Medical students’ perceptions of a career in family medicine

Data were collected from final-year medical students (6^th year which is the final year before internship) of two Israeli medical schools using a questionnaire designed to elucidate the various aspects of choosing a specialty by medical students. The questionnaire was distributed to three successive classes of final-year students at the Hebrew University, Hadassah School of Medicine, Jerusalem, Israel, plus one class at the Ben-Gurion University of the Negev School of Medicine, Beer-Sheva, Israel.

The methodological concept was adapted from marketing research and hypothesizes that when a consumer’s (i.e. student's) criteria match their perceptions of a product’s (i.e. specialty) features, the likelihood of a purchase (selecting the specialty) increases [10]. To provide insights into the selection process, this methodology examined both sides of the marketing equation, i.e. the students’ selection criteria and their perceptions of the various specialties.

The design was based on the AIUAPR (awareness, interest, understanding, attitudes, purchase and repeat purchase) and other models of consumer behavior) [10‐12]. The questionnaire queried the students on the following:

A 5-point Likert scale was used for answering the questions in Sections 1-4. Results from the current dataset have been published without an in-depth focus on issues surrounding FM [10, 13‐15].

The study received approval from the Institutional Review Board of the Hadassah Medical Organization. Participation was purely voluntary and there were no incentives aside from the intention to assist the researchers and contribute to the study. Questionnaires were completely anonymous and, therefore, the sampling design precluded assessment of the responder versus non-responder characteristics.

The data collected from the questionnaires were entered into Excel 2003 (Microsoft Inc., Redmond, WA) spreadsheets and then underwent statistical analysis with Systat Version 12 (Systat Software Inc., San Jose, CA).

In Israel FM clerkships are part of the curricula of all five medical schools. Some Israeli schools briefly expose students during their first year whereas others delay contact with FM until the final year. The latter was the case at the Hebrew University, Hadassah School of Medicine during the study period where there was a 2-week FM rotation during the final year. Therefore, it is possible to compare our findings to some European countries where FM is not well represented in the undergraduate curriculum [29‐33]. Brekke et al [29] found that 19% of the medical schools from 12 different European countries had no or a very brief GP/FM exposure. Pfarrwaller et al [34] found in their literature review, that a wide primary care exposure before and during clinical training were the only interventions that were consistently associated with attracting significant numbers of students to primary care. Isolated modules or clerkships were not as effective. Similarly, in the UK, a focus group study found that early, high-quality, ongoing and authentic clinical exposure during medical school promotes general practice and combats negative stereotyping [35]. Therefore, an important tactic in FM recruitment efforts is early positive exposure in the medical school curriculum [36, 37]. This is the approach taken by the European Academy of Teachers in General Practice (EURACT), which is launching efforts to improve exposure to primary care in all medical schools [29]. Other proposed interventions to increase the proportion of medical students choosing FM include medical school admission policies favoring students interested in primary care, giving preference to students with characteristics likely to predict a future primary care career and changing the composition of admission committees to increase the number of primary care members [26]. These steps were taken in the US by the Generalist Physician Initiative and the Interdisciplinary Generalist Curriculum Project [38, 39].

Israel is facing a looming shortage of primary care physicians, especially in its peripheral areas. Contributing to his looming shortage is the impending retirement of many primary care practitioners, especially, those elderly physicians who emigrated from Russia in the early 1990's. In a 2015 report 44% of the community primary care physicians were not specialists in any field, with many being immigrant physicians [40]. Only 32% were FM specialists and 12% were internal medicine specialists with the remainder having specialty certification in a variety of specialties [40]. In 2015, 38% of FM specialists were older than 55 years [41]. The impact of these impending retirements is compounded by a maldistribution of physicians among the various specialties including insufficient young physicians specializing in FM. The recent increase in medical school class size, opening of a fifth medical school and increases in newly issued medical licenses increases the pool of potential recruits to FM residencies [42]. Therefore, this is an opportune time to apply the lessons of the present study. The challenge to the FM leadership is twofold. Firstly, to ensure that students expressing interest in FM medicine actually enter FM residencies and are not enticed to switched to other primary care specialties, such as internal medicine and pediatrics, which are in the same interest cluster as family practice [13]. These two specialties often tempt students to pursue subspecialization leading to their loss as primary care providers. The other challenge is recruiting some non-FM inclined students to FM, recognizing that success might be limited given that many highly rated selection criteria indicating a surgical/procedural orientation. However, recruiting even a few non-FM inclined students would help increase the number of FM specialists.

A weakness is that the questionnaire did not specifically examine the major reasons that students were attracted to FM and thus there may be other factors that were operative, such as the influence of mentors and role models. The influences of mentors and role models were emphasized by Matson et al. [43] who described the "4 pillars" possibly influencing students choosing FM: 1. A pipeline promoting interest in FM to secondary school students; 2. The process of medical education (role modeling FM during medical school); 3. Practice (the interplay of learners with good FM practices); and 4. Salary (narrowing the gap between primary and specialty care). Although the response rate of 66% was high for a study of this type, it is unknown whether the students who did not answer differed from the group that did answer. The strength of this study is the marketing research approach used to explore the topic of specialty selection by medical students. This methodology allowed us to compare both sides of the selection issue, the students' selection criteria and their perceptions of FM, thus demonstrating areas that could be the focus of recruitment efforts.