Gender and other factors influencing the specialty choice among postgraduate medical students in Bangladesh, 2016 - 2020

Background: Over the last two decades, there has


INTRODUCTION
2][3][4][5][6] This paradigm shift in the medical field is commonly referred to as the feminization of Medicine.Bangladesh has also experienced this trend, with a growing number of females enrolling in medical education over the last two decades. 6From 2006 to 2016, a higher percentage of females, compared to males, were admitted to public and private medical colleges in Bangladesh (40.0% and 58.0% in 2006 and 64.0% and 71.0% in 2016).As of 2020, the percentage of registered physicians was 48.0% male and 52.0%female. 6though both male and female students enroll in medical colleges with similar positive motivational factors such as the instinct to help people, social respect, work independence, and fulfilling childhood dreams 6 , many female physicians drop out of work and become inactive in their careers after graduation. 6,7 ales are often pressured to prioritize their duties towards their families over their careers. 8ngabandhu Sheikh Mujib Medical University (BSMMU) is the only medical university in Bangladesh that produces specialized physicians.To be enrolled in BSMMU, students must successfully pass a competitive entrance examination after graduation.However, choosing a specialty poses a complex decision for medical graduates.It has been observed that physicians exhibit a gender preference in their specialty choices. 6, 9- 11 or instance, males have always outweighed surgery, while female physicians prefer obstetrics and gynecology as their career path. 612 The increasing number of female physicians opting for specific career paths leads to a workforce imbalance in service provision.
Future career opportunities, future income, the demand for a specific specialty, its prestige, workload, the influence of role models, work-life balance, and societal gender norms are all factors that can shape career preferences. 13,14 ender disparity exists in learning, wages, promotion, and societal acceptance, and it often leads to a higher female preference for specialization in one-centric fields rather than diverse ones. 8 is crucial to have a need-based and gender-balanced healthcare workforce to achieve healthy lives and promote well-being for all at all ages. 15Achieving gender equality and empowering women and girls, it is important to encourage female physicians to choose diverse specialties, maintain decision-making autonomy, and assume leadership roles across all sectors of the healthcare system.However, no published data is available on the proportion and distribution of male and female postgraduate medical students in Bangladesh.Therefore, we conducted this study to explore the gender and other factors influencing specialty choices among postgraduate medical students in Bangladesh.

Study design and population
This cross-sectional study was conducted at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka.Data from the Information and Technology Cell of BSMMU from 2016 to 2020 were used to track the trend in postgraduate medical students' (PGMS) choice of specialty.A checklist was used to gather data about each student's sex, field of study, faculty name, and year of admission from 9,112 such records.
A total of 118 PGMS from 37 different disciplines under five faculties-Surgery, Medicine, Basic Science and Para-Clinical Science (BSPC), Pediatrics, and Preventive and Social Medicine (PSM)-were selected for the study.Face-to-face interviews were conducted using a pretested questionnaire from November 2021 to January 2022.Results are expressed in percentage of total admission in the respective faculties.

The questionnaire
A semi-structured questionnaire was prepared, including participants' sex, age, marital status, job status before enrollment, the name of the specialty and faculty they are enrolled in, as well as various influencing factors and barriers to their choice of specialty.The questionnaire was prepared through a literature review 4,13,16,17 and consultative meetings, and finalized after a pretesting.

Data analysis
The collected data were analyzed using the Statistical Package for Social Sciences (SPSS-22), and the results were presented as frequency distributions.The chisquare test was used to analyze the association between the dependent and independent variables, with a statistical significance level set at a P <0.05.

RESULTS
The trend in specialty choice

Barriers to pursuing a desired specialty
Out of the 118 respondents, 59 indicated that they switched their initial choice of specialty and pursued a different one.The majority of participants identified the primary obstacles to pursue their desired specialty as the 'extreme competitive entrance exam' (n=19) and the 'heavy workload' (n=10).In the case of female; challenges included the lack of family support (n=5), gender roles (n=4), and inflexible working hours (n=4).

DISCUSSION
Enrollment in BSMMU by 2020 has achieved a gender balance.However, disparities between specialties are prevalent between male and female postgraduate students.The choice of specialty has been dominatal by personal preferences in Bangladesh.
The health workforce is the core component of the health care system.An adequate, effective, and efficient health workforce is crucial in achieving universal health coverage (UHC) and SDG-3. 15However, a shortage of skilled resources, maldistribution in specialization, imbalanced gender distribution, unsatisfactory working conditions, imbalance in geographical retention, and limited access of data regarding the health workforce are the challenges in achieving SDG-3.Health strategy addresses ending the challenges health human resource planning team, in collaboration with policymakers, must emphasize a need-based, skilled balanced, and gender-balanced workforce. 15On that concern, the Ministry of Health and family welfare of Bangladesh adopted a health workforce strategy addressing capacity development and production, identifying the shortage, and determining the needs of the health workforce. 18r study focused on identifying the production, distribution, and gender balance of the future skilled health workforce.Our study revealed that the percentage of female students has grown in residency and non-residency courses over the years.Still, most students are male in the Faculties of Surgery and Medicine.The ratio of female students in the Faculty of Surgery would be much less if the maternal specialties (Obstetrics and Gynecology, Gynecological Oncology and related subjects) were separated from the faculty.A similar pattern of specialty preference was observed in a study where male dominancy in Surgery and female dominancy in Gynecology and Obstetrics. 19Females seem less enthusiastic about choosing Surgery as their career due to heavy workload and the desire to have a balanced family life.Gender bias and burnout in surgical units are the major issues for female physicians to be consistent and retain in their surgical careers. 20r study trend showed that in the last five years, a small proportion of female student enrolled in maledominated specialties such as neurology surgery, orthopedics, otolaryngology, urology, indicating that self-motivation and career counseling in specialty choice can influence female PGMS in diverse specialty choices.If effective mentorship, improved postgraduate opportunities, and reduced workload are ensured, females will be encouraged to build careers in male-dominated specialties. 9r research identified a gender disparity in the  2019), it was revealed that some female physicians opt for basic medical subjects to steer clear of clinical chaos and ensure a secure working environment. 8In contrast, our study emphasizes that "avoiding night duties" and "avoiding patient interaction" are significant factors influencing female students' career choices.
Over these years at BSMMU, there was an unequal number and gender imbalance of PGMS across the disciplines.However, there is no national document to compare the population's needs with the production of each specialization.The health human resource (HHR) planning team of Bangladesh must be concerned that the deficit and imbalance of the health workforce are the obstacles to achieving UHC. 15 The study revealed that 52.1% of students enrolled as private candidates, indicating that after completing their post-graduate studies, they will either seek employment in private institutes or face unemployment.
A study conducted in Mexico revealed that the unemployment rate and wastage of labor are higher among female physicians. 7HHR should concentrate on the proper utilization of the resources within the system.Our study revealed that in the last five years, the majority of PGMS were graduates from government medical colleges.However, the enrollment of undergraduate students is higher in private medical colleges than in public medical colleges. 6 our investigation of the factors influencing specialty choice, we identified students' interest as the most frequently mentioned factor, as was reported from Iran 13 and Bangladesh 14 .While specialty choice is a personal decision and individuals should prioritize their own preferences, it is important to consider the potential impact of personal choices on the labor market.An approach that solely focuses on producing human resources based on individual preferences may result in imbalances, with certain specialties becoming oversaturated while others remain undersaturated.
Early career counseling in medical education could motivate students to consider a diverse range of specialty choices. 9 This study found multiple factors influencing specialty selection, with gender differences in motivational factors.Among men, career-related factors such as future opportunities and income had a stronger influence.However, women were more concerned about personal factors like working hours and work-family balance.Female participants showed a greater influence of professional factors such as avoiding emergency duties, night duties, and patient interactions.Similar patterns were observed in other studies. 13,21 ver half of the female students considered their "gender" as an important factor in career choice.On the other hand, the society tends to perceive male physicians as more intelligent and accomplished in certain specialties. 6rkplace security, promotions, wages, familial pressure, and societal acceptance are all linked to gender in the medical profession.This can be achieved by ensuring flexible working hours, providing childcare facilities, ensuring workplace safety, and promoting improved status for women in the family and society.

Conclusion
The proportion of female postgraduate medical students has been increasing in all five faculties of BSMMU.By 2020, an overall gender balance has been achieved.
Personal interest in the specialty, future career opportunity, and demand for the specialty dominate the specialty choice of the doctors.Moreover, a substantial gender preference persists to influence their choices.
The gender-based choices could probably be minimized with relevant interventions.

Ultimately, it is
possible to establish a need-based skilled health workforce by allocating postgraduate seats based on the requirements of the healthcare system.The medical colleges should provide career counseling during undergraduate medical education, taking into account the career development, and requirements in the healthcare system.To achieve a gender-balanced health sector, efforts should be made to minimize gender preferences in specialty choices.

TABLE 1
Trend in enrollment of male and female postgraduate medical students in BSMMU according to the specialty, 2016 -2020.

TABLE 2
Trend in enrollment of male and female postgraduate medical students of BSMMU according to the programmes, 2016 -2020 (n=9,112) total of 9,112 PGMS enrolled in 73 disciplines under five faculties of BSMMU, where 53.7% were male and 46.3% were female.There was a gradual increase in the percentage of female student enrollment from 41.6% in 2016 to 49.3% in 2020.The total PGMS enrollments in the faculties of Surgery, Medicine, BPCS, Pediatrics, and PSM were 43.1%, 23.3%, 17.0%, 9.1%, and 7.5%, respectively.Female enrollment in the faculties of Medicine and Surgery gradually increased throughout these five years, from 25.3% to 30.5% and 32.6% to 43.3%, respectively.The Faculty of BPCS consistently had a female representation above 70%.However, the number of male and female students enrolling in the Faculty of Pediatrics fairly over the years.The proportion of female students in the Faculty of PSM increased from 59.3% to 75.0% (TABLE1).BSMMU provides two different programmes: a residency programme consisting of Doctor of Medicine (MD), Master of Surgery (MS), and Master of Philosophy (M.Phil), and a non-residency programme consisting of Diploma, Master of Medical Education (MMEd), and the Master of Public Health (MPH) programme under the five faculties.Over the years, there has been a gradual increase in the number of female students in the MD, MS, Diploma, M.Phil, and students were female in all disciplines except for Medical Education (38.3%).There are eight disciplines Alam EV et al.Bangabandhu Sheikh Mujib Medical University Journal 2023; https://doi.org/10.3329/bsmmuj.v16i3.67860Specialty choice trends among post-graduate medical students 154 and a desire to avoid direct patient contact (TABLE 5).Alam EV et al.Bangabandhu Sheikh Mujib Medical University Journal 2023; https://doi.org/10.3329/bsmmuj.v16i3.67860Specialty choice trends among post-graduate medical students 155

TABLE 4
*Results are given in percent.BPCS indicates Basic Science and Para Clinical Science; PSM, Preventive and Social Medicine.

TABLE 5
Influencing factors in specialty choice among male and female postgraduate medical student of BSMMU by sex (n=118)