Comparison of medical students' considerations in choosing a specialty: 2020 vs. 2009/10.

BACKGROUND: Workforce shortage in healthcare and particularly in physicians poses a threat to healthcare delivery and its quality. In comparison to other OECD countries, Israel currently has a small number of medical graduates relative to its number of physicians, naturally emphasizing the importance of ensuring that this population chooses to remain in medicine. Understanding what is most important to medical students can help improve working conditions in residency. Such information is particularly needed to facilitate policy planning that will encourage the next generation of physicians to specialize in medical fields that are experiencing shortages. We hypothesized that between 2009/2010 and 2020, there were significant changes in medical students' preferences regarding their considerations for choosing a medical specialty. METHODS: We compared cross-sectional data from questionnaire-based surveys of 5th year medical students performed in 2009-2010 and 2020 at two Israeli universities. RESULTS: Of the 335 medical students who responded (237 and 98 in 2009/2010 and 2020, respectively) those in 2020 were 2.26 less likely vs. those in 2009/2010, to choose a residency for its high-paying potential (P < 0.05), and had significantly more interest in residencies with greater teaching opportunity (98.8% vs 82.9%, P < 0.05), increased responsibility and chances to make clinical decisions on their own (67.9% vs 51.6%, P < 0.05). Criteria important to both the 2009/2010 and 2020 students were choosing a bedside specialty (70.2%vs 67.9%, NS), and an interesting and challenging specialty (95.2%v s 91.3%, NS). CONCLUSIONS: These results partially supported our hypothesis that medical students' preferences have changed over the years, though there are fundamental factors that apparently reflect medical students' nature that do not change over time.

Unpopular medical specialties: exploring the concept that "the customer knows best".

BACKGROUND: Healthcare systems often face shortages of certain medical specialists due to lack of interest among medical students. We questioned a common "one solution fits all" approach to this problem which involves monetary incentives to lure students to these specialties. Instead, we used the marketing principle the "consumer knows best" to explore ways of elucidating the reasons and proposing solutions for such shortages. METHODS: A convenience sample of Israeli 6th-year medical students and interns completed questionnaires to determine why they thought three specialties (geriatrics, anesthesiology, emergency medicine) were unpopular and their ideas on increasing their appeal. RESULTS: 119 6th-year students and 84 interns completed questionnaires. Geriatrics was reported having a problematic patient population; not being interesting and challenging; and not considered prestigious by colleagues and the populace. This contrasts with emergency medicine which, although considered prestigious, has difficult working conditions both during and after residency accompanied by much pressure at work. Although, improvements in lifestyle and remuneration were thought by students and interns as possibly making these specialties more attractive, reducing the pressure at work and decreasing on-call obligations were designated by the students/interns as ways to increase emergency medicine's and anesthesiology's appeal. Half the students replied that anesthesiology would be more appealing if work was in shifts (< 16 h), while 60% replied so for emergency medicine and only 18% for geriatrics. 90% of students reported that control over lifestyle would make emergency medicine more attractive while 55% and 48% replied positively for anesthesiology and geriatrics, respectively. CONCLUSIONS: Using the concept "consumer knows best" provided additional insight into the specialty selection process. Students/interns have specialty-specific opinions as to why some specialties are unpopular. Their ideas about attracting more students to these specialties were also specialty-dependent, i.e. "one solution does not fit all". These observations render problematic a single solution aimed at ameliorating the workforce shortages of multiple specialties. Instead, these results advocate a differential approach wherein the lack of appeal of each unpopular specialty is analyzed individually and the students'/interns' (the "consumers") ideas sought resulting in solutions tailored to address each specialty's lack of attractiveness. TRIAL REGISTRATION: None.

Intensive Care Unit Caregivers Perception of Patient Discomfort: A Qualitative Study.

BACKGROUND: Being hospitalized in an intensive care unit ICU often involves pain and discomfort. While pain is commonly alleviated with analgesics, discomfort is more difficult to diagnose and treat, thus potentially leading to incorrect analgesic administration. AIM: To describe intensive care unit practitioners' perceptions of discomfort in the ICU, and their methods to discern between pain and non-pain discomfort. METHODS: Twenty-five intensive care unit practitioners (7 doctors and 18 nurses) were interviewed from medical and general intensive care units at one institution in Jerusalem, Israel. Data collection was performed using semi-structured interviews. Interviews were audio-recorded and transcribed. Transcriptions were coded and categorized by two researchers independently. Content analysis identified common themes. RESULTS: Two main discomfort themes were identified: unpleasant physical sensations and unpleasant psychologic feelings, with further subcategories. Physiologic and non-physiologic signs such as facial expression and motor activity helped to diagnose discomfort. Trial and error and cause and effect were used to differentiate pain from other sources of discomfort. CONCLUSIONS: Practitioners saw pain as a dominant source of discomfort. Treating overall discomfort should focus on improving the quality of the total intensive care unit experience. Strategies to diagnose non-pain discomfort and pain were similar. Differentiating pain from non-pain discomfort is essential in order to provide appropriate treatment for pain and non-pain-related discomfort.

Difficult airway management practice changes after introduction of the GlideScope videolaryngoscope: A retrospective cohort study.

BACKGROUND: Introduction of the GlideScope videolaryngoscope caused a change in use of other devices for difficult airway management. OBJECTIVE: The influence of the GlideScope videolaryngoscope on changes in the indications for and the frequency of use of flexible fibreoptic-assisted intubation and other difficult airway management techniques. DESIGN: Retrospective cohort study. SETTING: Tertiary care referral centre. METHODS: Two periods of equal length (647 days each) before and after introducing the GlideScope were compared. Information about patients who were intubated using nondirect laryngoscopic techniques were analysed. Data were retrieved from the anaesthesia and hospital information management systems. RESULTS: Difficult airway management techniques were used in 235/8306 (2.8%) patients before and in 480/8517 (5.6%) (P < 0.0001) patients after the introduction of the GlideScope. There was an overall 44.4% reduction in use of flexible fibreoptic bronchoscopy after GlideScope introduction [before 149/8306 (1.8%); after 85/8517 (1.0%), P < 0.0001]. The GlideScope replaced flexible fibreoptic bronchoscopy in most cases with expected and unexpected difficult intubation. In patients with limited mouth opening, flexible fibreoptic bronchoscopy was still mostly the first choice after the introduction of the GlideScope. There was a 70% reduction in the use of other difficult intubation techniques after the introduction of the GlideScope [before 84/8306 (1.0%); after 22/8517 (0.3%), P < 0.0001)]. CONCLUSION: The GlideScope videolaryngoscope replaced flexible fibreoptic bronchoscopy for most patients with expected and unexpected difficult intubation. In the case of limited mouth opening, flexible fibreoptic bronchoscopy was still the first choice after the introduction of the GlideScope. The reduced use of flexible fibreoptic bronchoscopy raises concerns that residents may not be adequately trained in this essential airway management technique. GlideScope use was disproportionately greater than the reduction in the use of flexible fibreoptic bronchoscopy and other difficult intubation techniques. This may be attributed to resident teaching and use in patients with low-to-moderate suspicion of difficult intubation.

The ratio of PACU length-of-stay to surgical duration: Practical observations.

BACKGROUND: Operating room (OR) and post-anesthesia care unit (PACU) activity are closely linked since the number, type, and sequence of surgeries influence subsequent PACU activity. We aimed to explore the relationship between duration-of-surgery (DOS) and PACU length-of-stay (LOS), the PACU-LOS:DOS ratio, since it is among the determinants of the number of PACU beds and nurse staffing required to insure efficient egress of patients from the OR. METHODS: PACU-LOS:DOS ratio was examined using retrospective data from a tertiary medical center's surgical information system (Phase 1) and prospectively collected data from a convenience sample of post-operative patients (Phase 2). RESULTS: Phase 1 included 17 047 patients, the majority (73%) with PACU-LOS:DOS ratios >1.0, indicating PACU-LOS longer than DOS. Median PACU-LOS was 117 minutes, median DOS was 80 minutes, and median PACU-LOS/DOS ratio was 1.5. PACU-LOS showed greater variability than DOS because of extended PACU stays. Phase 2 (n = 2054) confirmed Phase 1 results (median PACU-LOS/DOS ratio - 1.8). In both phases at a DOS of >130 minutes PACU-LOS/DOS ratio became <1.0. In 24% of Phase 2 patients PACU-LOS was prolonged because of administrative issues. Post-operative, more than pre- and intra-operative, measurements influenced PACU-LOS. CONCLUSIONS: The PACU-LOS/DOS ratio proved useful for demonstrating interactions between 2 central components of the surgical system. The many patients with PACU-LOS:DOS ratios >1.0 provides objective evidence for the number of PACU beds exceeding the number of ORs.

Using medical specialty and selection criteria clusters to study specialty selection by Israeli medical students.

BACKGROUND: During their final year of medical school, Israeli students must consider which specialty to choose for residency. Based on the vocational counseling literature we presumed that choices are made by selecting from a cluster of related specialties while considering professional and socio-economic issues. METHODS: Questionnaires distributed to final-year medical students at two Israeli medical schools ascertained inclinations toward various medical specialties and the importance of various selection criteria. Analysis focused on seven specialties where >20% of students reported they had positive inclinations. For each such specialty, the specialty and selection criteria query were compared using unpaired two-tailed Student's t-tests to determine differences between students with positive inclinations toward the specialty with those not so inclined. These data were placed in tables, with the significant differences highlighted to facilitate visual recognition of cluster patterns. RESULTS: Completed questionnaires were obtained from 317 of 455 students. Students often had positive inclinations toward more than one specialty (specialty clusters) associated with a group of selection criteria (selection criteria clusters). For example, interest in internal medicine was clustered with interest in internal medicine subspecialties, cardiology and research. Furthermore, there was a "reciprocal" aspect to some specialty cluster patterns. For example, those interested in internal medicine had little interest in surgical specialties. Selection criteria clusters revealed occupational interests and socio-environmental factors associated with the specialty clusters. For example, family medicine, which clustered with pediatrics and psychiatry, had a sub-cluster of: Bedside specialty with family orientation affording long-term patient care. Another sub-cluster was time for childrearing and family, only daytime work and outpatient care. Clusters also revealed students' perceptions that differed from expected: Cardiology is changing from a cognitive to a procedure-oriented subspecialty, clustering not only with internal medicine and its subspecialties but also with emergency medicine, surgical subspecialties and anesthesiology. CONCLUSIONS: The concept that career choice involves selecting from a cluster of related specialties provides information about the specialties students might be considering. Moreover, students are not only looking for individual aspects of a specialty, but for a package including clusters of socio-economic and occupational features. Practically, examining clusters can help in career counseling of medical students and assist residency program directors in marketing their specialties.

Therapeutic plasma exchange as treatment for propofol infusion syndrome.

Propofol infusion syndrome (PRIS), a rare complication of propofol sedation, is associated with high mortality. There is no specific therapy. A 16-year-old with head injury and status epilepticus is described. Three days after seizure resolution, whilst receiving propofol, he developed severe lactic acidosis, rhabdomyolysis, and hemodynamic instability. Suspected PRIS was treated with a single session of therapeutic plasma exchange (TPE). This was associated with immediate improvement in hemodynamic status, resolution of lactic acidosis within 24 h, normalization of CPK over 10 days, and a subsequent full recovery. TPE is suggested as a novel therapy for PRIS.

Multicentre validation of manufacturers' weight-based recommendations for laryngeal mask airway size choice in anaesthetic practice: A retrospective analysis of 20,893 cases.

BACKGROUND: Manufacturers' weight-based recommendations for laryngeal mask airway (LMA) sizes are not scientifically founded and have never been validated clinically. OBJECTIVE: The validation of manufacturers' weight-based recommendations in clinical practice and whether other patient variables such as sex and age may influence LMA size choice. DESIGN: A retrospective study. SETTING: Four Israeli hospitals (two tertiary and two secondary hospitals). METHODS: Data on LMA use were retrieved from the Anaesthesia Information Management System (AIMS). Multinomial logistic regression analysis including weight, sex and age amongst adults, adolescents and children was used to identify predictors of LMA size used (development data set). Concordance between the size of LMA used and that predicted according to the model and the manufacturers' recommendations was assessed (validation data set). RESULTS: LMA insertions were analysed in 13,743 (65.8%) adults, 1807 (8.6%) adolescents and 5343 (25.6%) children. Suitability of manufacturers' recommendations was higher in children [4075/5343 (76.3%)] than adults [5200/13743 (37.8%)] or adolescents [885/1807 (49.0%); P < 0.001 for children vs. adults or adolescents]. Sex influenced LMA size in adults and adolescents, but not in children. Age had no influence. Amongst adults and adolescents, LMA size was better predicted by the regression model than by manufacturers' recommendations [adults: anaesthetists/model 61.7%, 95% confidence interval (95% CI) 60.1 to 63.2, anaesthetists/manufacturer 38.4%, 95% CI 36.0 to 39.0, P < 0.001; adolescents: anaesthetists/model 68.1%, 95% CI 64.1 to 72.0, anaesthetists/manufacturer 46.9%, 95% CI 42.7 to 51.1, P < 0.001]. In children, the regression model and manufacturers' weight-based recommendations performed equally (anaesthetists/model 78.0%, 95% CI 75.9 to 80.0, anaesthetists/manufacturer 75.7%, 95% CI 73.6 to 7.8, P = 0.126). CONCLUSION: Manufacturers' weight-based recommendations for LMA size reflect clinical practice in children, but not in adults and adolescents. In these age groups, choice of LMA size is influenced by sex and weight, although with wider ranges than those recommended by manufacturers.

Troponin elevation in severe sepsis and septic shock: the role of left ventricular diastolic dysfunction and right ventricular dilatation*.

OBJECTIVE: Serum troponin concentrations predict mortality in almost every clinical setting they have been examined, including sepsis. However, the causes for troponin elevations in sepsis are poorly understood. We hypothesized that detailed investigation of myocardial dysfunction by echocardiography can provide insight into the possible causes of troponin elevation and its association with mortality in sepsis. DESIGN: Prospective, analytic cohort study. SETTING: Tertiary academic institute. PATIENTS: A cohort of ICU patients with severe sepsis or septic shock. INTERVENTIONS: Advanced echocardiography using global strain, strain-rate imaging and 3D left and right ventricular volume analyses in addition to the standard echocardiography, and concomitant high-sensitivity troponin-T measurement in patients with severe sepsis or septic shock. MEASUREMENTS AND MAIN RESULTS: Two hundred twenty-five echocardiograms and concomitant high-sensitivity troponin-T measurements were performed in a cohort of 106 patients within the first days of severe sepsis or septic shock (2.1 ± 1.4 measurements/patient). Combining echocardiographic and clinical variables, left ventricular diastolic dysfunction defined as increased mitral E-to-strain-rate e'-wave ratio, right ventricular dilatation (increased right ventricular end-systolic volume index), high Acute Physiology and Chronic Health Evaluation-II score, and low glomerular filtration rate best correlated with elevated log-transformed concomitant high-sensitivity troponin-T concentrations (mixed linear model: t = 3.8, 3.3, 2.8, and -2.1 and p = 0.001, 0.0002, 0.006, and 0.007, respectively). Left ventricular systolic dysfunction determined by reduced strain-rate s'-wave or low ejection fraction did not significantly correlate with log(concomitant high-sensitivity troponin-T). Forty-one patients (39%) died in-hospital. Right ventricular end-systolic volume index and left ventricular strain-rate e'-wave predicted in-hospital mortality, independent of Acute Physiology and Chronic Health Evaluation-II score (logistic regression: Wald = 8.4, 6.6, and 9.8 and p = 0.004, 0.010, and 0.001, respectively). Concomitant high-sensitivity troponin-T predicted mortality in univariate analysis (Wald = 8.4; p = 0.004), but not when combined with right ventricular end-systolic volume index and strain-rate e'-wave in the multivariate analysis (Wald = 2.3, 4.6, and 6.2 and p = 0.13, 0.032, and 0.012, respectively). CONCLUSIONS: Left ventricular diastolic dysfunction and right ventricular dilatation are the echocardiographic variables correlating best with concomitant high-sensitivity troponin-T concentrations. Left ventricular diastolic and right ventricular systolic dysfunction seem to explain the association of troponin with mortality in severe sepsis and septic shock.

Accuracy of manual entry of drug administration data into an anesthesia information management system.

PURPOSE: Data on drug administration are entered manually into anesthesia information management systems (AIMS). This study examined whether these data are accurate regarding drug name, dose administered, and time of administration, and whether the stage of anesthesia influences data accuracy. METHODS: Real-time observational data on drug administration during elective operations were compared with computerized information on drug administration entered by anesthesiologists. A trained observer (K.D.) performed the observations. RESULTS: Data were collected during 57 operations which included 596 separate occasions of drug administration by 22 anesthesiologists. No AIMS records were found for 90 (15.1%) occasions of drug administration (omissions), while there were 11 (1.8%) AIMS records where drug administration was not observed. The AIMS and observer data matched for drug name on 495 of 596 (83.1%) occasions, for dose on 439 of 495 (92.5%) occasions, and for time on 476 of 495 (96.2%) occasions. Amongst the 90 omitted records, 34 (37.8%) were for vasoactive drugs with 24 (27.7%) for small doses of hypnotics. Omissions occurred mostly during maintenance: 50 of 153 (24.6%), followed by induction: 30 of 325 (9.2%) and emergence: 10 of 57 (17.5%) (P < 0.001). Time and dose inaccuracies occurred mainly during induction, followed by maintenance and emergence; time inaccuracies were 7/325 (8.3%), 10/203 (4.9%), and 0/57 (0%), respectively (P = 0.07), and dose inaccuracies were 15/325 (4.6%), 3/203 (1.5%), and 1/57 (1.7%), respectively (P = 0.11). CONCLUSION: The range of accuracy varies when anesthesiologists manually enter drug administration data into an AIMS. Charting omissions represent the largest cause of inaccuracy, principally by omissions of records for vasopressors and small doses of hypnotic drugs. Manually entered drug administration data are not without errors. Accuracy of entering drug administration data remains the responsibility of the anesthesiologist.

Measuring pain or discomfort during routine nursing care in lightly sedated mechanically ventilated intensive care patients: A prospective preliminary cohort study.

BACKGROUND: Pain is routinely measured on mechanically ventilated ICU patients. However, the tools used are not designed to discriminate between pain and non-pain discomfort, a distinction with therapeutic implications. OBJECTIVES: To evaluate whether clinical measurement tools can discern both pain and non-pain discomfort. METHODS: A prospective observational cohort study was conducted in a General ICU at a tertiary Medical Center in Israel. The Behavior Pain Scale (BPS) and Visual Analog Scale (VAS) of Discomfort were simultaneously assessed by a researcher and bedside nurse on thirteen lightly sedated patients during 71 routine nursing interventions in lightly sedated, mechanically ventilated, adult patients. Patients were asked whether they were in pain due to these interventions. RESULTS: Statistically significant increases from baseline during interventions were observed [median change: 1.00 (-1-5), 1.5(-4-8.5), p < 0.001] as measured by BPS and VAS Discomfort Scale, respectively. BPS scores ranged between 4 and 6 when the majority (53 %) of the patients replied that they had no pain but were interpreted by the clinicians as discomfort. Endotracheal suctioning caused the greatest increase in BPS and VAS, with no statistically significant differences in BPS and VAS Discomfort Scale scores whether patients reported or did not report pain. A BPS>6 had a higher sensitivity and specificity to reported pain (accuracy of 76 %) compared to a BPS of 4-6. CONCLUSIONS: Standard assessments are sensitive to pain caused by routine nursing care interventions. However, this study presents evidence that among lightly sedated ICU patients, moderate BPS scores could also measure non-pain discomfort. ICU nurses should be aware that signs of unpleasantness measured by a pain scale could reflect non-pain discomfort.

The Israeli anesthesiology workforce crisis: a reassessment survey.

BACKGROUND: Anesthesiologists provide crucial anesthesiology services in the operating room and non-operating room locations. Combined with an aging and growing Israeli population, there is an increasing demand for anesthesiology services. A previous study performed in 2005 showed that most anesthesiologists are immigrant physicians with few Israeli medical school graduates. Since then, physician immigration decreased, many have retired and demand for anesthesia services has increased while insufficient numbers of new anesthesiologists were trained, leading to a shortage, limiting surgeries and other procedures in many hospitals. The present study examined the composition of the Israeli anesthesiology workforce in 2021and compared it to the 2005 workforce. METHODS: A cross-sectional survey of demographic and professional information about each Israeli hospital anesthesiologists was solicited from 34 anesthesiology department chairs responsible for 36 Israeli acute care hospitals. RESULTS: There are 1313 anesthesiologists in the 36 hospitals, resulting in a ratio of 14.2 anesthesiologists per 100,000 population. 22.6% of anesthesiologists will reach retirement age over the next ten years. The proportion of female anesthesiologists was 28.7%. While Israeli medical school graduates increased to 18.1% from 12.2% in 2005, non-Israeli citizens and non-permanent residents comprised 8.5% of the workforce. CONCLUSIONS: Despite growth in the ratio of anesthesiologists per population, a workforce shortage is expected to worsen over the next ten years due to retirements, shortened call hours, and the Yatziv reform which bans graduates of certain overseas medical schools from obtaining Israeli Medical Licenses. The current workforce has compensated for the existing shortage of anesthesiologists by enlisting non-Israeli trainees from overseas. Yet, it is crucial to maintain and enlarge the local Israeli workforce to forestall a worsening shortage.

Diastolic dysfunction and mortality in severe sepsis and septic shock.

AIMS: Systolic dysfunction in septic shock is well recognized and, paradoxically, predicts better outcome. In contrast, diastolic dysfunction is often ignored and its role in determining early mortality from sepsis has not been adequately investigated. METHODS AND RESULTS: A cohort of 262 intensive care unit patients with severe sepsis or septic shock underwent two echocardiography examinations early in the course of their disease. All clinical, laboratory, and survival data were prospectively collected. Ninety-five (36%) patients died in the hospital. Reduced mitral annular e'-wave was the strongest predictor of mortality, even after adjusting for the APACHE-II score, low urine output, low left ventricular stroke volume index, and lowest oxygen saturation, the other independent predictors of mortality (Cox's proportional hazards: Wald = 21.5, 16.3, 9.91, 7.0 and 6.6, P< 0.0001, <0.0001, 0.002, 0.008, and 0.010, respectively). Patients with systolic dysfunction only (left ventricular ejection fraction ≤50%), diastolic dysfunction only (e'-wave <8 cm/s), or combined systolic and diastolic dysfunction (9.1, 40.4, and 14.1% of the patients, respectively) had higher mortality than those with no diastolic or systolic dysfunction (hazard ratio = 2.9, 6.0, 6.2, P= 0.035, <0.0001, <0.0001, respectively) and had significantly higher serum levels of high-sensitivity troponin-T and N-terminal pro-B-type natriuretic peptide (NT-proBNP). High-sensitivity troponin-T was only minimally elevated, whereas serum levels of NT-proBNP were markedly elevated [median (inter-quartile range): 0.07 (0.02-0.17) ng/mL and 5762 (1001-15 962) pg/mL, respectively], though both predicted mortality even after adjusting for highest creatinine levels (Wald = 5.8, 21.4 and 2.3, P= 0.015, <0.001 and 0.13). CONCLUSION: Diastolic dysfunction is common and is a major predictor of mortality in severe sepsis and septic shock.

When policy meets reality: the new 18-hour on-call shift policy and the Israeli anesthesia workforce crisis.

BACKGROUND: The Israeli physician workforce faces multiple challenges. These include planned policies reducing physician on-call from 26 to 18 h and, from 2026, allowing only graduates of Ministry of Health approved foreign medical schools to take the Israeli licensing examination and an ongoing physician shortage (2019: Israel had 3.19 physicians/1000 persons vs. OECD average of 3.49 physicians/1000 persons). This study examines the potential impact of these planned policies on the Israeli anesthesiology workforce. METHODS: Surveys conducted among 34 public and private Israeli hospital anesthesiology department chairs collected data on their department's number of weekday on-call anesthesiologists and current shortage of anesthesiologists. A subsequent survey collected data on each anesthesiologist in the workforce, including the country where they studied medicine. RESULTS: Each weekday night there were 114 on-call anesthesiologists; 72 residents and 42 attendings. Using productive work coefficients, this translates to 104 resident and 51 attending anesthesiologists. Furthermore, 21 departments had existing anesthesia workforce shortages totaling 110 anesthesiologists. There were 873 anesthesiologists from non-OECD countries whose medical schools are not accredited by the World Federation for Medical Education, of whom 332 were residents (61.9% of residents). Only 20.1% of anesthesiology residents were Israeli medical school graduates. CONCLUSIONS: Descriptive survey data assessed the immediate and long-term consequences for the healthcare system and anesthesiology workforce of two new Health Ministry policies. Implementing the 18-h policy will immediately remove from the daytime workforce 155 anesthesiologists and who will be unavailable to staff elective surgery operating rooms. This will compound the current national shortage of 110 anesthesiologists. It is unclear how to replace this shortfall since there are no surplus Israeli physicians and very few Israeli graduates choose anesthesiology as a specialty. This situation will be exacerbated after 2026 when graduates of certain foreign medical schools will be unable to enter the medical workforce, further reducing the pool of potential anesthesiology residents. Both policies were promulgated without adequate operational and budgetary planning or fiscal or workforce resources; implementation of the 18-h on-call policy has already been postponed. Therefore, new or updated policies must be accompanied by specific operational plans, budgetary allocations and funds for additional workforce.

Does examining job market awareness among medical students provide insight into the specialty selection process?

BACKGROUND: The future composition of a country's physician workforce depends on medical students' choices of specialties. Students' familiarity with the job market (the healthcare system) they are about to enter and the influence job market conditions have on their choices has not been well explored. This study focuses on whether and how the healthcare system's employment landscape is taken into consideration by medical students and whether this facet adds information about the specialty selection process. METHODS: Fifth-year medical students completed a questionnaire querying their knowledge and perceptions of the national healthcare system, selection criteria for choosing a specialty and a post-residency work position. Data were analyzed with two-tailed Student's t-tests and multivariable regression analysis. RESULTS: The questionnaire was completed by 242 students (49% women). Forty per cent were interested in a specialty where it is 'easy to find work' and 64% in a specialty that 'provides job security'. Only 12% were attracted to specialties with empty positions due to a workforce shortage. A high salary was considered an important selection criterion by 45% of students, who were also not deterred by specialties with surplus workforce, especially, if accompanied by high salaries or controllable lifestyles. Only 17% thought it would be easy to find a residency in any hospital in the specialty they chose, reflecting the low rate (3%) of positive responses to the statement that 'there are sufficient residency positions in all specialties'. CONCLUSIONS: This study demonstrated the utility of querying medical students about their market awareness when investigating the specialty selection process. Students' poor rating of selection criteria, such as specialties with ease in finding jobs because they are suffering workforce shortages and have empty positions, provide insights and concerns for healthcare leaders. It should aid them in approaching the challenge of attracting students to specialties with workforce shortfalls.KEY MESSAGESThis study demonstrated the feasibility and potential value of adding queries about market awareness when investigating the medical student specialty selection process.Medical students were more interested in a specialty that provides job security than one where it is easy to find work.It could be useful for the healthcare leadership and medical educators in all countries to learn what medical students know about their national healthcare system and whether they need to add more healthcare delivery and system subjects to their curricula.