Why ophthalmology? Analysis of the motivating factors influencing the choice of ophthalmology as a career among different generations in Brazil

OBJECTIVES: The increasing demand for medical specialties with flexible working hours has been associated with the important role of quality of life as a determining factor when choosing a career in medicine, which might change the motivations for pursuing a career in ophthalmology. We aim to identify the main determinants of ophthalmology as a career choice as well as the reasons that motivated previous generations to follow this path. METHODS: Responses to self-administered online questionnaires were analyzed. RESULTS: A total of 225 responses were analyzed, including those of baby boomers (21), generation X (48), generation Y (131) and generation Z (25). Although the main reasons for choosing ophthalmology as a career are the same for all the generations in this study (flexible working hours, self-satisfaction from helping people improve their vision and the possibility of performing surgical procedures), some reasons for this career choice are more important to the younger generations (short-term results and short procedures), and some are more important to the older generations (the influence of an ophthalmologist in the family). CONCLUSION: The main reasons for choosing ophthalmology as a career are essentially the same over time. The differences in secondary motivations could be explained by generational differences.


' INTRODUCTION
In recent years, the search for professional areas with flexible working hours by new graduate physicians has attracted the attention of scholars worldwide, showing a shift in the profile of new physicians. A growing demand for positions in ophthalmology, dermatology, otorhinolaryngology, psychiatry and radiology has been reported (1)(2)(3)(4).
Changes in motivation can be explained by generational differences, as members of each generation have their own attitudes, preferences and key characteristics. In spite of better dealing with differences and working better in a group, the current generation of medical students and residents, known as generation Y or millennials, is often described as being immediatist, desiring change, being individualistic and advocating for quality of life and leisure time (19)(20)(21)(22)(23). Their particular traits could influence their main motivations in their career choices.
Many studies have investigated the current reasons for choosing different medical specialties; however, only a few have focused on understanding the selection of less traditional specialties and the differences among generations. This study aims to characterize the main current determinants of the choice of ophthalmology as a specialty as well as the reasons that influenced previous generations to pursue this career.

Participants
The sample was composed of Brazilian medical students participating in ophthalmology interest groups, ophthalmology residents in institutions accredited by the Brazilian DOI: 10.6061/clinics/2019/e1101 Copyright & 2019 CLINICS -This is an Open Access article distributed under the terms of the Creative Commons License (http://creativecommons.org/licenses/by/ 4.0/) which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is properly cited.
No potential conflict of interest was reported.
Council of Ophthalmology and ophthalmologists in private practice. One thousand two hundred fifty-three subjects were contacted by email to answer a self-administered online questionnaire. Acceptance of the electronic consent form was necessary before proceeding to the questionnaire itself.

Instruments
The instrument used in this study was an online self-administered questionnaire with objective questions regarding demographic information, reasons for choosing ophthalmology as a specialty, the presence of ophthalmologists in the family and the time of selection of the specialty. The questionnaire was sent via email by the Brazilian Council of Ophthalmology and the Brazilian Association of Ophthalmology Interest Groups. A sample of the administered questionnaire is shown in Figure 1.

Data Analysis
Data analysis was performed with the aid of the computer program SPSS v.24.0 (IBM, Armonk, New York) using the appropriate tests for each variable, which are displayed after each table.

Ethical Approval
Ethical approval for this study was obtained from the Research Ethics Committees (Comitês de Ética em Pesquisa -CEP) under protocol 2.622.328/2018.

' RESULTS
The response rate was 17.95%. A total of 225 responses were analyzed, which consisted of the responses from the baby boomers (n=21), generation X (n=48), generation Y (n=131) and generation Z (n=25) groups, as shown in Table 1. The participants included 114 ophthalmologists, 51 ophthalmology residents and 60 medical students (Table 1). There were no significant differences in the gender composition of the groups ( Table 1).
The majority of the participants were from the Southeast Region (64%), followed by the Northeast Region (12%) and South Region (11%), as shown in Table 1.
When asked about having an ophthalmologist in the family, 70.7% of the participants in our study answered negatively ( Table 1).
The main motivations behind each generation's choice of a career in ophthalmology as well as the significant differences among them are shown in Table 2.
The majority of the participants chose to follow ophthalmology as a career after being exposed to the area during medical school (77.7%), except for those who had a relative who was an ophthalmologist, who chose the career earlier, as seen in Table 3.

Old but still gold
In our study, we tried to identify whether younger generations aiming for a career in ophthalmology are influenced by different reasons than older generations in making their career choices, following the current trend of deciding on lifestyle-friendly residency programs (2)(3).
According to previous studies (9,(24)(25)(26)(27), the main reasons for choosing ophthalmology as a career are the possibility of performing surgical procedures, flexibility, earning potential and intellectual stimulation.
The strongest determining factors of career choices for all generation groups in this study were in accordance with the previous results in the literature, and there were no  significant differences among the groups, showing that the main reasons for choosing ophthalmology may be essentially consistent over time ( Figure 2).

All things come to those whoy want?
Although the main reasons for choosing a career in ophthalmology were the same for all groups, some reasons were significantly more important to the generation Y and generation Z physicians. This motivational trend can be explained by differences among generations.
Known for their impatience and immediatism, generation Y craves instant gratification, which may reflect the motivations that influence their career choices. In fact, direct access (no requirement to first complete an internal medicine residency) to ophthalmology residency programs and short-term results were significantly (p=0.002 and p=0.047) more important to the younger generations than to the older generations. Additionally, the short length of ophthalmic surgical procedures was statistically more likely to be identified by the generation Y and Z participants than by the participants from previous generations (p=0.000) (Figure 3).

The apple does not fall far from the tree
The influence of an ophthalmologist in the family was noted as a determinant for the choice of ophthalmology by 33.3% of the baby boomers, 18.8% of the generation X participants, 12.2% of the millennials and 36% of the generation Z participants, with statistically significant differences among the groups (p-value of 0.008) (Figure 4).
Although having an ophthalmologist relative was not one of the most cited reasons, 34.8% of the participants who had an ophthalmologist in the family chose a career in ophthalmology before being exposed to the area during medical school; this finding differed from that for the other participants without an ophthalmologist in the family, as 83% of these participants had decided on a career in ophthalmology during the last years of their graduate studies (p-value of 0.003) ( Table 3).

Last and least
The least cited reasons among all generation groups for choosing ophthalmology as a career were altruism, the intellectual challenge and social recognition. This finding is inconsistent with the main determinants of the choice of medicine as a career that have been traditionally described in the literature (28)(29)(30)(31). Whether future ophthalmologists will choose to attend medical school for different reasons remains to be investigated.
Pursuing an academic career was an important motivator for 28% of the generation Z participants and for 11% of the respondents overall (p=0.022). This result might arise from a selection bias since, at the time of the study, most of the participants in the generation Z group were involved in academic research activities linked to their participation in ophthalmology interest groups, which are organizations run by medical students interested in ophthalmology who organize and participate in extracurricular activities related to the field.

' CONCLUSIONS
The main reasons for choosing ophthalmology as a career differ from the determinants for deciding to be a physician. Whether a change in motivation occurs during medical school for those who decide on the ophthalmology career path remains to be investigated.
The differences in the motivations for deciding to become an ophthalmologist could be explained by generational differences. The immediatism of members of younger generations may impact their career choice determinants so that not only quality of life but also short-term results are highly valued. However, the main reasons for choosing ophthalmology are essentially consistent over time.