyone should have formal basic HPE education and training.
1. Recommended "We need pragmatists, inspirational leaders as fulltime faculty and would suggest young graduates to join. I would encourage females, young students that have an inclination towards teaching. It is need of the day, and there is a lot of market right now. I encourage people but not just the ones who think that they cannot perform well in other disciplines and consider this is a fall back option but the toppers and the best students to come and join this field and take up leading roles" 2. Not recommended "Just like that, I condemn impulsive decisions. I would to like them to assess if they really want to opt this as a career. Career counselling should be offered. I have seen many who left this field in the middle, and were adversely affected. So, for recommendation, assess a person, offer proper consultation and guidance for his or her career"

Discussion
Our study was aimed at exploring the factors that influenced the choice of HPE as a career. Various themes, sub-themes, and categories were derived. Some of these were recurring factors that influenced specialty selection; others were novel and specific findings. Collectively, it may present as one of the steps towards proposing a framework for HPE specialty selection. Novel factors: Our results showed that there were characteristic/specific factors, themes, and sub-themes that influenced health professions 'education, which are:  Core Area or Theme, and Problems of the system: Health professions' education aims to produce a population of ethical, knowledgeable, skilled, and up-to-date professionals. 9-11 Furthermore, DME is responsible for the development of methodologies and has the expertise to address the problems in the Curriculum of our Medical and Dental Colleges, Students, Teachers, Assessment, and Educational psychology. 17,18 This factor was related to another influencing factor 'Problems of the system'. The most common recorded subtheme that was identified as 'Problems of the system' was documented to be 'Misalignment of teaching and assessment'; this was embedded in the HPE Core Area of Student assessment and Curriculum development. Similarly, the other problems that were mentioned by the respondents had their corresponding core areas. Additionally, another interesting relationship was established, participants were more likely to choose those areas of HPE that had influenced them as their topic of research during their Master's or Ph.D.  Motivation and Aim There were some personal factors that motivated individuals to choose HPE as a profession and some aims they wanted to achieve that influenced their choice. Though, we found that the motivations and aims depended on the problems in the system. Participants wanted to work to make a difference, become policymakers, taking up this specialty as a challenge to extract all the strength from the system and make the most impact on the healthcare community, and change the fate of the students to come. Two noteworthy motivations were, the identification that doctors/dentists were not teachers by default and needed formal training and education; a personal journey to find their identity.
Other factors: Mentioned below are the influencing factors that were documented to be common in other specialties too.
 Specialty choice: In accordance with other studies, on 'planning' specialty choice, four of our participants had also assessed and weighed other options before they had come to their final conclusion of the choice of HPE. 19 One of the participants had chosen HPE by 'exclusion-of-choice', a hit-and-trial, working in various specialties, assessing which best matched the participant's personality. However, they chose this specialty due to the oversaturation in other fields; both these participants had a similar background process but their journey led them to better assess their options. Once chosen, it was natural to consider opportunities for advancement, which were found to be interdependent with current pursuits, goals, and future significance. There emerged an HPE 'PG ladder' that all participants seem to be following. Responses yielded, Certificate, Diploma, Masters/MPhil, and Ph.D. as the qualification ladder, and irrespective of whether a participant had planned to join, or opted by chance, they were all motivated to pursue PG qualifications with four, following the 'ladder' were Ph.D. fellows and only one who had completed the Ph.D.  Gender and Marital status: Numerous studies have attempted to identify the relationship between gender and marital status, and specialty choice. An inference may safely be made that gender was an important factor directly and indirectly in influencing specialty choice, and was unique to a specific location and its culture. 20,21 Gender clearly influenced the choice of career. Two out of the four female participants mentioned that it had affected their choice positively, and all the female participants had further recommended that females opt for HPE as a specialty. Furthermore, all female participants acknowledged the fact that being married with children was a positive influence on choosing HPE as a specialty. 22,23 Interestingly, both males responded that gender had no effect. However, one of the female respondents recommended a specific type of male to opt for HPE as a specialty. Therefore, it can be proposed those female graduates, more so if married, were likely to choose HPE as a specialty, and it had no relationship with the male gender. Nevertheless, one of the participants thought that it was all about priorities.  Personality: One of the major factors that influenced specialty preference was Personality. 24 The significance was the overall behaviors and interests of an individual, becoming co-dependent with lifestyle and nature of work. Participants mentioned numerous personality traits that are necessary for HPE. Five participants explicitly mentioned that it matched their personality and influenced their choice. However, one mentioned that they were completely opposite but had now changed. Participants even mentioned what type of personality should be present in full-time HPE facilitators, as well as part-time. Therefore, it can be inferred that personality was a significant factor influencing the choice of HPE as a specialty.  Role Model or Mentor: Several studies have documented Role Model and/or Mentor to have an influence on specialty preference. 25,26 All participants mentioned that Role Models/Mentors had influenced their choice. Four of the participants mentioned that their Role Model/Mentor were senior professionals.
Remarkably, it was also noted that female participants had female Role Model/mentor and vice versa. From our results, it was implied that similar to other specialties, Role Models and/or Mentors also influence the choice of HPE. Secondly, having family members in a similar specialty do sway choice towards that specialty. 27,28 Lastly, again in accordance with a previous study we also documented that graduates were more likely to have same-gender role models/mentors(28)  Previous experiences: All the participants had previous experiences that may have led to influence their choice. Workshops were the most common experience that had been attended by all participants and oriented them about HPE. It may be suggested that previous experiences were a significant factor that influenced HPE as a specialty.

Conclusion
We aimed to conclude the thought process behind the numerous dynamics converging towards a finalized decision for opting for Health professions' education as s career and It can safely be concluded that demographics, personality, core area or theme, previous experiences, problems with the system and role models/mentors; all influence the choice of HPE as a specialty.

Limitations
There was limited availability of literature that documented factors influencing the choice of doctors and dentists for a specialty and absent literature on Health Professions' Education. Secondly, the results cannot be generalized, as the sample size was very limited. Further research needs to be performed for this purpose. Specialty preference is constantly evolving and researchers further attempt to identify and document novel factors.

Recommendations
After having completed this study, it may be suggested that an improved structured, systematic literature review with meta-analysis be performed. To this date, we were unable to find any study that explored factors influencing HPE as a specialty. Large multi-centered research that will span across various platforms including relevant stakeholders should be performed, which will be productive and assist in addressing this niche in an effective manner.