Working in preventive medicine or not? Flawed perceptions decrease chance of retaining students for the profession

Preventive medicine (PM) should be a priority in developing countries where preventable diseases cause death of millions of people every year, especially of children under 5 years old [1]. However, it is an international problem that primary health care (PHC) specialties, such as PM, are not attractive to medical students [2, 3]. Previous studies have shown that students’ knowledge and experiences of specialties influence their career decision-making processes [4]; they increase or decrease students’ preferences for PHC careers [5, 6] and working in rural settings [7]. Insufficient understanding or knowledge of the role of PHC specialties is a major factor discouraging students from pursuing a career in those specialties [8, 9]. However, little is known about the development of students’ perceptions of PHC specialties over time. Particularly, it is underexplored how the perceptions of students with different specialization interests develop in different phases of the curriculum, and whether students’ perceptions of the specialty relate to their willingness to work as a PHC doctor.

Medical students gradually collect more knowledge and experiences during different phases of their studies, mostly during their training in clinical clerkship [10, 11] and community practice [7]. Based on those experiences, senior students make more definite and consistent decisions on their career choice in PHC than junior students do [9]. Nonetheless, some studies show that the career preferences of students are not always related to their actual knowledge of the specialty [8, 12] but primarily to their values and goals [13]. Some scholars recommend that students should be more guided to gain a more accurate view of PHC specialties [12] and that educators should consider the risk of fostering a negative attitude toward PHC specialties among students during their training [13, 14].

In medical education, motivation for or interest level in pursuing a career in a particular specialty has been found to influence medical students’ persistence in their study [15] and their specialty choice [16]. Moreover, motivation is a predictor of students’ satisfaction during the study, including levels of distress or burnout [17, 18]. Another study [19] showed that “second-choice students,” who chose to study the specialty because they were not accepted into their preferred program (i.e., general medicine), regretted their choice and wanted to change to another specialty or even another profession, more than “first-choice students,” who were admitted to their preferred program, did. A primary reason for these feelings of regret was that students were not properly informed about the specialty they chose to pursue, meaning they were not fully aware of the mission, working conditions, and job prospects. This observation is consistent with other studies noting that the major impediment to students’ career decisions is a poor understanding of the specialties [9]. However, we have not found pre-existing studies on how perceptions of a specialty vary among students who have different levels of interest in that specialty. Also, it is as yet unclear how students’ perceptions change over the course of their studies, as a result of the accumulation of experience and knowledge, and whether this impacts first-choice students and second-choice students differently. This kind of information is crucial for teachers and vocational educators who have to aid all students in forming adequate understanding about a specialty.

Studies reveal that although medical students choose to study medicine because of their desire to help people and they are well aware of the importance of PHC in the health care system, these motivations do not translate into a willingness to work in the community and in rural areas [8, 9, 12]. However, few studies have focused on the perceptions of students who have already expressed a willingness to work in the PHC field. It would be valuable to get insight into the perceptions of those studying PHC at the undergraduate level in relation to their levels of interest in PHC and their willingness to work as a PHC doctor in the future.

The fact that PHC specialties are not attractive to medical students is an international problem and can also be observed in Vietnam, where medical schools are not highly successful in recruiting appropriate PM students. Students often choose to study PM for various reasons, such as curiosity about the profession, likely high-income jobs, low entry requirements and study burden compared to general medicine, and chance to uphold family traditions [19]. The fact that none of these reasons relates to a personal passion for prevention indicates that the students may not fully understand PM, public health (PH), and the role of PM doctors in community health protection. As a consequence, it is not surprising that only 60% of PM students anticipate choosing a job within the specialty after graduation, because the rest look for a “higher prestige” job, e.g., a clinical doctor in a hospital in big cities [19]. These views seem very removed from reality where one of the main motivating factors that keep PH workers, including PM doctors, in their jobs is that they realize that their contribution to health protection is appreciated by colleagues and the community [20]. Therefore, the differences between students’ perceptions and those of doctors regarding the characteristics of PM practice should be examined in more depth.

In this study, we investigated PM students’ sense of the reality of the PM specialty by comparing their perceptions with the perceptions of practicing PM doctors, focusing on key characteristics as necessary knowledge and skills for PM doctors, day-to-day PM doctor work life, types of practice, and the pressure and benefits of work as a PM doctor. We were guided by the following research questions:

Our study provides new insight into the impact of levels in the curriculum and career preferences on students’ perceptions of a specific primary health care specialty, PM. The results show that students have different views than practicing doctors. More specifically, students considered most of the PM characteristics to be more important than they are in practice, even for the typical ones such as the community aspect that defines the meaning of PM, or the working stress that describe the daily job features of PM. Clinical aspect was the only one characteristic that students perceived similarly to the reality; this point was a warning signal about PM students’ tendency to pursue clinical careers. In particular, by ranking of importance of characteristics of PM based on mean subscale scores of students and doctors, we see a similar picture in the top-3 ranking. Doctors ranked the following as of most importance: (1) PM knowledge and skills, (2) daily work characteristics, and (3) clinical practice. Students chose (1) daily work characteristics, (2) PM knowledge and skills, and (3) basic sciences as their first three priorities. Although students realized the importance of daily job and the application of PM knowledge and skills in the specialty, they seemed to underestimate the application of clinical practice while they overemphasize the basic sciences in their future work. Our findings confirmed the conclusion of previous studies [8, 12, 13] that students’ career preferences are not always related to their actual knowledge of the specialty, and our results provide specific evidence about perceptions of PM from the point of view of undergraduate students. Considering the state of PM training in Vietnam, a heavily theoretical and less practical curriculum, in which the first 4 years focus on basic sciences and basic medical knowledge, could be responsible for students’ flawed perceptions of the importance of most PM aspects.

Regarding the question on how students’ realistic perceptions change over the course of the curriculum, our results show that after getting some PM experience in the fifth and sixth years, senior students developed more accurate perceptions of basic sciences, clinical aspects, and working stress, but overemphasized the importance of community in PM practice compared to the reality. Previous studies have shown that the knowledge and experience that medical students gain during practice in the field helps them to develop more realistic perceptions of a particular specialty [7, 10, 11]. Our findings confirm these observations in the case of PM, and they also indicate a notable point that training in the community should be more practical to help students to have realistic perceptions of this aspect of PM practice.

Concerning the impact of degree of interest in PM on students’ realistic perceptions, our study reveals that first-choice students always had more realistic perceptions of basic sciences and clinical practice than second-choice students, and they had more realistic perceptions of working stress than second-choice students in later years. However, second-choice students had more realistic perceptions of PM knowledge and skills and daily work characteristics than their first-choice counterparts. One explanation for this observation could be that lower interest in PM could increase the stressful feelings that second-choice students reported during their studies. Previous studies have indicated that motivation and career choice play a role in the prevalence of burnout [17, 18]. Applying this to our case, we may speculate that second-choice students, who showed a lower interest in PM and higher expectation of work stress in PM practice, could be at risk of burnout and therefore should be given more attention in efforts at prevention. Moreover, in light of previous findings about the impact of early education programs on improving attractiveness of PHC to medical students [5‐7], the fact that second-choice students had more accurate perceptions of some PM characteristics in their final years is a promising sign for developing an intervention strategy. This program should early introduce the practical information such as important knowledge and skills that are useful for PM doctors, a typical work day of a PM doctor, how working in PM helps to protect the community, and so on to PM students, specifically to second-choice students who are willing to work in PM, though it was not their initial preference.

Our results revealed that students who had high willingness to work in PM overemphasized the importance of PM knowledge and skills, PM daily work characteristics, and the community aspects compared to the reality. A potential reason for this phenomenon could be that students who expressed a willingness to work in PM also had more motivation to learn and to look for information about the specialty; however, the information they found was theoretical and removed from reality. Therefore, our findings could be a foundation for developing a more appropriate information provision program, which would help students, specifically those who are not willing to work in PM, to have accurate perceptions of their future work, focusing on the role of PM knowledge and skills, PM daily work characteristics, and the community aspects of PM practice.

Remarkably, we found that first-choice students, whether they were willing to work in PM after graduation or not, had a more accurate perception of the community and clinical aspects of PM practice than second-choice students. This finding reinforces the idea of introducing community-oriented values and the concept of community interest to students during the course of training, especially to those for whom PM was not their first choice, to produce a greater number of PM doctors.

Examining the extent to which students’ perceptions of PM practice are realistic as compared to doctors’ perceptions helps us to better understand students’ specialty preferences and willingness to work in PM. Hopefully, these insights can contribute to methods of attracting more appropriate students to work in PM, by providing students with additional information during their medical studies. Our findings indicate the kinds of misconceptions students have about the real working situation of practicing PM doctors, such as their daily work characteristics or the specific knowledge and skills applied in PM practice, which could be corrected before and during studying as part of the curriculum’s vocational component. Another implication of our study is that second-choice students have a greater tendency toward stress and might be at risk of burnout. Appropriate vocational interventions focusing on community-oriented values and interests should be directed to second-choice students, especially those who are not willing to work in PM, in order to increase the number of students entering the PM field after graduation. These findings may also have implications for other less attractive PHC specialties that are struggling to recruit and retain students.

PM students have a perspective on their specialty that is different from that of PM doctors. In general, they overestimate the importance of most of PM practice’s characteristics. During their studies, second-choice students report more stressful feelings about their future work than first-choice students. Although students realize the importance of PM knowledge and skills, daily work characteristics, and community practice, their perceptions are theoretical and far from reality. Identifying specific flawed points in students’ perceptions, as well as trying to encourage target subjects, such as junior students, second-choice students, and students who are not willing to work in PM, to develop a positive attitude, could be helpful for vocational interventions in the curriculum. Consequently, these measures might help to recruit and retain qualified people in the PM field.