Thailand special recruitment track of medical students: a series of annual cross-sectional surveys on the new graduates between 2010 and 2012

Three consecutive, cross-sectional surveys were conducted with all new medical graduates who gathered at the meeting convened by the MOPH to choose hospitals for their mandatory rural services on 2 April 2010, 1 April 2011, and 1 April 2012, respectively.

The target population was all the 1,545, 1,479 and 1,679 new medical graduates in 2010, 2011, and 2012 who gathered in the meeting convened by MOPH to choose their work place. The questionnaire was distributed to all these new graduates along with their registration documents. Having given verbal consent, a total of 576 (37.2%), 872 (59.0%) and 754 (44.9%) graduates from each year anonymously responded to the questionnaire. Confidentiality of information was strictly kept according to the standard operating procedure of health science research. The National Ethical Review Committee waived ethical clearance for this study.

The questionnaire was developed from a consultative meeting in the MOPH. Content validity was checked by canvassing the opinions of senior officers in the MOPH. A reliability test was performed through a pilot test on the final-year medical students in KhonKaen University (Cronbach’s alpha = 0.64; considered acceptable reliability). There were four parts in the questionnaire: (1) demographics of graduates including age, gender, mode of admission to medical education(normal admission track through competitive national entrance examination or direct admission, and special tracks under CPIRD and ODOD), location of their medical school (in Bangkok or outside), location of residence for the ages 1 to 15 years, location of current residence, location of secondary school, and education profile of parents; (2) attitudes toward rural practice measured by level of attitude using the Likert scale, ranging from one (least positive) to five (most positive) arranged in five questions indicating ‘peers in rural settings are supportive’, ‘working in rural areas provides greater opportunity in meeting professional colleagues’, ‘amenities and facilities are available in rural areas’, ‘people in rural areas are generous and friendly’, and ‘working in rural areas can maintain close contact with friends and families; (3) intention to complete the 3-year mandatory service and the plans thereafter; and (4) confidence in medical and public health competency using fourteen questions and self assessment using the Likert score ranging from one (least confident) to five (most confident). All the four parts were arranged in a single attachment.

The fourteen competency questions cover: (1) public health; (2) health administration; (3) communication; (4) inter-professional collaboration; (5) internal medicine care; (6) obstetric and gynecologic care; (7) pediatric care; (8) surgical care; (9) general disease care; (10) difficult labor management; (11) patient referral management; (12) overall clinical competency; (13) clinical knowledge; and (14) clinical skill. The questionnaire was tested on the content validity, then redesigned and finalized. Completed questionnaires were dropped in a collecting box anonymously.

Analyses were performed using Stata Version 11 (STATA Corporation, College Station, TX, USA). The analysis consisted of four parts: (1) descriptive statistics were used to understand the socio-demographic profiles of graduates and their parents, and Pearson’s Chi-square test was used to explain the association between modes of admission and location of secondary school; (2) average rural attitude scores were compared between two modes of admission; (3) Pearson’s Chi-square was used to explain association between various attributes and the intention to fulfil the 3-year mandatory service; furthermore, multivariable logistic regression with marginal effects was conducted to determine the association between the intentions to fulfil the 3-year obligations and the significant attributes identified by the univariable analysis; and (4) a composite competency score was produced using exploratory factor analysis of the fourteen competency questions. Principal component analysis was applied to identify factors which addressed around at least 75% of variance. Varimax rotation was executed to group the fourteen questions into each factor. The composite score of each factor was calculated using Bartlett’s formula [21]. The competency composite score was assessed against the mode of admission.

Across the three batches, graduates were on average 24 years old and more were female than male. It was noted that the majority of graduates came from normal track recruitment and graduated from medical schools located in Bangkok (Table 1). Opportunities for students from secondary schools located outside provincial cities to enrol in medical education was small, around 11.5 to 15.0% of total graduates, while a majority of graduates were students from secondary schools located either in Bangkok (33.0 to 53.2%) or in a provincial city (35.3 to 52.0%). A majority of all three batches of medical graduates came from well-educated parents; more than two-thirds had at least one parent with at least a bachelors degree, while the other third did not have a parent with a degree.

Modes of admission were significantly related to the location of the secondary school where these graduates studied at grade 12. In 2010, most graduates who were recruited via the normal track came from secondary schools located in Bangkok (65.3%), followed by those located in a provincial city (23.1%). Only 11.6% of graduates came from secondary schools outside a provincial city.

Among graduates recruited through the special track, most of them (76.0%) came from secondary schools in a provincial city; a small proportion (10.5%) came from outside a provincial city. Despite the intention of offering more opportunities for students living in either provincial or non-provincial cities through special track recruitment, a meaningful portion of graduates (13.5%) came from secondary schools in Bangkok. Similar findings emerged across the three batches (Table 2).

Across the three batches of graduates, there is a slight difference in rural attitudes between those recruited through the normal track and the special track. Graduates from the special track scored higher on attitude (four out of five) on the impression that people in rural areas are generous and friendly and there is good professional peer support in rural settings. However, on the lack of amenities and facilities in rural areas, and inadequate meetings with professional colleagues they got a lower attitude score, less than 3 out of 5 (Figure 1).

The univariable analysis in Table 3 shows the association between seven attributes and the intention to fulfil their obligations. Despite all graduates being subject to mandatory rural service, a number of them chose not to adhere to this and instead paid the financial penalty.

From the analysis, four out of seven attributes have a statistical association with the intention to fulfil the 3-year compulsory rural service. Medical graduates across the three batches who were recruited through the normal track, who spent their childhood life in Bangkok, whose current residence was in Bangkok and whose secondary school was located in Bangkok had a lower intention to fulfil the 3-year compulsory service with statistical significance. It is noted that graduates from medical schools outside Bangkok in the 2012 batch had a higher intention to fulfil their obligations with statistical significance, but this was not the case in the other two studied batches.

Furthermore, when multivariable analysis was conducted using the five attributes having significant influence on the intention to fulfil the 3-years compulsory service, the odds of having the intention to fulfil the 3-year compulsory service among graduates recruited thorough the special track were 2.23-, 2.45-, and 2.46-fold larger than graduates recruited through the normal track in the three batches with statistical significance. Meanwhile the other four attributes showed no significance (Table 4).

When Principal Component Analysis was applied, the fourteen questions were regrouped into five main domains, namely ‘COMMUNICATE’ (including communication and inter-professional collaboration), ‘PUB_HEALTH’ (including health administration and public health competency), ‘PROCEDURE’ (including management of referral cases, clinical competency, clinical knowledge and clinical skill), ‘MAJ_CLINIC’ (including competencies in internal medicine care, pediatric care, surgical care and general disease care), and ‘OB_GYN’ (including managing difficult labor and obstetric and gynecologic care).

Figure 2 clearly shows that graduates recruited by special track across the three batches had higher scores in COMMUNICATE by showing an average score of 0.06, 0.06, and 0.03 in 2010, 2011, and 2012, respectively. A similar pattern was also observed in PUB_HEALTH (0.09, 0.03, and 0.08), and PROCEDURE (0.27, 0.35, and 0.31 in the three corresponding batches). The level of confidence among graduates recruited by special track in obstetric and gynecologic skill (OB_GYN) also increased between 2011 and 2012. While graduates recruited by special track had higher competency in four domains, those recruited by normal track had higher competencies in major clinical subjects (MAJ_CLINIC) with an average score of 0.03, 0.04, and 0.02, respectively.

Evidence suggests that special track recruitment is better than normal track recruitment in terms of the intention to fulfil the mandatory rural service and higher clinical competency. Furthermore, ODOD provides a more precise method of solving chronic shortage in certain districts than CPIRD. Based on this evidence, it is recommended to expand the proportion of recruitment from the special track, while reducing normal track recruitment. Within the special track, efforts should be given to increase the proportion of students recruited through the ODOD program.

The National Ethical Review Committee waived ethical clearance as this is a regular monitoring work conducted by the Government, confirmed by ethical review committee: IHRP 47.2/2553 date 28 January 2553 BE (2010 AD). However, informed consent was sought and the protection of confidentiality was strictly followed.