How and why do French medical students choose the specialty of infectious and tropical diseases? A national cross-sectional study

Infectious and tropical diseases (ID) physicians are needed now more than ever to tackle existing and emerging global threats. However, in many countries, ID is not recognized as a qualifying specialty. The creation of ID residency in 2017 in France offers the opportunity to know how and why the specialty is chosen by medical students. 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 in January 2019 to all ID residents in France (n = 100) to assess the factors influencing their choice of specialty and their career plan. 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 (n = 100). 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 potential deterrents were the work-life balance, the workload and the salary. The recent recognition of ID as a qualifying specialty in France can be considered a success insofar as the specialty is the most popular among all medical and surgical specialties. Individuals who choose ID are attracted by the intellectual stimulation of the specialty but express concerns about the working conditions and salaries.


Background
In 2019, the World Health Organization published a list of 10 threats to global health among which 6 are related to infectious and tropical diseases (ID): the threat of a global influenza pandemic, antimicrobial resistance, Ebola and other high-threat pathogens, vaccine hesitancy, dengue, and HIV [1]. ID specialists' consultations have been shown to decrease mortality rates and healthcare costs and antimicrobial stewardship programs have shown to reduce the number of infections with resistant bacteria [2][3][4][5]. In the context of the COVID-19, ID physicians are needed now more than ever to tackle this pandemic as well as the future ones and improve outcomes for patients [6].
However, in many countries, ID fellowship programs remain unfilled every year. In 2019, 75 out of 401 positions in ID (19%) were unfilled in the USA and only 3 medical specialties among the 68 specialties evaluated had a higher number of unfilled positions (geriatric medicine, nephrology and ultrasound medicine) [7]. Canada has also described difficulties in finding ID residents and fellows [8,9]. Moreover, ID is still not widely recognized as a qualifying specialty in many countries including Spain or India [10,11]. 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 [12,13].
In 2017, France undertook a reform of 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 and why 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 are published every year in the French ministry of Health official journal [14]. 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 Survey-Monkey® 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 [12,13] 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, expectations from ID residency and career plan. 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 (Fig. 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 box plots. To capture other factors that could have been missed, we asked the participants if they thought of other factors that influenced their choice. The third part collected information about likely measures to increase the attractiveness of ID. We asked the participants to decide if a selection of 12 measures were very unlikely, unlikely, neutral, likely or very likely to increase the attractiveness of the specialty. We selected the 12 measures based on the literature [12,13] and on the modifiable factors that were evaluated in the second part of the questionnaire. The 36 factors and 12 measures were displayed in a random order for each participant to avoid biases due to changes in the participant's way of rating during the questionnaire (e.g. modification of the concentration level).
The questionnaire was sent on 29th January 2019 by email to all the residents who had chosen ID since the creation of the specialty in 2017 (n = 100) via the Young French Infectious Diseases Physicians' Network (RéJIF), a working group of the French Society for Infectious

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). Forty-nine and 51 positions for the ID specialty were respectively opened in 2017 and 2018 and all were filled. ID was the first-chosen specialty among all specialties with a mean median rank of 526/8539 (Fig. 1). Both in 2017 and in 2018, the first nationally ranked medical student chose the ID specialty. ID was not available for medical students ranked over 3709th out of 8372 in 2017 and over 3209th out of 8706 in 2018. ID specialty was followed by ophthalmology (mean median rank 604) and plastic surgery (mean median rank 723).

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). Residents from every residency program of ID in France participated in the survey (supplementary material). The median delay between the beginning of the ID residency and the survey was 9 months (IQR 3-15). Among the residents who participated in the study, two (2%) dropped out of the ID residency program, one to join the general medicine residency because of the workload in ID and one who finally chose the orthopedic surgery residency after having hesitated between the two specialties for years.

Expectations and career plan
Seventy-one participants (79%) did an internship in an ID department during medical school and 27 participants (30%) had experience working 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 school and 51 participants (57%) took their decision after the national ranking exam. The participants mainly hesitated between ID and internal medicine and clinical immunology (n = 31, 34%), family medicine (n = 18, 20%), intensive care (n = 18, 20%), nephrology (n = 17, 19%) and hematology (n = 16, 18%).

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 nonacademic hospital positions by 71% and increasing the availability of academic positions by 71% (Fig. 3). Overall, the 12 measures evaluated were judged very likely or   (21) Multidisciplinary health clinic 19 (21) Private hospital 18 (20) Governmental organization 18 (20) Public health institute 8 (9) Private surgery 6 (7) a Only the specialties cited by more than 5 participants are reported 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 boosted 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 [15,16]. 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 [7]. Yet the deterrents 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 [12]. 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. Motivations and reservations to choose ID specialty. Legend: Boxplots of the 36 factors that were evaluated by ID residents. The residents had to use a slider to say if this factor encouraged them to or discouraged them from choosing ID. The slider position was attributed a figure between 0 (strongly discouraged) to 10 (strongly encouraged). The lower and upper hinges correspond to the first and third quartiles. The upper and lower whisker extends from the hinge to the largest value no further than 1.5 x IQR from the hinge. The bold lines correspond to the medians Indeed, > 86% of medical students in the US graduate with debt (approximately $120,000/student) [17], whereas French medical education is supported by the government and costs around $500 per year. As ID physicians are among the lowest paid physicians in the USA [18], student debts may have a higher potential to influence medical students than in France. An increase of the salary of ID physicians in France 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 have been published and include suggestions such as awarding financial compensation for ID who work in the public service or ensuring that the financial compensation for ID physicians reflects the added value to public health [2]. Studies have reported high rates of burnout symptoms among ID physicians [19,20] and our results confirm that the concerns about the quality of life, the workload and the work-life balance are potential deterrents from choosing ID. The need to improve the worklife balance of physicians is part of the global healthcare system and have to be tackled at the national and political level. To achieve this aim, the ID community probably needs to develop a common advocacy for the ID specialty directed at policy makers and the general public. This research was done before the COVID-19 outbreak but this pandemic further highlights the need to support and encourage students and residents who want to become ID specialists as they are and will be increasingly needed to organize the response to existing and future infectious threats [21].
According to our results, most ID residents want to have a clinical activity (97%) and a teaching activity (56%) but less than half want to participate in research (43%). Scientific research is particularly important in ID with global challenges such as emerging diseases and antimicrobial resistance. The fact that ID physicians in France have an important clinical workload and do not have a dedicated time for research may be an important barrier to the motivation to participate in research [22]. Increasing early research opportunities in ID has been cited as a potential measure toward a reinvigorated interest in the specialty [23,24]. 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 [23], 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 [25,26], however this might be due to the fact that vaccination is a clinical area shared with family medicine and public health.
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. The network of young ID doctors that is behind this work has been created approximately at the same time as the ID specialty and thus we cannot compare our results with previous data. 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 [12,13,23].

Conclusion
The recognition of ID as a qualifying specialty in France can be considered a success insofar as the specialty reached first rank 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.