Although physicians are spending more time with patients than in earlier periods, increased public and patient expectations towards the medical system and administrative and regulatory controls contribute to perceptions of increased time pressures and erosion of autonomy. As is known, these conditions lead to job strain 7 .

Lifestyle and career orientation have changed in the younger generation, and this applies to doctors as well. Both male and female doctors are looking for a better balance between work and personal life. Not as many are willing to prioritize their professional career at the expense of their personal life 7 8 9 .

Several studies report on the residents' dissatisfaction with their postgraduate training, both clinical and scientific 10 11 . Half of these residents complained of unstructured residency programmes – especially in surgical fields -leading to an extension of the time needed for qualifying in their speciality. Furthermore, a sizable number of doctors intending to specialize in surgery change their minds because of insufficient training and unfavourable workplace conditions.

One major reason for young physicians leaving medicine is the drop in income over the past decade 12 . Compared to other academics, return on educational investment over a working lifetime is fairly low 13 . Instead of embracing curative medicine and facing unattractive working conditions, they choose a career in health management, pharmaceutical companies, or medical informatics.

Health care systems have a great impact on the working conditions and the doctors' job satisfaction 1 14 15 16 17 . State-administered health care systems seem to provide work environments which contribute to reasonably high job satisfaction as long as the professional autonomy is not eroded 15 17 . In competition-based settings, the job satisfaction declined in the last decades, mainly caused by financial incentives that strain doctors' professional principles, loss of control over their clinical decisions, and consuming administrative work.

Some of the mentioned reasons might contribute that a considerable number of doctors prefer to pursue a career outside medicine. Nine years after graduating from medical school, 5% of the BMA cohort doctors had chosen a career outside curative medicine or had already left medicine 3 . In Germany, about one quarter of medical school graduates do not enter the medical profession 18 . Unfortunately, there are no such statistics for Switzerland.

As part of quantitatively assessed data of a prospective Swiss residents' career- development and life-satisfaction study 19 20 participants were asked (1) what arguments there still were in favour of or against a career in medicine, and (2) whether or not they would again choose to become doctors.

The present study is part of an ongoing prospective survey of a cohort of graduates of the three medical schools in German-speaking Switzerland, beginning in 2001 (T1). Of the 1,004 registered final-year students, 719 (72%) participated in the first assessment (T1) 19 . Subjects were re-evaluated after two years in 2003 (T2) 20 21 . The present paper refers to results of the third assessment (T3), conducted in the fourth year of residency (in 2005). The postal questionnaire consisted of multiple-choice and free-response items. The free-response items were embedded in the multiple-choice questions addressing the issues of what arguments still speak in favour of or against a career in medicine. A total of 577 subjects (306 females, 53%; 271 males, 47%) participated in the third assessment (T3).

The study was approved by the research and ethical committee of the Zurich University. The deans of the involved three medical faculties Basel, Bern and Zurich supported the survey by a letter of recommendation which was enclosed to the first inquiry. As the survey addressed healthy people on a voluntarily and anonymous basis without a planned intervention no further special ethical considerations had to be followed. To ensure participants' anonymity, the returned questionnaires were only identified by a code. The respondents sent their addresses to an independent address-administration office, allowing for follow-up.

The free-response items of the questionnaire read as follows: "In your opinion, what arguments are there still in favour of or against a career in medicine? ("Welche Argumente sprechen Ihrer Meinung nach heute noch für bzw. gegen den Arztberuf?") Please mention three arguments for and three against."

In addition, participants answered the question of whether or not they would again choose to go into medicine ("yes" or "no") ("Würden Sie sich heute nochmals für den Arztberuf entscheiden?").

Not all of the (n = 577) participants of the third assessment (T3) were included in the qualitative analysis. Ten of the respondents did not answer this question. The study sample therefore consisted of 567 residents (n = 303 females, 53.4%; n = 264 males, 46.6%). The mean age was 31.3 years (SD 2.4 y, range 27–46 y).

Residents were grouped according to the speciality qualification they aspired to. "Internal Medicine fields" comprised all sub-specialities of Internal Medicine and fields related to Internal Medicine, as well as Primary Care; Surgery, Obstetrics & Gynaecology, Urology, Orthopaedics, Ophthalmology and ENT were categorized as "Surgical fields"; "High-technology medicine" comprised Anaesthesiology, Emergency Medicine, Intensive Care, Nuclear Medicine, and Radiology. Further speciality groups were identified: "Paediatrics", "Psychiatry", "Other Specialities" such as Preventive Medicine, Pathology, and "Speciality not yet decided". Distribution of the aspired-to specialities of the 567 residents (100%) was as follows: Internal Medicine, n = 197 (34.7%), Surgical fields, n = 106 (18.7%), High-technology medicine, n = 51 (9.0%), Paediatrics, n = 48 (8.5%), Psychiatry, n = 27 (4.8%), Other specialities, n = 53 (9.3%), and Not yet decided, n = 85 (15.0%).

The qualitatively assessed data (reasons for and against entering the medical profession) were evaluated according to Mayring's content analysis 22 by a researcher not involved in the quantitative data analysis, as follows: First, the respondents' handwritten answers (headwords or whole sentences) were transcribed into an Excel file. In a second step, content categories were inductively formulated, and their descriptions written down in a code manual (definition, examples, and rules for coding). In a further step, the passages of text were encoded according to the code manual and assigned to the content categories. Frequency distributions were given for categories and tested with Chi^2-tests for differences in gender, speciality fields, and whether or not the respondent would again choose a career in medicine. Inter-rater reliability: A random sample of 20% of the analyzed statements was submitted to two additional raters (staff from the department experienced in qualitative analyses). The index of concordance (ratio of identically rated answers to all rated answers) was 0.79 and Cohen's Kappa 0.76.

The 567 residents gave a total of 3,343 responses (5.90 per subject on average) in terms of both "statements for" and "statements against" a career in medicine. Of these, there were 1,640 "statements for" (mean 2.89, range 1 – 6) and 1,703 "statements against" (mean 3.00, range 1 – 6). I.e. some of the subjects gave more than three arguments, some less in terms of "statements for" and "statements against" a career in medicine respectively. The content analysis of the residents' answers resulted in eight categories with arguments both for and against a career in medicine. (The following order of the categories follows the ranking of the frequency distribution of the arguments given in favour of a career in medicine.)

- Personal experiences in day-to-day working life

- Interpersonal experiences in professional relationships

- General work-related structural conditions

- Further training and speciality qualification conditions

- Enjoyment/Meaning

- Social prestige and health-policy aspects

- Income

- Leisure/Private life

Non-distinctive statements such as "curiosity", "science", "the human being", "challenge" were assigned as not codable.

Table 1 shows the allocation of the responses to the eight categories differentiated according to "statements for" and "statements against" content by gender, and ranked by frequency of the "statements for" arguments.

Of all "statements for" responses of both men and women, 70% fell into the categories of Personal experiences in day-to-day working life (41.2%) and Interpersonal experiences in professional relationships (28.8%), which occupied first and second place in the ranking for both genders. The top-ranking "statements against" responses were in the category General work-related structural conditions (32%), followed by Social prestige and health-policy aspects (21%). The frequency distributions of the eight categories and the "statements for" or "statements against" differ greatly according to their respective content.

The ranking of the arguments for a career in medicine categories was the same for male and female residents, while there were some differences in ranking between men and women in the arguments against categories: males rank negative arguments concerning Income in third place and Leisure towards the bottom, while females rank Personal experiences in day-to-day working life in third place and Leisure/Private life in fourth place.

In a further step, we investigated whether the arguments for and against a career in medicine differed according to the residents' speciality field. As seen in Table 3.1 and 3.2, there were almost no differences between the statements of residents of the various medical fields, apart from significant differences for statements against a career in medicine in the category Further training and speciality qualification conditions for residents in High-technology medicine and Psychiatry; more negative entries were given in this category than for residents in the other speciality fields.

In addition, we were also interested in whether the frequency distribution of the given arguments for and against a career in medicine would vary according to whether or not residents would all over again decide to go into medical training (Table 4.1 and 4.2). Of the present study sample (n = 567), 442 (78%) participants (231 females, 76.2%; 211 males, 79.9%) would choose to become doctors again, while 117 (22%) residents (67 females, 22.1%; 50 males, 18.9%) would not. Five (1.7%) of the women doctors and 3 (1.1%) of the male doctors have not given a response. There were no significant gender-relevant differences.

As expected, residents who would not choose to go into medicine again named significantly more "statements against" in terms of Personal experiences in day-to-day working life (p < .05) and Enjoyment/Meaning (p < .05) (Table 4.2). They reported significantly fewer "statements for" in terms of Enjoyment/Meaning (p < .01) but surprisingly more in terms of General work-related structural conditions (p < .05) (Table 4.1).