What is the motivation of young emergency physicians to pursue an academic career in Emergency Medicine?


 Background

The study aims were to assess the motivation behind embarking on a university hospital career in Emergency Medicine, as well as any potential motivational barriers and levers.
Methods

We carried out a multicenter prospective observational study. All interns from the first year to the fourth year of a residency program in Emergency Medicine as well as young emergency physicians at 5 universities in the west of France were interviewed. A questionnaire with 37 questions was developed based on the literature and in line with the Delphi method. The questionnaires were self-administered online. This questionnaire assessed 4 aspects: demographic data, overall motivational factors, specific motivational factors, and motivational barriers and levers.
Results

The participation rate was 70%, with 193 answers. A median of 3 (2–4) out of 6 was the result for motivation to pursue an academic career in Emergency Medicine. Twenty respondents (10%) showed a genuine motivation for an academic career, rating this item at 5 or 6 (out of 6). The most motivated students were those who had received research training (first-level master’s degree, Master 1) (OR, 3.2 [95%CI: 1.3 to 3.9]). Among them, the most important potential levers were the possibility to devote at least 50% of the time to clinical activity, the time dedicated to missions, clear recruitment prospects, and supervision/guidance in preparing for an academic career.
Conclusions

Ten percent of the young emergency physicians who responded to this questionnaire have a high motivation for an academic career, which suggests that there is a large potential reserve of academics in emergency medicine. There are several levels to maintain this motivation and transform it into commitment in the academic course.


Abstract Background
The study aims were to assess the motivation behind embarking on a university hospital career in Emergency Medicine, as well as any potential motivational barriers and levers.

Methods
We carried out a multicenter prospective observational study. All interns from the rst year to the fourth year of a residency program in Emergency Medicine as well as young emergency physicians at 5 universities in the west of France were interviewed. A questionnaire with 37 questions was developed based on the literature and in line with the Delphi method. The questionnaires were self-administered online. This questionnaire assessed 4 aspects: demographic data, overall motivational factors, speci c motivational factors, and motivational barriers and levers.

Results
The participation rate was 70%, with 193 answers. A median of 3 (2-4) out of 6 was the result for motivation to pursue an academic career in Emergency Medicine. Twenty respondents (10%) showed a genuine motivation for an academic career, rating this item at 5 or 6 (out of 6). The most motivated students were those who had received research training ( rst-level master's degree, Master 1) (OR, 3.2 [95%CI: 1.3 to 3.9]). Among them, the most important potential levers were the possibility to devote at least 50% of the time to clinical activity, the time dedicated to missions, clear recruitment prospects, and supervision/guidance in preparing for an academic career.

Conclusions
Ten percent of the young emergency physicians who responded to this questionnaire have a high motivation for an academic career, which suggests that there is a large potential reserve of academics in emergency medicine. There are several levels to maintain this motivation and transform it into commitment in the academic course.

Background
Emergency Medicine has been recognized in France as a full specialty, with a specialized studies diploma since 2017. (1) In French medical schools, the number of tenured teachers decreased between 2012 and 2016, while new university specialties appeared.(2) Also in the United States, the proportion of full or near-full professors in medical schools has declined noticeably in recent decades.(3,4) At the same time, student and internship enrollments have doubled, and university support rates for students and interns have declined. (2,5) In France, the average ratio is 3.6 interns per permanent university hospital (UH) staff, with strong variations between universities and the different specialties, from 2.2 to 10.7 interns per permanent UH staff. (2) A shortage of academics in certain centers and the need to ensure teaching, research and management functions means that such missions are more di cult to ful ll, makes a hospital-university career less appealing, and offers fewer opportunities to prepare candidates for an academic career. 4 Yet for several years young interns and doctors from many disciplines feel progressively less drawn to these careers in France including in Emergency Medicine in some regions. The situation could be caused by a lack of interest to engage in this course.
In education, the learner's motivation is de ned as "a phenomenon born from the perception that students have of themselves and their environment that makes them choose to carry out the educational activity proposed, and to persevere and engage with it in order to learn from it.". (6) By extension, the approach to choosing a university career by the question of motivation helps identify and understand the personal factors that in uence both the decision to take this path and the different feelings toward this course. A high level of motivation is also associated with genuine commitment and better learning skills. (7)(8)(9) This approach angle is a key resource when it comes to thinking about how to change a training system or sectors. Little is known about the motivation for embarking on an academic career for young emergency physicians. (10,11) The study objectives were to assess the motivation behind embarking on a university hospital career in Emergency Medicine as well as the possible motivational barriers and levers.

Methods
This was an observational study carried out at 5 universities in western France. The study population included all residents from the rst to the fourth year of Emergency Medicine diploma and young doctors working in an emergency department of the ve university hospitals.
The rst step was designing the questionnaire. A Delphi development of consensus method was used. validated a French-language questionnaire designed to explore them, which was later used by Pelaccia et al. (15,16) The ve factors are lifestyle (working hours, family/work balance), societal orientation/impact (improving/promoting health, social commitment), prestige/ nancial security (potential salary, nancial stability, social recognition), the eld of activity/area of activity (research, level of complexity of the practice) and the in uence of a role-model (teacher, professional met during internships, medical gure, friends/family). These overall motivational factors have been broken down into 16 speci c appeal/deterrence factors in uencing the drive to pursue a UH career in Emergency Medicine. These include: lifestyle; various responsibilities or activities relating to teaching, research and management, and clinical activities; being involved in teaching; being involved in research; managerial responsibility for a department; intellectual challenge/complexity level; the possibility to promote Emergency Medicine; the lack of many candidates within the specialty; career prospects; the potential salary, the duration of the preparation to be declared t to perform the functions of a full professor; compatibility with family life; having to work in a University Hospital; social recognition; recognition by peers; and the possibility of following in a role-model's footsteps. They were measured on a six-point Likert scale (from 1, a strong deterrent to 6, very appealing). The experts produced a list of 8 potential motivational levers, which were also measured on a Likert scale. The panel of experts was made up of academics in Emergency Medicine, whether tenured or not. Experts could add or remove an item but were required to explain why they disagreed by adding a comment. According to the Delphi method and after being sent to the experts twice, all the questionnaire items obtained an absolute (> 90% agree) or strong (> 75% agree) consensus. The four parts have been kept. The questionnaire consisted of 37 questions (Annex 1).
The second step was to assess wherher the questionnaire was understandable and feasible on a panel of students (n = 8 students, or 4% of the study population). No changes were made as a result.
The third step was sharing the questionnaire electronically. Students were asked by email to complete a self-administered online questionnaire (Google Forms®). If anyone did not respond within 10 days, two email reminders were sent at seven-day intervals. Checking email addresses helped ensure that there were no double entries in the questionnaire. Taking part in the study was voluntary and anonymous (after checking that there were no duplicate email addresses). The study was approved by the Ethics Committee of Angers University Hospital on December, 4 2020 (N°2020/146). We followed the checklist for reporting electronic survey results over the Internet (CHERRIES). (17) Statistical analysis After the questionnaire was closed, a post hoc analysis was carried out. We rst calculated the response rate, then the epidemiological data of the interns who responded were compared with the data of nonrespondents, mainly concerning sex, year and place of training in order to assess potential selection bias. Comparisons were made using the Chi-squared test or the Wilcoxon rank sum test, depending on the type of variable studied. The median and the inter-quartile range were used to describe the different levels of motivation. A difference was considered signi cant for a p value of less than or equal to 0.05. Logistic regression was used to assess factors associated with high motivation for an academic career (de ned as motivation rated at 5 or 6). A Principal Component Analysis (PCA) of the 16 motivational factors was also performed in order to identify the motivational factors associated with a strong motivation for an academic career in emergency medicine. No imputations were made. Questionnaires with missing data were excluded.
Statistical analyses were carried out using R Core Team software (2017). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria (URL https://www.Rproject.org/).

Results
Of the 288 people surveyed, 2 expressed their wish not to answer and 4 had an invalid email address. In total, 202 people (70%) responded to the questionnaire. Of the respondents, 9 (4%) were later excluded from the analysis due to missing data. In the end, the analysis was based on 193 people. The average age was 27 (± 2) years old. The sex ratio was 0.48 (93 women/193). Among the 193 respondents, 73 (38%) were single without children, 103 in a relationship without children (53%), and 17 in a relationship with children (9%). The respondent sample included 43 (22%) students in their 1st year of specialty in emergency medicine, 56 (29%) in their 2nd year, 31 (16%) in their 3rd year, 30 (16%) in their last year of specialty (4th year), a student on call, 5 (3%) students undergoing additional training in pediatric emergency, and 26 (14%) had been young graduates for < 1 year.
For each promotion, Table 1 details respondents' motivation to practice Emergency Medicine and for an academic career in Emergency Medicine (rated out of 6), as well as the order of importance for the ve overall motivational factors in uencing their career choice (lifestyle, prestige/salary, orientation/social impact, interest in the eld of activity, a role-model's in uence). On a scale from 1 to 6, motivation to practice Emergency Medicine was a median of 6 (6-6) and that for achieving an academic career in Emergency Medicine was a median of 3 (2-4). Twenty participants (10%) showed a genuine motivation for an academic career by rating this item 5 or 6 (out of 6).
The proportion of students strongly motivated by an academic career was not different according to the year of study (from the 1st year to the 5th year, 9%, 12%, 13%, 5%, 12%, P for trend, 0.83), nor by sex (12% for men, 9% for women, p value of 0.59). On the other hand, it was higher among the 77 students with a rst-level master's degree (17% vs 6%, p value of 0.03) ( Table 1 and Fig. 1).
The proportion of students with a rst-level master's degree was higher among men (47% vs 32%, P = 0.054) and decreased with the year of study (from year 1 to year 5, 46%, 47%, 39%, 30%, 28%, P for trend, 0.03). The multivariate logistic regression showed a signi cant association between a high motivation for a university career and a rst-level master's research degree (OR, 3.2 [95%CI 1.3 to 3.9]) but did not show a signi cant association between higher motivation and sex or year of study.

Motivational factors
For all respondents, the overall motivational factors were, in descending order: eld of activity, societal impact, lifestyle, a role-model's in uence, and prestige/salary. Across the years of training, the societal impact and the eld of activity were the two main overall motivational factors for an academic career (Table 1). Lifestyle, prestige and salary were the least important motivational factors at the end of the course. At the start of training a role-model's in uence was not a motivating factor but became more important toward the end of the course.
The speci c appeal or deterrent factors for pursuing an academic career in Emergency Medicine were shown in Fig. 2. There is a strong appeal factor for teaching, but weaker factors for research and management. The time it takes to prepare the skills for an academic position and compatibility with family life were both deterrents. The 5 most important motivational factors for students strongly motivated by an academic career were: the variety of responsibilities and activities, teaching, intellectual challenge, promotion of emergency medicine, and working in university hospitals, with a median rating of 5 or 6 out of 6 ( Table 2). The appeal of research and management were ranked in 7th and 8th position, with a median rating of 4.5 and 4, respectively.
Principal component analysis of motivational factors did not discriminate respondents who were highly motivated by an academic career compared to others (Fig. 3). However, highly motivated students tended to have higher scores on the 1st principal component (PC1) and lower scores on the 5th principal component (PC5). Higher PC1 and lower PC5 were associated with a higher appeal of working in a university hospital, research, and managerial responsibility for an Emergency Department. Higher PC1 and PC5 were associated with a higher appeal of teaching, peer recognition, a mentor's in uence, and varied activities. Higher PC1 combined with PC5 close to 0, was associated with a higher appeal of intellectual challenge. Among PC1 and PC5, the appeal of research and teaching seemed poorly correlated, which was con rmed by linear regression that showed no association between these motivational factors (estimate, 0.05 (0.06); p value of 0.38).

Measures to improve the appeal of UH careers in Emergency Medicine
Among the 8 motivational levers, 6 favored the appeal of an academic career for more than 50% of respondents (Fig. 4). Among respondents strongly motivated by an academic career, the 5 most important potential levers were the possibility of devoting at least 50% of the time to clinical activity, the time dedicated for assignments, clear recruitment prospects, the possibility to undertake only one or two assignments among teaching and research, and the opportunity to have experienced mentor oversight for an academic career (Table 2).

Discussion
This study shows that 10% of young emergency physicians who answered this questionnaire have a high motivation for an academic career. This percentage, signi cantly higher than the percentage of academics among emergency physicians, suggests that there is a large potential pool of emergency medicine academics. It raises the question of how to maintain such a high level of motivation over time, and how the motivation is related to effectively preparing for a university career.
Motivation is a multidimensional and dynamic phenomenon.(6) Deci et al. distinguish between intrinsic motivation, which is doing something because it is inherently interesting or pleasurable, and extrinsic motivation, which is doing something because it leads to an external bene t.(18) The motivation to embark on an academic career in Emergency Medicine seems more intrinsic since the main overall motivational factors were the eld of activity and the societal impact, while the motivational factors rather linked to extrinsic motivation are in last position (prestige, salary). This is a positive outcome, because when a person is intrinsically motivated, they act for the pleasure or challenge involved rather than because of external encouragement, pressure or rewards. (18,19) In a previous study, we found the same pro le concerning the motivation of interns in the rst year of Emergency Medicine diploma. (20) Analyzing motivational factors and levers in detail helps consider ways to foster strong motivation for an academic career among young emergency physicians.
Students' attraction to research and their interest in knowing the research laboratories likely to recruit them are low in the whole sample studied, although they are somewhat higher among students who are highly motivated students by an academic career. The above ndings con rm how closely involved they are in research during the internship, which is decisive when choosing to engage in the academic course.
(11) This is consistent with two studies conducted in the United States, which found an association between having conducted research in Emergency Medicine while being a medical student on clinical rotations on the one hand and an interest in an academic career on the other. (21,22) The feeling of having received adequate training in research while being a medical student on clinical rotations was also an appeal factor.(22) A rst-level master's degree of research was associated with a draw to research and motivation to pursue an academic career. The youngest students were more often graduates of a rst-level master's degree. If this trend is con rmed, it would suggest that the overall motivation of young emergency physicians for an academic career may increase in the future. These elements suggest that increasing the motivation of young emergency physicians to pursue a university career requires making research more appealing to them before and during the internship, encouraging them to complete a rstlevel master's degree in research.
The possibility of following in the footsteps of a role-model was neutral in terms of appeal for an academic career, and the overall in uence of a role-model seemed more important at the end of training. In addition, respondents strongly motivated by an academic career had a strong interest in a mentor overseeing the preparation for an academic career. This role should be taken into account in the tutoring set up during the internship. It is emphasized in programs aimed at maintaining and fostering academic careers at various universities. (23,24) This method also depends on how representative university staffs are. In this study, women reported a motivation to pursue a university career in Emergency Medicine that was as strong as men's. However, the current number of female student doctors in Emergency Medicine in France is very low. Female under-representation in these careers has been observed in many countries. (3,25) Three main hypotheses can be put forward. The rst is an ongoing pro le change in Emergency Medicine that re ects the growing proportion of women in medical studies. Second, the study's results may re ect the persisting inequalities in access to such courses. In our study, this is suggested in particular in by the lower proportion of women with a rst-level master's degree, and a strong appeal of research and for teaching. A third hypothesis is that the results re ect a secondary disinterest in this course given the necessary involvement and the di culty in ensuring a work-life balance. The internship years and the beginning of professional life usually happen around the same time as creating a family home and having children. This is consistent with the deterrent nature of balancing an academic career with family life, also reported in other studies. (21,22,26) Whatever the reasons, the higher number of female academics in emergency medicine could encourage new female candidates to come forward.
Several other potential ways of boosting the motivation of young emergency physicians to pursue an academic career relate to managing working time. The wish to be able to devote at least 50% of one's time to clinical activity and to have dedicated time to carry out university assignments probably explains the interest in the possibility of limiting one's commitment to either teaching or research. Although the question was not asked speci cally, considering the greater appeal of teaching than research, it is possible that respondents are more drawn to a career focused on care and teaching. This point should be clari ed in any subsequent works, and is consistent with the strong appeal teaching for non-university hospital practitioners. (27) Respondents strongly motivated by an academic career also pointed out that having clear recruitment prospects was an important motivational lever. In a centralized state like France, university recruitment policies in medicine depend on the Ministry of Higher Education and Research and the Ministry of Health. Informing young doctors of local and medium-term objectives for university recruitment could strengthen the motivation of young emergency physicians to prepare for an academic career.

Limitations
Our study has limitations. We have scarcely assessed the amotivation to pursue an academic career de ned as "an individual's complete lack of motivation". Apart from the initial motivation score, the questions assessed the components of motivation under the assumption that there was at least one.(28) Although relying on the literature and pre-existing questionnaires, it is possible to have overlooked components of this motivation. However, the respondents could send us open-ended comments and analyzing them did not seem to reveal any additional proposals. The length of the questionnaire (37 questions) may have limited the response rate by discouraging people who are probably least interested in the subject, which could have led to a selection bias, with a possible over-representation of respondents showing a motivation to pursue this type of academic career.

Conclusions
The study shows that 10% of young emergency physicians who answered this questionnaire have a high motivation to pursue an academic career. This strong motivation is associated with a strong appeal of teaching, but the appeal of research, which is insu cient, must be reinforced. The main levers identi ed by young emergency physicians to strengthen their motivation to pursue an academic career are linked to the maintaining clinical activity, clear recruitment prospects, and supervision in preparing for a university career.
Abbreviations OR: Odds Ratio Motivation to pursue an academic career based on years of study. Motivation is assessed using a 6-point Likert scale (1: unmotivated, 6 highly motivated). In the box plots, the boundary of the box closest to zero indicates the 25th percentile, a black line within the box marks the median, and the boundary of the box farthest from zero indicates the 75th percentile.

Figure 2
The speci c appeal or deterrence factors in uencing the choice of whether to follow an academic career in emergency medicine or not. Students used a slider to indicate whether the item encourages or discourages them from choosing an academic career. A value of 1 corresponds to a very dissuasive factor and 6 to a very appealing factor. The upper and lower limits correspond to the rst and third quartiles. The line in the middle is the median. The crosses are the averages. Biplot of the principal component analysis of motivational factors for an academic career in Emergency medicine among residents in EM and young doctors. Note. PCA was performed on 16 motivational factors (black arrows). Only the most discriminating motivational factors were represented. First and 5th principal components explained 23.9% and 7.3% of the total variance of motivational factors, respectively. Each point represents a respondent. Respondents were grouped according to their motivation to pursue an academic career in EM (red: high motivation; blue: low or moderate motivation).