#KeyLIMEPodcast 112: Who’s the Boss?  Freud and #Meded

What specialty did you choose in medical school? What specialty did you avoid? Can you feel your counter transference rising?  The Key Literature in Medical Education podcast explores an interesting take on health human resources this week.  The article uses a psychological framework (Social Dominance Theory) to characterize specialty choice among medical students.

Not sure if this topic is for you?  Check out the abstract below for more details.  For a richer debate (and there is lots of it) download the podcast here.

– Jonathan (@sherbino)

KeyLIME Session 112 – Article under review:

Listen to the podcast

View/download the abstract here.

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Lepièce B, Reynaert C, van Meerbeeck P, Dory V. Social dominance theory and medical specialty choice. Advances in Health Sciences Education. 2016 Mar;21 (1):79-92

Reviewer: Jason Frank(@drjfrank)


One important ingredient in an effective health workforce is getting the right type, mix, and distribution of physicians for a population. In most countries, there is a large degree of choice for medical students when they enter residency training en route to specialty certification. The factors that influence future physicians’ career choice are therefore an important topic for medical educators.

Incidentally, there are numerous studies looking at the whole specialty choice enterprise. Few tackle a theoretical psychological model, while most describe a set of influences. The latter papers have previously identified a large number of systemic, intrinsic, and extrinsic factors, including:

  • Perceived future income;
  • Debt load;
  • Difficulty getting a training spot;
  • Work hours during residency;
  • Work-life balance in practice;
  • Length of training;
  • Degree of holism/generalism vs. specialism;
  • Nature of practice setting;
  • Degree of technical vs. cognitive work;
  • Clinical problems of interest;
  • Role models; and
  • Prestige

The literature on this topic continues to grow; the contextual nature of admissions prevents any kind of definitive paper from being published.


In this paper, Lepièce et al explore this idea of prestige in specialty career choice in meded with a unique twist: using Social Dominance Theory (SDT). They sought to characterize the relationship between an interest in hierarchy and specialty career intentions.

Type of Paper

Research: Observation Study

Key Points on Methods

For the purposes of this paper, “prestige” was defined as, “…the respect gained from perceived expertise or know-how…” Social Dominance Theory (SDT) describes the psychosocial practices that contribute to social hierarchies. Social dominance orientation (SDO) is the individual’s preference for hierarchy and prestige. SDO varies by environmental factors and institutional norms.

The authors hypothesized that more technical disciplines would attract those with a higher SDO score. So by their construct, they operationalized “medical prestige” as “person-centred” vs. “technique-oriented” to classify disciplines.

The authors surveyed Belgian medical students at a single site in years 4, 5, & 7 of a 7-year med program. The survey included some general demographics, items about career intentions, and a standardized, previously validated SDO scale by Pratto. They used logistic regression to look for relationships between variables.

There was no research ethics review. This is clearly a single school convenience sample. And there was no effort made to validate the authors’ prestige taxonomy.

Key Outcomes

359 students participated across the 3 cohorts. Participation rate was in the 80s% approximately. The authors found no relationship to age or gender vs. SDO. Undecided students tended to be younger. Those interested in technique-oriented disciplines were more likely to be male, and had higher SDO scores, with an OR of 1.56. SDO scores increased with further training.

Key Conclusions

The authors conclude that SDO predicts career choice of one of two broad groups of specialty prestige. They further posit that greater exposure to hospital-based medicine contributes to progressive SDO scores over time.

(Of course, this is all “on thin ice”, to use a Canadian expression: there are many assumptions and threats to validity in this paper.)

Spare Keys – other take home points for clinician educators

  1. This is an example of a study that shows the power of looking at a meded phenomenon through a novel theoretical lens. We should all be grounding our work to existing theory, where possible.
  1. This journal, Advances in Health Sciences, is particularly oriented to psychological-theory-based papers, even when they have–ahem–significant limitations.
  1. MedEd really is a global enterprise, so this topic, admissions and career choice, is ripe for a cross-border study.

Shout out

A shout-out to Stephen Choi (Ottawa) & Ian Incoll (Sydney), who gave a great session on selecting trainees for successful residency training at ICRE 2015.

Access KeyLIME podcast archives here