The following is a table with some findings on the left and comments on the right. Be sure to send in your comments ASAP.
| Study of Factors Influencing Medical Students in Their Choice of Family Practice as a Specialty by Janet H. Senf, Ph.D., Doug Campos-Outcalt, M.D., M.P.A., and Randa Kutob, M.D. Department of Family and Community Medicine, University of Arizona | Comments by Rural Faculty, literature, new studies, Robert C. Bowman, M.D. |
| Between 1998 and 2001 there was a 35.3% decline in the number of U.S. graduating seniors choosing family practice (826 fewer students). The largest decline occurred in 2001 when 17.4% fewer students matched in family practice than the year before. In 2001 only 11.2% of U.S. graduates participating in the National Residency Matching Program matched in a family practice program. This was the lowest proportion since 1991, when it was slightly below 11%. | The numbers of
in-state students in even the larger state schools continues to decline as
medical schools continue to attempt to attract those who will do research
and help them compete in this important area of medical school finance.
Fahey and Bauer noted that declines in the match were preceded by declines
in class size, this is effectively what is happening with admissions
changes. Changes in tuition, declines in the numbers coming from lower socioeconomic groups, changes in affirmative action all would likely be negative factors. There was also much political and other pressure to graduate more into primary care with family medicine the lead agent. The rebound caught family medicine in the crosshairs. Without medical school leadership and political pressure, the primary care efforts caved. The fears passed on to medical students in these years also created a demand for many specialties that increased their salaries and perks and thus the attraction for future students. |
| Student Characteristics | |
|
Rural background and socioeconomic status
|
Declines in the
numbers of rural background students have been noted by AAMC for several
years. Declines in the numbers coming from lower socioeconomic groups is
inferred from Canadian studies demonstrating this. In some states the numbers of acceptable candidates from rural or underserved areas is declining rapidly. Small and minority and community colleges where rural and lower socioeconomic students go to school, are also losing preprofessional training with cutbacks in education and centralization of educational expenditures. |
| Research suggests that gender, age, marital status and ethnicity are only weakly related to the choice of specialty. In contrast, research continues to support the existence of a positive relationship between a student’s rural background and choice of family medicine and a relationship between parents’ lower socioeconomic status and level of education and a choice of family medicine. | Not a surprise, since the inception of FP there have been about 600 - 700 students a year graduating from FP residency programs into rural practice. Massive changes in FP numbers and programming have not changed this. This points to admissions as a more important way to increase the match, more than medical student interest or programs See Admissions for generalists and rural physicians |
|
Stated goals to enter family medicine prior to entry to medical school do not appear to be related to eventual specialty choice, although reported contact with a specialty is. Students who believe primary care is important, have lower income expectations and who do not plan on a career in research are more likely to choose family medicine.
|
These are characteristics documented in AAMC GQ regarding students interested in rural practice as well as minority students. Again it may be that the contribution of students from underserved backgrounds or with rural interest are influencing the report see Characteristics of Rural Interested Students |
| Studies support the conclusion that interest stated at matriculation is positively related to an eventual choice of family medicine. (It is speculated that what students state during their interviews versus their interest after acceptance to medical school is the critical point.) However, these studies also show that preferences for a particular specialty change considerably during the years of medical school. There is attrition to other specialties among those initially interested in family medicine and significant recruitment to family medicine among students who had not planned on family medicine on entry to medical school. | Rabinowitz noted
this with the grads choosing rural practice, rural background plus FP
interest at matriculation was 78% of the choice of rural practice.
AAMC study of GQ demonstrated that 30% of rural interested senior students knew their rural career choice at matriculation as compared to 15% of other students. Characteristics of Rural Interested Students |
| Institutional Characteristics | |
| Recent research suggests a complex relationship between specialty choice and the school’s mission, admissions practices, and legislative mandate to produce generalists. A school’s focus on research appears to have a negative impact on students choosing family practice. | Again not a surprise from research by Rosenblatt, although this was a fairly weak factor. |
| Senior administrative support (above the level of department head) appears to be a more relevant factor to career choice than actual legislative mandates or school initiatives. | Having a rural person in leadership, a mission for rural health, a more rural state is related to graduating more rural doctors (Rosenblatt, Bowman). Sounds familiar. It is not enough to be a part of an effort, those interested in change must lead the effort Leadership Factors in Developing RME |
| Medical School Experiences and Outcomes | |
| The informal culture or ‘hidden curriculum’ created by opinions and comments of students, residents and faculty influences students’ specialty choice. Family practice is still viewed by a number of faculty as not being equal to other specialties in terms of prestige and academic rigor. The view that the content of family practice is too broad and cannot be mastered is commonly held. The current content and structure of FP training programs are seen as inadequate to prepare residents for such a broad scope of practice. As a result, many students are actively discouraged from choosing family practice. | The limitations in the number of ambulatory months may never allow this to be overcome. Verby demonstrated that even rural interested students in his RPAP program were overwhelmed at 3 months of immersion in a small town, at 6 months they were neutral, and at 9 months they did not want to leave. Ambulatory care is complex and demands immersion. This is something only a handful of medical students get and even few family medicine residents as well. It is not surprising that they are confused or that faculty do not think that FP can be taught, it cannot in only a few months. We need the full 7 years to teach such an important and complicated area. |
| Large-scale programs with a goal of increasing the number of students entering primary care do appear to influence the number of students who select family practice residencies. Required family medicine curriculum in the third and the first half of the fourth year is positively related to higher numbers of students selecting family medicine. | Since the early 1980's we have known that we needed coordinated comprehensive all level pipeline strategies impacting all levels of training, particularly the early preprofessional levels. Why do we ignore this? |
| Faculty role models in medical school are important, serving both as positive and negative influences. Role models seem to be an influence for those who switch their specialty preference to or from family practice – the presence of university FP faculty who are perceived as competent and individuals the students see as role models is important. | We are running off many of the faculty who prioritize service and a clinical focus. Our faculty are running in a number of directions and can only be seen as being confused. Community-based teachers are a better selection but even here the hassle factors need to be addressed for all physicians, particularly those in FP. |
| Recent research indicates that recruitment to family practice after admission accounts for the majority of students who select family practice residencies at the end of medical school. | Don't understand this statement in the context
of the rural data, the declining numbers over the course of admission, the
hidden curricula item noted above, etc. This may be a previous research
finding during the short managed care era when students ran to family
medicine that normally would not do this.
The only thing that makes sense over the decades is that a significant population of individuals resist the influences and continue in a pathway toward FP or service. The ones discovering that FP is service may be the ones recruited by volunteer efforts, community service, and other items deemed less than adequately taught by students in the AAMC GQ follow up. |
| Students develop
definite and influential perceptions about the content and characteristics
of each specialty during medical school. Students who reject family practice
state concern about prestige, low income and breadth of knowledge required. A clear-cut relationship between debt and specialty choice has never been demonstrated and the more recent research indicates that if there is a relationship, it is complex. |
Students reject FP
because they have little contact with it.
Family medicine is about service. Those who reject service, reject family medicine. Madison demonstrated that you could pick students that would go into primary care based on their service characteristics. Service Orientation Those who reject FP on the basis of income, we really do not want or need. |
|
Comments or questions may be submitted to the AAFP Division of Medical Education at fpchoice@aafp.org . |
Comments to rbowman@unmc.edu |
This weeks BMJ has an article showing that UK year 2000 medical school
grads entering general practice is up 3 % over 1996. (Lambert TW. BMJ
2003;326:194-5) 27.5 % of the 2000 class is entering General Practice.
It really is the health care system that influences career selection.
We proved this in the US in the 90s when students thought we were going
to be a managed care health system and saw increased interest in FM.
--
Thomas C. Rosenthal MD
trosenth@acsu.buffalo.edu
Managed care has had an impact on career decisions, see Instate Medical Students and FP Choice. However the best bang for our effort is admissions of those who are different since Family Physicians Are Different rcb
Choice of Family Medicine: Past, Present, Future
FP Graduates 1997 - 2003 Summary Tables