What factors influence these students’ decisions to enter the MD/MBA program - Dual degree students were asked to rate the degree to which a set of factors influenced their decision to participate in the program on a scale of 0 to 3 (0 being no influence, and 3 being a strong influence). The most influential factors were career opportunities, opportunity for innovation, opportunity to make a difference in medicine, consistent with my skills and abilities, opportunities to lead in medicine, and consistent with career interests. Table 1 includes mean scores for each factor, indicating how dual degree students prioritize influences on their decision-making.
Factor analysis can be used to analyze an instrument with a large number of items and to determine whether different factors related to a concept are being tapped by various subgroups of questions. Factor analysis explores whether items group together in some logical way; items which measure the same concept are expected to be more highly correlated. Principal components factor analysis was used to analyze the data related to students’ reasons for seeking the MD/MBA. In the model, eigenvalues greater than one determine which factors are selected. Four factors had eigenvalues greater than one and accounted for over 50 percent of the variance in responses. Variance accounted for by each factor was 19.26 percent, 13.37 percent, 8.67 percent, 8.20 percent for Factors 1, 2, 3, and 4 respectively. Reasons students identified for the dual degree grouped into the following factors:
- Group 1: (eigenvalue 4.62) opportunity to make a difference in medicine, career opportunities, desire to influence the future of medicine, desire to know more about the economics of medical practice, opportunities to lead in medicine, desire to retain influence over clinical practice;
- Group 2: (eigenvalue 3.21) intellectual content of program, challenge of program, consistent with my skills and abilities, intellectual stimulation, interest in MBA course content, opportunity to obtain additional education;
- Group 3: (eigenvalue 2.08) income prospects, prestige of dual degree, uncertainty of job market for physicians, job security, opportunity for independence;
- Group 4: (eigenvalue 1.97) encouragement of a mentor, encouragement of a physician.
Of twenty-four items, only three did not “load” on one of the four groups, a possible indicator that this particular instrument in the survey is a reliable one. One of the factors that did not load in the groups was the “demand for physician executives”. Students’ interview comments suggest that they may have misunderstood the terminology in this factor. Discussion regarding issues such as the market for physician services indicated a lack of understanding of market related terms such as “demand”.
Other influences that did not load in the four groups were “desire for authority” and “encouragement from other students”. This result is consistent with responses to the questions related to the influence of mentors. Only five of the dual degree students reported that they were influenced to enter the program by other medical students, while greater numbers reported that they were influenced by physicians or family members.
The most influential factors in students’ decisions to obtain dual degrees were in group one. Although social desirability bias could be an issue, these results support the idea that these students want to “make a difference in medicine” and have goals to be leaders in the health care system. They value innovation as well as opportunities to influence the future of medicine. The following are examples of the numerous interview comments which illustrate such priorities: “I want to influence the direction that health care is going to take”; “It is important for physicians to have business backgrounds so they can shape where medicine is going”; “The reason I got into medical school was to make a difference, but now the humanistic-philanthropic side of medicine seems to be out the door. I figure I will use the MBA to incorporate the values of why I became a physician in the now capitalistic medicine…. I say I can’t beat the system and this will help me get into it”. “I decided I want to have a broader scope in my medical career and take leadership roles in addition to practicing medicine. I am interested in changing what is going on in health care in the 90s”.
Group three factors were not rated as highly by the students. As a group, these factors seem to be more related to income prospects, job security and prestige. Again, these could be indicators of students’ values and plans for the dual degree. Nevertheless, numerous students commented in the interviews that they anticipated career benefits from having both business and medical degrees. One student stated, “I want to help them (physicians) make money doing well for patients so that everyone’s interests are served”.
When are these students deciding to enter the dual degree programs - This information is relevant to dual degree programs in recruiting efforts. What information about the programs is getting to students applying for medical schools, and does the existence of these programs have an impact on recruitment at medical schools? Of all the dual degree students surveyed, 51.4 percent of respondents decided to participate in the dual degree program when applying for medical school. Forty-two percent of dual degree students report that they decided before medical school that they would participate in the MD/MBA program, and a smaller number elected the program during the first year of clinical training. This would suggest that the existence of the dual degree program must have had some impact on student selection of medical schools. Only three students decided to apply during the second year of medical school, and one decided to apply during the third year of medical school.
The fact that so many of the students determined that they would apply for the dual degree program before applying or when applying to medical school suggests that the medical schools could use the dual degree programs as a recruitment tool for students interested in the interdisciplinary nature of the dual degree.
Mentors and other influences - Dual degree students were asked whether individuals such as mentors and physicians were influential in their selection of the dual degree program. Fifty-three percent of students stated that individuals influenced their program decisions. Of those that did answer this question in the affirmative, the top two categories of influence were family members and physicians (See Table 2). Student comments in interviews reflect that many students are being encouraged to get business training by experienced physicians as well as residents.
MD/MBA student income expectations - Both the dual degree and control groups were asked what they expected to earn five and ten years after completing residencies. The MD/MBA group had an expected mean income after five years of $167,986 (range of $40,000 to $400,000), while the M.D. students had a mean of $132,208 (range of $45,000 to $250,000). These figures are significantly different; t (147)=3.66, p<.0001. According to the AAMC national survey of all medical students graduating in 1996, the mean income expectation five years after completing all training is $142,578; t(71)=3.01, p=003. Students were also asked about income expectations ten years after completing training. Mean for the MD/MBA group was $293,422, while mean for the MD group was $182,467; t(147)=5.98, p<.0001 The differences between the two groups surveyed were significant, as well as the difference between the national group of medical students and the dual degree students.
Several traditional medical students responded to the questions regarding income with written comments such as “no idea”, while almost all of the dual degree students provided a numeric response. Could this suggest that dual degree students are more comfortable with issues of finance and income, or have they given more thought to their future economic status? A number of responses and interview comments suggest that dual degree students anticipate earning more money later in careers by assuming new duties that combine administrative and clinical activities. For example, one student clearly expressed a desire to practice in primary care and stated that he expected to make $65,000 five years out of residency. Yet the same individual reported that he expected to earn $300,000 after ten years.
Several responses to the income questions indicate that students may have misunderstood these questions. Some responses seemed to reflect what students’ might have considered residency salaries (such as $45,000). In particular, one individual reported that he planned to enter the field of hand surgery and would make $45,000 five years after finishing training and $350,000 ten years after training. Perhaps the student assumed that the question referred to five years after medical school graduation, at which point he/she would be in residency training. To control for such response error, unreasonable (or inconsistent) responses were removed, and descriptive statistics recalculated. Dual degree students expected $170,929 in income after five years, and traditional medical students expected $134,533 (significant differences, t(143)=3.76, p<.05). Ten year expectations were also adjusted for response error. Again, the responses by dual degree students ($293,329) were significantly different than those from traditional medical students ($181,333) (t(143)=6.04, p<.000).
As might be expected, income expectations were significantly different among students planning to enter primary and specialty care. For all respondents to the survey, the mean expected five year salary for students going into primary care was $119,305, while the mean expected salary of those going into specialty care was $168,091. For ten years from training, the income mean for primary care group was $183,472, and the specialty group reported average expected incomes of $248,873. Table 3 provides a breakdown of salary expectations by type of field for the dual degree and control groups.
Career plans / job activities - As an indicator of their career plans and aspirations, dual degree students were asked to rank activities according to how they would feel about them as primary job responsibilities. Job responsibilities ranged from CEO of a for-profit hospital to Medical Director of an inner city health clinic. Job responsibilities were developed to provide indicators of the types of positions these students might desire, particularly related to their tendencies toward more altruistic positions and activities that might be traditionally associated with the “business” of medicine. Table 4 provides mean scores for the job activities, ranked in order of those jobs that were most desirable to the students.
Another analysis that was done of these questions involved dividing the job activities into subgroups based on activity type. Subgroups were developed to reflect items that might indicate students’ altruistic versus economic philosophies. The first group included medical director of an HMO, CEO of biotechnology company, medical director of insurance company, and chief of staff of a for-profit hospital system. In contrast to the first group of activities, which were related to for-profit or “business” medicine, the second group included activities traditionally associated with the caring aspects of medicine. This group included medical director of inner city health clinic, chief of staff of a rural hospital, medical liaison for WHO, and Deputy Director for State Board of Health. The combined group ratings were compared with t-tests. As expected, the subgroup scores were significantly different. Mean for the “business” subgroup was 1.85; the “altruism” subgroup mean was 2.25. t(105)=3.02, p=.003. That is, students considered the business group more appealing.
Some items were not included in the analysis of the two activity subgroups. Although medical director of a multi-specialty group was ranked as a favorite job activity by dual degree students, it was not chosen as a logical indicator of economic focus versus altruistic tendencies and thus was not in the groupings.
Although the results of this information would indicate that the students prefer business activities, the comments in the interview do not support the idea that the dual degree students are “in it for the money”. As one student stated, “I want to be in a position where I make good decisions for my patients in a hospital that will benefit them whether that will be cutting costs for them or getting them better care. I want to keep patients first.”
Both dual degree and traditional medical students were asked to select their preferences from a list of career activities, including such things as full-time faculty appointment, private clinical practice and administrative duties. Seventy-eight percent of dual degree students expressed an interest in a combination of clinical and administrative duties; only 13.5 percent of dual degree students planned administrative jobs with no clinical practice. A similar question regarding career preferences was included on the AAMC survey of graduating medical students. Only 1.8 percent of graduating students expressed an interest in health care administration without clinical practice. Table 5 provides additional results on career preferences.
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