To be or not to be an Obstetrician / Gynaecologist

Objectives: This qualitative study aimed to explore motivational sources of physicians, at the time of selection and while pursuing ObGyn career. Secondary aim was to explore challenges and strategies adapted by these physicians to overcome these challenges. Methods: This is qualitative study with constrictive worldview. ObGyn residents and consultants of Aga Khan University, Karachi, were interviewed from July 2017 till Jan 2019, after ethical approval, using purposeful maximum variation sampling. Analysis were conducted by identifying keywords and phrases, these unedited verbatim with no assumptions provided basis for codes, which then clustered as trends. Emerging findings were discussed among authors and themes were finalized with consensus. Conclusion was formulated by linking these themes. Results: Four themes emerged were, ‘grounds for selecting ObGyn as career’, ‘Motivational Factors’, ‘Demotivating Factors’ and ‘Strategies to Cope with Challenges’. Results showed that aptitude and passion not only have pivotal role in career selection but also helped in pursuance. Personal fulfilment and hands-on experience satisfy emotional needs, while family and friends supported participants in maintaining work-life balance and in over-coming challenges. Conclusions: Considering personal preference and aptitude at the time of career selection helps in endurance and keep motivations high, while challenges in pursuance can be overcome by strong support system.


INTRODUCTION
Obstetrics and Gynaecology (ObGyn) is one of the highly demanding fields with obvious gender polarization. 1 Specially in social structure like that of Pakistan, women prefer female doctor for ObGyn services. This cultural influence makes ObGyn a preferred choice of female physicians for postgraduate training. 2 Personal aptitude and desires of family also contribute to this decision. 3 While prolonged working hours with family commitments makes ObGyn extremely challenging, especially for young female doctors. It is often difficult for them to maintain work-life balance. Although national data is not available but dropout rate and switching to specialty, were observed among ObGyn resident. Even the residents with a diehard passion for this speciality, are sometime unable to cope with the challenges. 2,4 High levels of commitment and motivation are required to deal-in with day to day challenges.
International literature has analysed various aspects of selecting ObGyn and motivational undercurrents for career pursuance, but to the best of our knowledge local studies did not focus on ObGyn physicians and most of these are descriptive studies. 5 This qualitative study was intended to explore motivational sources at the time of selection and while pursuing ObGyn career. While, secondary aim was to explore challenges and strategies adapted by these physicians to overcome these challenges. It can serve as a career-guide for medical graduates and mentoring junior doctors. Moreover, it can be helpful in modifying post-graduate curricula in accordance with participants interests.

METHODS
This qualitative study with constrictive worldview targeted physicians including residents and consultants of ObGyn department, Aga Khan University (AKU), Karachi Pakistan conducted from July 2017 till Jan 2019. Phenomenology Design was used for data analysis. Considering limited population and their willingness for participation, purposeful maximum variation sampling technique was used. Approval was obtained from 'Ethical Review Committee, The Aga Khan University' (4524-Obs-ERC-16 (Nov 21,2016). Study subjects were divided into two groups; 'residents group' included post-graduate trainees from year one to four and 'consultants group' comprised of physicians working in ObGyn. Participants were approached after seeking permission from chairperson of ObGyn department. Variation among participants was managed by including residents from each year of training, while consultants from different subspecialties, age groups and years of experience.
In-depth Interviews were conducted, with written consents of participants, until data was saturated. Semistructured predetermined interview guide was used, consisting of open-ended questions with predecided probes. Dry run of interview guide was conducted before formal interviews. Ideas were further explored depending upon responses but four basic questions were asked form each participant. Sequence of questions and alternate phrases complemented one another and maintained the dependability of responses.

The basic questions were:
• Why did you select OBGYN as a career?
• What are the factors that kept you motivated to pursue OBGYN as career? • What were the factors that made it difficult to continue in this field? • How did you cope with the difficulties?
Interviews were conducted in English and recorded on voice recorders. Field notes were taken by the researcher including observations of nonverbal gestures, tone and unintended responses. These field notes helped in triangulation of data and transcripts were sent back to respondent for member checking. Confidentiality was assured by maintaining participants' anonymity and not mentioning age, year of experience subspecialty. Code 'R' represents residents and 'C' is for consultant whereas number was allotted to each participant, alphabetically. Recordings were destroyed two weeks after validation while transcript will be stored with password protection for five years as a property of AKU.
Analysis were conducted by identifying keywords and phrases, these unedited verbatim with no assumptions provided the basis for coding. Codes were clustered as trends and overarching themes were extracted from these trends. Emerging findings were discussed among authors and themes were finalized with consensus. These themes were then linked together to formulate a conclusion.

RESULTS
All participants partake in our study were females. Post-graduation experience of consultants ranged from five to 30 years. Data got saturated after interviewing nine participants from each group. Four themes emerged after interpretation and comprehension of trends include; 'Grounds for Selecting ObGyn as Career', 'Motivating factors', ( Table-I Tables-II).
Prevalent themes, trends within these themes, and selected comments verbatim form participants, representing different data chunks in transcripts are shown in Table-I and II. Selected comments and total responses coded together as a trend are given in parentheses (selected comments/total comments). Table-

DISCUSSION
This study focused on motivations of doctors while selecting and during pursuing career in ObGyn. It also explored demotivating factors and some strartegies adapted by our participants to overcome these challenges. Qualitative method was used, for in-depth exploration and understanding. These findings will help in career-counselling and mentoring young doctors during different phases of their career. It will be a contribution to literature in local perspective.
Personal Preference was the fore-most reason for career-selection. Eleven out of 18 participants either have a passion for ObGyn or for surgery, 6 (Table-I 7 This attitude towards surgery is highly motivational, most of our participants enjoy hand-on surgeries and found experiential learning highly effective. (Table-I, comment 20-23). 4,[8][9][10] Therefore, ObGyn postgraduate curriculum should include more of psychomotor component.
Decisions of participants seemed to be influenced by families (Table-I 6. 'Sometimes the feedback which we got. I think there are less people who encourage you, but more will discourage you…' (R9)  (Table-II,  comment 07-11) Overall medical professionals are compassionate, especially female doctors are more social and connected to their patients emotionally. 9,[11][12][13][14] Empathy and altruism was obvious among our physicians as well. Almost every participant (16/18) considered Emotional Satisfaction as a major motivating factor. (Table-I,  comment [16][17][18][19].

Theme IV: Strategies to cope with challenges
A proven influence of role models and mentors was found to be a continuous source of inspiration and support during different career-stages in our study. 4,10 (Table-I, comment 26) Although Higham considered 'lack of positive role models' in ObGyn causing disinterest among medical students, 7 but it compelled one of our consultants to become an ObGyn specialist. (Table-I, comment 09).
Gender polarization in ObGyn was evident as a cultural norm in this group as well. Four out of them considered it as 'female-oriented' field and were comfortable in dealing with female patients and co-worker. 4,8,13,[15][16][17] (Table-I, comment [10][11] Interestingly, in ObGyn department all but two consultants are females, while over past ten years no male doctor opted for ObGyn residency. ObGyn, being one of the highly paid specialties, was chosen by medical students for financial benefits and paying debts. 3,8,13,16,18 However, our results were more consistent with Scott et al., because financial aspect was not the primary motive among this group. 9 Three out of eighteen participants have mentioned it as a secondary consideration. (Table-I comment, [14][15] ObGyn with narrow scope of practice, may be a good choice for those who looking for a short course-line, however this doesn't mean a less hectic job or a controllable life-style. 9 This subliminal thought was shared by two of highly committed and busy consultants. Interestingly they both resumed their career after completing their families. (Table-I, comment [12][13] As reported by Shirley and Hochberg, major trials for our subjects were maintaining work-life balance (Table-II, comment 1-2) and prolonged working hours (Table-II, comment 3-5). 10,14,18 But most of our participants accepted it as a challenge and tried to manage it with positive attitude and healthy activities. (Table-II, comment 12-15) Maintaining work-life balance, according to them, would be a challenge for any working women in medical and nonmedical professions, especially if dealing-in with emergencies (Table-II, comment  01, 05).
To be or not to be…

Limitations of the study: Study focused only on
ObGyn residents & consultants at a single centre where the principle investigator works. Since these are the doctors who are already committed to this profession so may not represent those who have already quit. Moreover, AKU is a private university therefore, this study may not represent the views of doctors in other hospitals of private and government sector.

CONCLUSION
Pursuance of career needs passion, therefore, aptitude of individual should be considered during career-counselling and on induction in postgraduate programmes. Structured mentoring programmes can be introduced in ObGyn for support and guidance to overcome the potential challenges. Further research is needed, to broaden the understanding for designing ObGyn curriculum and shaping physicians' motivations.