Impact of AOA Status and Perceived Lifestyle on Career
Choices of Medical School Graduates
Martha S. Grayson, MD1, Dale A. Newton, MD2, Patricia A. Patrick, DrPH3,4,
and Lawrence Smith, MD5
1Office of Medical Education and Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA;2Departments of Medicine
and Pediatrics, Brody School of Medicine at East Carolina University, Greenville, NC, USA;3Office of Health Outcomes Research, Winthrop
University Hospital, Mineola, NY, USA;4School of Health Sciences and Practice, New York Medical College, Valhalla, NY, USA;5Hofstra North
Shore-LIJ School of Medicine, Hempstead, NY, USA.
BACKGROUND: Based upon student ratings of such
factors as predictable work hours and personal time,
medical specialties have been identified as lifestyle
friendly, intermediate, or unfriendly. Lifestyle friendly
programs may be more desirable, more competitive,
and for students elected to the Alpha Omega Alpha
(AOA) Honor Medical Society, more attainable.
OBJECTIVE: The objective of this study was to evaluate
whether AOA students increasingly entered lifestyle
friendly residency programs and whether trends in
program selection differed between AOA and non-AOA
DESIGN: This retrospective cohort study examined
PGY-2 data from the Association of American Medical
Colleges and the 12 allopathic schools in the Associated
Medical Schools of New York.
PARTICIPANTS: Data on 1987–2006 graduates from
participating schools were evaluated.
MAIN MEASURES: Residency program selectionoverthe
20-year period served as the main outcome measure.
KEY RESULTS: AOA graduates increasingly entered
lifestyle-friendly residencies—from 12.9% in 1987 to
32.6% in 2006 (p<0.01). There was also a significant
decrease in AOA graduates entering lifestyle unfriendly
residencies, from 31.6% in 1987 to 12.6% in 2006 (p<
0.01). Selection of lifestyle intermediate residencies
among AOA graduates remained fairly stable at an
average of 53%. Similar trends were found among non-
AOA students. However, within these categories, AOA
graduates increasingly selected radiology, dermatology,
plastic surgery and orthopedics while non-AOA gradu-
ates increasingly selected anesthesiology and neurology.
CONCLUSIONS: While lifestyle factors appear to influ-
ence residency program selection, AOA graduates differ-
entially were more likely to either choose or attain certain
competitive, lifestyle-friendly specialties. Health care
reform should be targeted to improve lifestyle and
decrease income disparities for specialties needed to
meet health manpower needs.
KEY WORDS: career choice; medical students; workforce; residency;
J Gen Intern Med 26(12):1434–40
© Society of General Internal Medicine 2011
Omega Alpha Honor Medical Society (AOA), a national honor
society with chapters at 95% of the medical schools in the
United States.1Election criteria to AOA can vary between
institutions but are based largely on academic achievement
with consideration given to leadership, service, professional-
ism, and promise of future success in medicine.2With medical
school graduates in the United States increasingly selecting
subspecialties that offer more predictable work hours and
greater income potential, AOA recognition may give those
medical students an advantage in applying for competitive
residency programs.3,4Earlier studies have examined career
choices of honor medical students in the 1970s and 1980s5–7
and the National Resident Matching Program summarizes AOA
match data for specialties each year, but recent trends in
selection of lifestyle-friendly careers by honor graduates
Recent studies have investigated the changing factors
that may influence medical students in their career
specialty choices with lifestyle emerging as one of those
considerations that has become increasingly important to
students.3,8–10Some students even remark about “heading
for the ROAD”—radiology, ophthalmology, anesthesiology
and dermatology, all of which are considered the epitome of
lifestyle-friendly careers.11A previous study by two of the
current authors (MG, DN) used medical students’ ratings on
various career attributes to classify medical specialties as
“lifestyle friendly,” “lifestyle intermediate” and “lifestyle
Nationally there has been very little growth in the
number of residency positions offered. In the context of
increasing desirability (or demand) for the lifestyle-friendly
careers, investigators used residency program selection
data from a large cohort of medical school graduates to
test the hypothesis that entry to these lifestyle-friendly
programs has become increasingly competitive with AOA
students at an advantage in attaining their career choice.
uring the third or fourth year of medical school, top-
performing medical students can be elected to the Alpha
Electronic supplementary material The online version of this article
(doi:10.1007/s11606-011-1811-9) contains supplementary material,
which is available to authorized users.
Received November 29, 2010
Revised May 2, 2011
Accepted July 14, 2011
Published online August 12, 2011
Correspondingly, the investigators formulated the following
research questions: 1) have AOA students increasingly
entered training in lifestyle-friendly residency programs?;
2) is there a difference in trends between AOA and non-AOA
graduates entering each lifestyle category (friendly/inter-
mediate/unfriendly)?; and 3) regardless of lifestyle category,
is there a difference in trends between AOA and non-AOA
graduates entering specific residency specialties?
This retrospective cohort study examined the career choices of
all medical students who graduated from all New York
allopathic medical schools over a 20-year period.
Subjects and Setting
Subjects were medical students graduating from the 12
medical schools included in the Associated Medical Schools
of New York (AMSNY): Albany Medical School; Albert Einstein
College of Medicine of Yeshiva University; Columbia University
College of Physicians and Surgeons; Mount Sinai School of
Medicine; New York Medical College; New York University
School of Medicine; SUNY Downstate College of Medicine;
SUNY Upstate Medical University; Stony Brook University
School of Medicine (SUNY); University at Buffalo School of
Medicine and Biomedical Sciences (SUNY); University of
Rochester School of Medicine and Dentistry; and Weill Cornell
Students were eligible to be included in this study if they
graduated from one of the AMSNY schools during the 20-year
period (1987–2006) and chose one of 18 categorical residency
programs previously defined by investigators as lifestyle
friendly (radiology, emergency medicine, urology, otolaryngolo-
gy, ophthalmology, dermatology, physical medicine and reha-
bilitation, anesthesiology), lifestyle intermediate (internal
medicine, pediatrics, psychiatry, orthopedics, family medicine,
internal medicine-pediatrics, neurology, plastic surgery), or
lifestyle unfriendly (surgery-general, obstetrics-gynecology).
These categories were established by investigators using
questionnaire data from students graduating from two
medical schools between 1998 and 2004. Students
responded to questions regarding the influence of career
attributes on the selection of a specialty.3Seven factors that
influenced career choice were generated by that study. One
of those factors was lifestyle. Our current study focuses on
the five items that clustered to form the lifestyle-friendly
factor: 1) allows more leisure time; 2) provides an opportu-
nity to enjoy life outside of work; 3) allows predictable work
hours; 4) allows time to pursue activities outside of work;
and 5) allows more time with family. Ranking each residency
based on the results of these analyses yielded a list of
specialties by student perceived “lifestyle friendliness” in one
of the three categories noted above. Three specialties—
nuclear medicine, pathology, and public health—had not
been categorized by lifestyle because too few students
This study cohort, which consists of slightly more than
10% of all U.S. medical school graduates, is noteworthy for
representing a national group of students who cover the
spectrum of applicant academic competitiveness from a
diverse group of institutions—public and private, urban
and rural, patient care- and research-oriented. In addition,
New York medical schools attract and enroll students from
every region of the U.S.—an average of 42.1% of these
graduates (range: 2.6% to 77.0%) from the entire cohort are
out-of-state residents (AAMC [firstname.lastname@example.org], e-mail,
February 4, 2010).
According to 2006 AAMC data, this cohort has a similar
ethnic/racial distribution (56.5% non-Hispanic white, 26.0%
Asian, 6.5% non-Hispanic black, and 4.7% Hispanic graduates)
compared to other medical schools in the country.12The gender
distributionisalsosimilartooverallnationalproportions for the
years 1987–2006 with an average of 42.2% female gradu-
ates from New York medical schools (range: 32.8% in 1987
to 50.0% in 2006) compared to 40.2% from all U.S. medical
schools (32.3% in 1987 to 48.7% in 2006) (AAMC [fact-
email@example.com], e-mail, February 18, 2010). The 20 years
included in this study span multiple “generations” of
students ranging from the last of the baby boomers through
Generation X and into the start of Generation Y.13
Data were collected from the Association of American Medical
Colleges (AAMC) and the 12 participating medical schools
through AMSNY. With written authorization from the dean at
each school, investigators then received the names of the AOA
students who graduated between 1987 and 2006. The AAMC
provided investigators with residency survey data collected
annually from program directors during the 20-year project
period. The data set also included 2007 to capture information
for 2006 graduates.
To determine residency selection and ensure only categorical
residencies were captured (i.e. excluding transitional and
preliminary residency positions), investigators examined
AAMC survey data for the 2nd year of residency (post-
graduate year 2; PGY2). The names of AOA graduates
provided by the participating schools were matched by
name, school and graduation year to PGY2 data provided by
the AAMCtoidentify the selectedresidencyprograms ofAOAand
The frequency that medical specialties were chosen by
graduates was calculated for each graduation year. The special-
ties were then categorized by lifestyle status—friendly, interme-
diate and unfriendly. Simple linear regression analyses were
used to summarize AOA and non-AOA graduates entering each
lifestyle category and each specialty over the 20-year period. In
these analyses, graduation year served as the exposure variable
and proportion of graduates entering the three lifestyle
categories served as the primary outcome variables. The
coefficient of determination (r2) was also calculated to
describe how much of the total variation in the proportion
Grayson et al.: Impact of AOA Status on Career Choices
of graduates was explained by its linear relationship with
graduation year. Trend lines were compared between AOA
and non-AOA graduates with the null hypothesis that the
slopes were identical.14Given the three primary outcomes
examined, results that obtained a p-value of less than 0.02
were considered statistically significant. Specific residency
program selections were compared similarly but with no
correction given their role as secondary outcomes.15
This study was approved by the Institutional Review Board
of New York Medical College.
The AAMC provided investigators with the names and specialty
choices of 35,211 residents who graduated from participating
Figure 1. Sample selection of AOA and non-AOA graduates.
Grayson et al.: Impact of AOA Status on Career Choices
schools during the 20-year study period. The twelve New York
schools provided the names of 5,738 AOA students who
graduated during that same period (one school was unable to
provide the names of AOA graduates from 1986 to 1989). After
applying eligibility criteria stated above, investigators achieved
a sample of 26,482 graduates—4,265 AOA and 22,217 non-
AOA (see Fig. 1).
Trends among AOA and non-AOA graduates entering life-
style-friendly, intermediate and unfriendly residencies are
shown in Figure 2. There was an overall increasing trend in
AOA graduates entering lifestyle-friendly residency programs
from 1987 to 2006 (r2=0.79, p<0.01). There was also a
residencies over the 20-year period (r2=0.74, p<0.01). However,
similar trends occurred among non-AOA graduates for lifestyle-
friendly (r2=0.90, p<0.01) and unfriendly residencies (r2=0.79,
p<0.01). Selection of lifestyle intermediate residencies among
AOA graduates remained fairly stable at an average of 53% over
the 20-year period (r2=0.26, p<0.05). Similarly, non-AOA gradu-
atesselected lifestyle intermediateprograms at an average of 57%
overall, with an average of 63% selecting such programs in 1997
through 2000 (r2=0.32, p<0.01). Overall, the trends by lifestyle
category were not different between the two groups of medical
There were specific specialties where significant differences in
trends between the AOA and non-AOA groups were found:
increase in selection by AOA over non-AOA graduates—radiolo-
gy, dermatology, plastic surgery and orthopedics (figure available
online); increase in selection by non-AOA over AOA graduates—
anesthesiology and neurology (figure available online); and
decrease in selection by non-AOA compared to AOA graduates
—combined internal medicine-pediatrics (5.9% to 1.3% among
non-AOA vs. 3.9% to 0.8% among AOA graduates (p<0.05)).
Graduates entering emergency medicine, ophthalmology, otolar-
yngology, and pediatrics increased significantly over the study
period, but the increases were similar for both AOA and non-
AOA graduates (figure available online). Residency specialties
where selection by both groups decreased significantly over the
study period included general surgery, obstetrics-gynecology,
physical medicine/rehabilitation and urology (figure avail-
able online). Selection of psychiatry decreased significantly
among AOA graduates (from 7.7% in 1987 to 3.3% in 2006,
r2=0.37, p<0.01) but fluctuated among non-AOA graduates
(8.3% in 1987 to 3.3% in 1996 to 6.0% in 2006, r2=0.11, p=0.16)
over the study period.
No statistically significant trends among or between AOA
and non-AOA graduates entering family medicine or internal
medicine were found (see Fig. 3). Over the 20-year period, an
average of 3.1% of AOA (range: 0.6% to 6.8%, r2=0.10) and
6.2% of non-AOA graduates (3.8% to 10.1%, r2=0.03)
entered family medicine while 26.6% of AOA (18.6% to
33.5%, r2=0.01) and 26.1% of non-AOA graduates (22.6%
to 32.1%, r2=0.11) entered internal medicine.
Although it was our expectation that students elected to AOA
would be more likely than non-AOA colleagues to select and
achieve residencies in the more lifestyle-friendly careers, our
study did not support this hypothesis. The trends over time for
students entering these broad categories of lifestyle friendly,
intermediate and unfriendly were actually quite similar for the
two groups of students. Medical school graduates, both AOA
and non-AOA, increasingly entered lifestyle-friendly careers,
while both groups were less likely to enter lifestyle unfriendly
careers over the 20-year study period. However, while the
trend for the three lifestyle categories for the two groups was
similar, more notable differences were found when considering
individual specialties, suggesting that within each lifestyle
category, some may be more competitive than others.
AOA graduates were significantly more likely than non-AOA
graduates to enter two of the popular lifestyle-friendly careers—
radiology and dermatology. Both of these two fields attract
residents with average USMLE Step 1 and 2 scores among the
highest compared to other specialties, and well above the
national mean.16Interestingly, anesthesiology, another lifestyle-
friendly career, had increasing numbers of graduates overall
choosing this field. For reasons that are unclear, the increase
among non-AOA students was greater than the increase among
Trends for the other lifestyle-friendly residencies were similar
for the two groups, with more students overall entering
emergency medicine, ophthalmology, and otolaryngology. It is
noteworthy that AOA graduates were significantly more likely to
attain positions within two specialties that did not fall into the
lifestyle-friendly category but have become increasingly popular
over the study period, orthopedics and plastic surgery. Although
these specialties did not have the same high rating for lifestyle,
prior work has suggested these specialties are perceived as
Figure 2. AOA vs. non-AOA graduates entering lifestyle-friendly,
intermediate and unfriendly residencies over 20 years (1987 to
Grayson et al.: Impact of AOA Status on Career Choices
Another lifestyle intermediate option, the career track of
combined internal medicine-pediatrics (Med-Peds) had interest-
ing findings. While fewer total graduates in this study were
choosing that career path over this 20-year period, AOA student
choice of Med-Peds was relatively maintained compared to that
of the non-AOA students. Conversely, non-AOA students were
significantly more likely to enter neurology residencies, another
lifestyle intermediate career choice, when compared to their
Four careers showed significant decreases in medical student
choiceregardless ofAOA status.Twoofthese fourare the lifestyle
unfriendly careers of general surgery and obstetrics-gynecology.
These results are similar to other studies that found long work
hours have been strongly associated with dissatisfaction and
that physicians are increasingly concerned with work–life
balance.4,17,18Urology and physical medicine/rehabilitation,
while seen as lifestyle friendly, have decreasing numbers
suggesting the influence of other factors.19
Internal medicine and family medicine are both categorized
as lifestyle intermediate careers, and neither career showed a
significant trend over the 20 years relating medical student
choice with AOA status. The lack of a relationship between
choice of an internal medicine career and AOA status may mask
any number of underlying relationships. Many graduates
Figure 3. AOA vs. non-AOA graduates entering general internal medicine, family medicine and internal medicine-pediatrics residencies
over 20 years (1987 to 2006).
Grayson et al.: Impact of AOA Status on Career Choices
entering internal medicine go on to subspecialize. For
example, the percent of third year internal medicine resi-
dents choosing to pursue a career in a subspecialty has
risen from 42% in 1998 to 58% in 2007.20Yet, the
subspecialties of internal medicine vary greatly in lifestyle
attributes and income. Those characteristics may make
certain subspecialties more attractive, hence more competitive,
and as a result, more AOA graduates may enter those subspe-
cialties. Over the time period of this study, the new internal
medicine career track as hospitalist has also evolved. The
relationship between these career choices and AOA status
obviously cannot be addressed by the current study.
Our analysis differs somewhat from prior studies that
dichotomized residencies into two groupings, controllable vs.
uncontrollable lifestyle, as these studies defined controllable
lifestyle careers on the basis of the investigators’ a priori
perceptions.4,10We made the decision to look at the perception
of fourth-year medical students. The data from our earlier
studies revealed some important differences between the views
of the students as opposed to the views of the investigators cited
above. For example, urology emerged as a lifestyle-friendly
career even though past studies placed it in the uncontrolla-
ble-lifestyle category. Second, physical medicine/rehabilitation,
a specialty not included in prior studies, was rated as the
second most lifestyle-friendly study in our previous work. Our
data suggests that the past investigators’ tendency to dichoto-
mize careers into lifestyle-controllable vs. uncontrollable may
have masked important complexities, as some of the careers
typically lumped into the uncontrollable lifestyle category
(family medicine, general pediatrics and general internal
medicine) may actually reside between the lifestyle-friendly
and unfriendly extremes.3
We are aware that by framing our analysis of the relation-
ship between AOA status and careers choice by lifestyle
characteristics, we were not accounting for the myriad of
other factors that influence that decision.19Some are societal
and others institutional, but most are related to the values
and aspirations of the individual medical student/resident.
Our study confirms the increasing influence of lifestyle
aspirations on career choice. While not included in our
analysis, anticipated income plays a key role in influencing
and attaining a certain lifestyle.4It is worth noting that all of
the lifestyle-friendly specialties have annual incomes consid-
erably higher than those of the unpopular career choices of
general internal medicine and family medicine.21There is
conflicting evidence, however, as to whether anticipated debt
affects specialty choice.22,23Prestige within the profession
may also play a role in specialty selection by the very high-
achieving AOA students.
This study is limited by the varying response rates for the
AAMC annual resident survey over the study period; how-
ever, since 2000, the response rate has been approximately
90%. In addition, this study did not track graduates who
chose to subspecialize beyond their primary residency
program selection. It is possible that AOA status could be
a factor in differentiating between students choosing to
become generalists after a residency in internal medicine
or pediatrics and those who go on to fellowship training.
There is also literature suggesting that AOA status might
also differentiate between students becoming general sur-
geons and those who enter a surgical subspecialty after
This study also does not account for other factors, such as
on career choice in previous studies.19Additional research is
needed to clarify the contribution of gender and AOA status to
from one state; however, as stated earlier, New York schools
traditionally have broad representation geographically, economi-
cally, and academically. Investigators also cannot draw conclu-
sions about the residency program selection of top-performing
students in the 5% of medical schools without AOA chapters.
In summary, AOA status does not result in significant
differences in student attainment of training in careers catego-
rized by lifestyle status. However, certain specialties in both the
lifestyle-friendly (e.g., radiology, dermatology) and lifestyle inter-
mediate (orthopedics and plastic surgery) categories appear to be
more competitive than other fields in those same categories. AOA
status (and/or the related factors) may either convey an
advantage in achieving training in those fields or in influencing
Recent analyses of health care needs point to a national need
for more students to enter primary care, obstetrics, general
surgery and psychiatry.26–32Health care reform and funding
priorities should be targeted to increase the popularity and
attractiveness of these fields by systematically addressing the
need to improve lifestyles and decrease income disparities. If
adequate funding can be provided to allow students who enter
these fields to have predictable work hours and adequate time for
life outside of work, they shouldbecomeincreasinglyattractiveto
all students, including those who have been elected to AOA.
Contributors: Investigators acknowledge the assistance of Ms.
Jennifer Faerberg, Association of American Medical Colleges, and
Ms. Jo Wiederhorn, Associated Medical Schools of New York, in
obtaining the source data for this study, neither of whom received
any compensation for such assistance. Investigators also acknowl-
edge the twelve New York State medical schools that participated in
this study by providing the requested data.
Prior Presentations: Preliminary findings of this study were
presented at the Annual Meeting of the Association of American
Medical Colleges, Boston, MA, November 2009 (poster).
Conflict of Interest: None disclosed.
Corresponding Author: Martha S. Grayson, MD; Office of Medical
Education and Department of Medicine, Albert Einstein College of
Medicine, Bronx, NY, USA (e-mail: firstname.lastname@example.org).
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