Family collective agency in career decision-making among medical and dental students: a qualitative intersectional study in Peshawar, Pakistan

Background: Career decision-making in medical education predominantly reflects Western individualistic frameworks emphasizing personal autonomy. The intersection of clinical rotation experiences with family collective agency and culturally embedded gender norms in collectivist contexts remains insufficiently examined. Methods: = 14; 8 female, 6 male) aged 20-25 years across four institutions in Peshawar, Pakistan (August-November 2024). We used reflexive thematic analysis, applying Social Cognitive Career Theory (SCCT), Communities of Practice (CoP), and intersectionality as sensitizing concepts to examine how rotation experiences are interpreted through family decision-making and Pashtun sociocultural norms. Results: ), extending beyond individual performance concerns. Career decision-making operated through collective family deliberation, with economic obligation commonly shaping men's specialty trajectories and marriage-related expectations consistently constraining women's career planning through anticipatory specialty screening. Participation patterns ranged from progressive apprenticeship to persistent gender-based marginalization, including exclusion of female students from male patient examinations and restricted access to night shifts in Peshawar institutions. Female participants described a "doctor daughter" paradox in which medical education was encouraged while post-graduation practice was constrained. The absence of female role models in surgical specialties undermined surgical self-efficacy among female participants considering male-dominated fields. Conclusion: Career development in collectivist contexts operates through family collective agency and culturally structured participation norms that are not well captured by individualistic models. Our findings suggest SCCT may require reconceptualization to incorporate collective efficacy, honor-based outcome expectations, family approval-filtered goal formation, and cultural context as a central organizing condition. Medical education policy should recognize career "choice" as a negotiated family process rather than an exclusively individual decision.