Medical career choice and practice location: early factors predicting course completion, career choice and practice location

AIMS: The overall aim of the study was to identify the factors that best predict medical career choice and practice location. METHOD: A longitudinal, cohort study was conducted. This followed 2 cohorts of students, numbering a total of 229 students, who commenced medical studies at the University of Western Australia in 1984 and 1989. Data concerning the students' sociodemographic backgrounds, admission scores and personality characteristics were collected in Year 1. Regression analyses were performed to identify the student characteristics that best predicted course completion, a choice of general practice 4 years after graduation and a rural location of practice. OUTCOMES: We found that students who had lower university admission scores and who were less outgoing were less likely to complete the course. Students who were male, had a father in medicine and were more creative and abstract in their thinking and more conscientious and rule-bound were more likely to choose a specialist career. A rural background was found to be the most important predictor of both rural general and specialist practice.     

Do students from rural backgrounds engage in rural family practice more than their urban‐raised peers?

INTRODUCTION: In a previous prospective study, students from rural backgrounds were found to be significantly more likely to consider rural practice than their urban-raised peers. The purpose of this study was to determine whether the students with rural backgrounds who participated in the original investigation were more likely than their urban-raised peers to be currently engaged in rural family practice. METHOD: In Canada, family doctors have the greatest opportunity to practise in rural communities. Consequently, rural and urban background students from the original study who entered the discipline of family medicine as a career were identified for practice location follow-up. Participants were categorised as either rural (population less than 10 000) or urban practitioners according to the population of the community in which they practised. The proportion of rural and urban background students engaged in rural or urban practice was analysed using chi-square and relative risk probability. RESULTS: A total of 78 students from the original cohort were found to be practising family medicine; 22 of them had been rurally raised. Seven (32%) of the rural background students were practising in a rural community, compared to 7 (13%) of the 56 urban background students (RR = 2.55; P < 0.05). CONCLUSIONS: Rural background students who went on to complete family medicine residency training were approximately 2.5 times more likely to be engaged in rural practice than their urban-raised peers. Altering medical school admission policy to recruit more rural background applicants should be part of a multi-dimensional approach to increasing the number of rural practitioners.     

Characteristics of doctors and nurses as perceived by students entering medical school: implications for shared teaching

INTRODUCTION: Debate continues with respect to when to introduce interprofessional education for maximal potential benefit. One perspective is that interprofessional education should be introduced early in the undergraduate curriculum before students develop stereotyped impressions of other professional groups. However, it may be that students at entry to medical school have already developed these stereotypical impressions. This study examines perceived professional characteristics of doctors and nurses by students entering medical school. METHODOLOGY: Year 1 medical students in 4 consecutive years completed a questionnaire on their perceptions of the characteristics and backgrounds of nurses and doctors and on their attitudes to shared teaching. RESULTS: Year 1 medical students were found to perceive the characteristics of doctors and nurses differently. They considered nurses to be more caring and doctors to be more arrogant. They considered nurses to have lower academic ability, competence and status, although comparable life experience. They were generally very positive about beginning shared learning at an early stage of training. DISCUSSION: Whilst it is encouraging that medical students are positive about shared teaching, it is of concern that they have a poor perception of the academic ability, status in society and professional competence of the nurse at entry to medical school. These perceived impressions, which may reflect societal misconceptions regarding the roles and responsibilities of nurses within a modern health care system, may have an impact on the success of early interprofessional teaching initiatives in undergraduate curricula.     

Evaluation of procedural skills training in an undergraduate curriculum

CONTEXT: A substantial proportion of medical students enter their intern year without any basic skills experience. Lack of experience is a significant source of stress for many junior doctors. OBJECTIVES: To evaluate the effect of a basic procedural skills tutorial for Year 3 medical students on their competence in relevant skills at Year 5. SUBJECTS: The control group consisted of 93 medical students who completed Year 3 in 1996. The intervention group consisted of 92 medical students who completed Year 3 in 1997. The intervention group received a practical skills tutorial in Year 3; the control group did not. Both groups were assessed on their practical skills competence during Year 5. METHODS: A 3-hour practical tutorial on injection and suturing techniques was delivered to the intervention group. The effectiveness of the intervention was assessed by self-reported experience of giving injections, inserting sutures and sustaining needlestick injuries, and by teacher-rated competency in four basic procedural skills. RESULTS: Students who received the Year 3 tutorial were significantly more likely to record a satisfactory assessment for their performance in all four basic skills compared with students who did not receive the tutorial. They were less likely than controls to refuse invitations to give injections, but not invitations to insert a suture, during Years 4 and 5. CONCLUSIONS: A single session of formalised teaching in procedural skills in the early stages of a medical degree can have long-term effectiveness in basic skills competence and may increase students' confidence to practise their skills.     

Impact of a new curriculum on medical students' interpersonal and interviewing skills

OBJECTIVES: In 1998 we reported on the rise and fall of medical student communication skills during the 4 years of medical school. Since then, the University of Connecticut School of Medicine has completed a major curriculum renewal project with an emphasis on early clinical work, lifelong learning and more ambulatory training. The goals of this study were to compare students' interviewing and interpersonal skills in standardised patient (SP) assessments in the old and new curricula and to assess the success of the new curriculum in preventing a decline in student skills in this domain. METHODS: The clinical skills of 202 students were measured longitudinally during encounters with SPs in each of their 4 years of medical school. Students in this study and the earlier study were evaluated using the Arizona Clinical Interviewing Rating (ACIR) Scale. RESULTS: Compared with students from the previous curriculum, students on the new curriculum in this study showed an improvement in ACIR scores. Year 1 mean ACIR scores (1 = poor to 5 = excellent) were, respectively, 3.6 for the old curriculum cohort and 4.0 for the new curriculum group. In Year 4 the mean score for the old curriculum cohort was 3.7 and that for the new curriculum group was 3.8. Students on the new curriculum still showed a decline in ACIR scores from Years 1 to 4, but it was not as severe a decline as it had been previously. CONCLUSIONS: Pre-clinical medical students perform better on measures of interpersonal communication than their clinical counterparts. The students who participated in the new curriculum demonstrated an earlier acquisition of and a less steep decline in interviewing and interpersonal skills during the course of medical school.     

Academic misconduct among medical students in a post-communist country

AIM: To assess the prevalence of, attitudes towards and willingness to report different forms of academic dishonesty among medical students in a post-communist transitional country. METHODS: An anonymous, self-administered questionnaire was distributed to medical students in Years 2-6 at the Zagreb University School of Medicine; 827 (70%) valid questionnaires were returned and analysed. RESULTS: Most of the students (94%) admitted cheating at least once during their studies. The most frequent type of misconduct was 'signing in an absent student on a class attendance list' (89.1%), and the least frequent 'paying for passing an examination' (0.7%). The number of committed types of misconduct out of 11 listed types increased from Year 2 (median 2) to Year 6 (median 4). Cheating behaviours could be clustered into 4 groups based on self-reported cheating, perceived prevalence of cheating, attitude towards cheating, and willingness to report cheating. The clustered behaviours that most students admitted to were perceived as the most frequent, more approved of and less likely to be reported. The strongest predictors of dishonest behaviour were attitude, perception of peer group behaviour and study year. Almost half (44%) the students said they would never report any form of cheating. CONCLUSION: Academic misconduct is widespread among medical students at the largest medical school in Croatia and its prevalence is greater than that reported for developed countries. This may be related to social and cultural factors specific to a country in the midst of a post-communist transition to a market economy, and calls for measures to be instigated at an institutional level to educate against and prevent such behaviour.     

Does a rural educational experience influence students' likelihood of rural practice? Impact of student background and gender

CONTEXT: The family medicine clerkship at the University of Calgary is a 4-week mandatory rotation in the final year of a 3-year programme. Students are given the opportunity to experience rural practice by training at 1 of several rural practices. OBJECTIVE: To determine whether exposure to a rural educational experience changes students' likelihood of doing a rural locum or rural practice and whether student background and gender are related to these practice plans. METHOD: Clinical clerks from the Classes of 1996-2000, who trained at rural sites, responded to questionnaire items both before and after the rural educational experience. Responses to the questionnaire items and discipline of postgraduate training served as dependent variables. Student background and gender were independent variables. RESULTS: As a result of the rural educational experience all students were more likely to do a rural locum. Compared to their urban-raised peers, students from rural backgrounds reported a significantly greater likelihood of doing a rural locum and practising in a rural community, irrespective of gender or participating in a rural educational experience. There was no relationship between background and career choice. CONCLUSION: A rural educational experience at the undergraduate level increases the stated likelihood of students participating in rural locums and helps to solidify existing rural affiliations. Students with rural backgrounds have a more favourable attitude toward rural practice. This pre-post study provides further support for the preferential admission to medical school of students with rural backgrounds to help alleviate the rural physician shortage.     

Comparison of academic, application form and social factors in predicting early performance on the medical course

OBJECTIVES: To compare the relative importance of social, academic and application form factors at admission in predicting performance in the first 3 years of a medicine course. DESIGN: Retrospective cohort study. SETTING: A single UK medical school. PARTICIPANTS: A total of 738 students who entered medical school between 1994 and 1997. MAIN OUTCOME MEASURE: Performance in Year 3 objective structured clinical examination (OSCE). RESULTS: School-leaving grades were significant predictors of success in the OSCE. Non-academic activities as assessed from the application form were associated with poorer performance. Mature students performed extremely well, and male and ethnic minority students performed less well. Socioeconomic status and type of school attended were not found to affect performance on the course. CONCLUSIONS: The relatively poor performance of male and ethnic minority students urgently needs further investigation. Our results carry no suggestion that, other things being equal, widening access to medical school for mature students and those from less affluent backgrounds would result in poorer performance.     

Factors affecting the probability of first year medical student dropout in the UK: a logistic analysis for the intake cohorts of 1980-92

BACKGROUND: In the context of the 1997 Report of the Medical Workforce Standing Advisory Committee, it is important that we develop an understanding of the factors influencing medical school retention rates. AIMS: To analyse the determinants of the probability that an individual medical student will drop out of medical school during their first year of study. METHOD: Binomial and multinomial logistic regression analysis of individual-level administrative data on 51 810 students in 21 medical schools in the UK for the intake cohorts of 1980-92 was performed. RESULTS: The overall average first year dropout rate over the period 1980-92 was calculated to be 3.8%. We found that the probability that a student would drop out of medical school during their first year of study was influenced significantly by both the subjects studied at A-level and by the scores achieved. For example, achieving 1 grade higher in biology, chemistry or physics reduced the dropout probability by 0.38% points, equivalent to a fall of 10%. We also found that males were about 8% more likely to drop out than females. The medical school attended also had a significant effect on the estimated dropout probability. Indicators of both the social class and the previous school background of the student were largely insignificant. CONCLUSIONS: Policies aimed at increasing the size of the medical student intake in the UK and of widening access to students from non-traditional backgrounds should be informed by evidence that student dropout probabilities are sensitive to measures of A-level attainment, such as subject studied and scores achieved. If traditional entry requirements or standards are relaxed, then this is likely to have detrimental effects on medical schools' retention rates unless accompanied by appropriate measures such as focussed student support.     

Attachment theory in health care: the influence of relationship style on medical students' specialty choice

INTRODUCTION: Converging sources suggest that patient-provider relationships in primary care are generally of greater intensity and duration than those in non-primary care specialties. In this study, we hypothesised that Year 2 medical students whose close relationships were characterised by security and flexibility would be more likely than students who were less comfortable in close relationships to plan to pursue primary over non-primary care postgraduate training. METHODS: We determined the relationship styles and demographic characteristics of 144 Year 2 medical students. We also gathered information regarding their predicted choices of postgraduate training, which were clustered into primary or non-primary care categories. We compared student choices with respect to their interpersonal relationship styles based on attachment theory. RESULTS: Prevalences of attachment styles were similar to those found in the general population, with 56% of students rating themselves as having a secure relationship style. Students with a secure style were more likely to choose primary care (61%) over non-primary care compared to those whose styles were characterised by self-reliance, support-seeking or caution (41% chose primary care). Compared to those with a secure relationship style, students with a cautious style [OR = 5.9 (1.9, 18.7)] and students with a self-reliant style [OR = 2.4 (0.96, 5.9)] were more likely to choose non-primary over primary care, after controlling for gender. CONCLUSIONS: Assessing relationship styles using attachment theory is a potentially useful way to understand and counsel medical students about specialty choice.     

Student perceptions of medico-legal autopsy demonstrations in a student-centred curriculum

Objectives  Teaching autopsies in undergraduate medicine, although traditionally considered valuable by both educators and students, have been marginalised in modern curricula. This study explored medical students' experiences of the medico-legal autopsy demonstrations which formed part of their training in forensic medicine.
Methods  In this phenomenological study, qualitative data obtained by interviewing 10 Year 4 medical students from various socio-cultural backgrounds were interpretively examined. One-to-one, semi-structured interviews were tape-recorded and transcribed. The data were thematically organised and then analysed using a theoretical framework of three dimensions of learning, namely, cognitive, emotional and societal.
Results  Students still perceive autopsies as essential even in the context of self-directed learning. They identified a better understanding of anatomy and traumatology as the main cognitive benefits. At an emotional level students felt they had developed a degree of clinical detachment and would be better equipped to deal with issues surrounding death. Although socialisation influenced students' feelings about the autopsy, it did not detract from their appreciation of the educational value of the experience.
Conclusions  The results support previous findings from both students, prior to curriculum reform, and medical educators who were canvassed for their opinions in relation to a modern curriculum. Besides the obvious cognitive advantages, educators should be mindful of the hidden curriculum that emanates from autopsies because it impacts on the development of professionalism and ethical behaviours of future medical practitioners.     

Students' opinions about their preparation for clinical practice

INTRODUCTION: There are data that suggest that medical students do not feel sufficiently prepared for clinical practice in the clerkships. The transition from pre-clinical to clinical training causes problems. OBJECTIVES: To seek quantitative verification of qualitative findings from an earlier focus group study on problems medical students encounter when entering the clinical phase of undergraduate training. METHODS: At the start of the clinical phase, all Year 4 students at Maastricht Medical School were surveyed on the transition from pre-clinical to clinical training and its effects on workload, knowledge, skills and learning. RESULTS: The response rate was 67%. Students were uncertain as to how to behave and act, mainly because they did not know what was expected of them. They experienced a drastic increase in workload and a lack of time for studying. They considered themselves to be moderately prepared with regard to knowledge and they regarded their physical examination skills as satisfactory. Students reported having difficulty applying theoretical knowledge in clinical practice and perceived shortcomings in basic science knowledge. In addition, they felt compelled to change their learning strategies. DISCUSSION: The results of this study confirm the findings of the focus group study. The students experienced problems related to professional socialisation and workload and deficiencies in knowledge and the organisation of knowledge. A good starting point for improvement may involve exploring students' suggestions of an extensive introduction into the clerkships, a more gradual transition with regard to workload and closer integration of pre-clinical and clinical education.     

Stress, debt and undergraduate medical student performance

INTRODUCTION: Against the background of current debate over university funding and widening access, we aimed to examine the relationships between student debt, mental health and academic performance. METHODS: We carried out an electronic survey of all medical undergraduate students at the University of Aberdeen during May-June 2004. The questionnaire contained items about demographics, debt, income and stress. Students were also asked for consent to access their examination results, which were correlated with their answers. Statistical analyses of the relationships between debt, performance and stress were performed. RESULTS: The median total outstanding debt was pound 7300 (interquartile range 2000-14 762.50). Students from lower socioeconomic backgrounds and postgraduate students had higher debts. There was no direct correlation between debt, class ranking or General Health Questionnaire (GHQ) score; however, a subgroup of 125 students (37.7%), who said that worrying about money affected their studies, did have higher debt and were ranked lower in their classes. Some of these students were also cases on the GHQ-12. Overall, however, cases on the GHQ had lower levels of debt and lower class ranking, suggesting that financial worries are only 1 cause of mental health difficulties. DISCUSSION: Students' perceptions of their own levels of debt rather than level of debt per se relates to performance. Students who worry about money have higher debts and perform less well than their peers in degree examinations. Some students in this subgroup were also identified by the GHQ and may have mental health problems. The relationships between debt, mental health and performance in undergraduate medical students are complex but need to be appreciated by medical education policy makers.     

Undergraduate medical students: who seeks formative feedback?

OBJECTIVE: This study aimed to monitor which undergraduate students collected formative feedback on their degree essays and to quantify any correlations between gender or summative mark achieved and whether formative feedback was sought. METHODS: We carried out a study at the University of Aberdeen Medical School, involving a total of 360 Year 3 students, comprising all 177 students in the 2004 cohort and 183 in 2005. Data on gender and summative mark were routinely collected during the degree assessment processes in March 2004 and 2005. Students signed on receipt of their feedback. RESULTS: Less than half the students (46%) collected their formative feedback: 47% in 2004, and 45% in 2005. Overall, females were significantly more likely than males to seek formative feedback (P = 0.004). Higher achievers were significantly more likely than lower achievers to seek their feedback (P = 0.020). CONCLUSIONS: Our findings indicate that these medical students, particularly males and poor students, may not use assessment feedback as a learning experience. Female and better students are keener to seek out formative feedback that might be expected to help them continue to do well. We need to explore further why so many students do not access formative feedback, and develop strategies for addressing this issue effectively.     

Medical students' personality characteristics and academic performance: a five-factor model perspective

OBJECTIVES: This study investigates: (1) which personality traits are typical of medical students as compared to other students, and (2) which personality traits predict medical student performance in pre-clinical years. DESIGN: This paper reports a cross-sectional inventory study of students in nine academic majors and a prospective longitudinal study of one cohort of medical students assessed by inventory during their first preclinical year and by university examination at the end of each pre-clinical year. SUBJECTS AND METHODS: In 1997, a combined total of 785 students entered medical studies courses in five Flemish universities. Of these, 631 (80.4%) completed the NEO-PI-R (i.e. a measure of the Five-Factor Model of Personality). This was also completed by 914 Year 1 students of seven other academic majors at Ghent University. Year end scores for medical students were obtained for 607 students in Year 1, for 413 in Year 2, and for 341 in Year 3. RESULTS: Medical studies falls into the group of majors where students score highest on extraversion and agreeableness. Conscientiousness (i.e. self-achievement and self-discipline) significantly predicts final scores in each pre-clinical year. Medical students who score low on conscientiousness and high on gregariousness and excitement-seeking are significantly less likely to sit examinations successfully. CONCLUSIONS: The higher scores for extraversion and agreeableness, two dimensions defining the interpersonal dynamic, may be beneficial for doctors' collaboration and communication skills in future professional practice. Because conscientiousness affects examination results and can be reliably assessed at the start of a medical study career, personality assessment may be a useful tool in student counselling and guidance.     

Career intentions of medical students in the setting of Nepal's rapidly expanding private medical education system

The number of medical students trained in Nepal each year has increased nearly fifty-fold in the last 15 years, primarily through the creation of private medical schools. It is unknown where this expanding cohort of new physicians will ultimately practice. We distributed an anonymous survey to students in their last 2 years of medical school at four medical schools in Nepal to examine two dimensions of career intention: the intention to practice in Nepal and the intention to practice in rural areas. Eighty-five per cent of the eligible study population participated, for a total of 469 medical students. Of these, 88% thought it was likely they would practice in Nepal and 88% thought it likely they would practice in urban areas. Those students who indicated a greater likelihood of practicing abroad came from families with higher incomes, were more likely to think earning a good salary was very important to their decision to become a physician, and were less likely to think they could earn a good salary in Nepal. Students whose tuition was paid by the government were no more likely to indicate an intention to practice in Nepal than students paying their own tuition at private medical schools. Students who indicated a greater likelihood of practicing in rural areas were more likely to be male, to have gone to a government secondary school, to have been born in a village, or to have received a scholarship from the Ministry of Education that requires rural service. Based on our findings, we suggest the following policy changes: (1) medical schools consider selecting for students from rural backgrounds or government secondary schools who are more likely to intend to practice in rural areas, and (2) increase the number of post-graduate positions--weighted toward rural health needs--to retain students in Nepal.     

Graduate entry to medical school? Testing some assumptions

BACKGROUND: Debate abounds regarding the most appropriate candidates to admit to medical school. This paper examines whether there is any advantage to admitting 'graduate' entrants over secondary school leavers on selected medical school and practice outcomes. AIM: To compare the medical school experiences, research and academic achievements and practice outcomes of graduates who entered 1 medical school in Australia directly from high school (secondary school entry) to those of graduates who entered with tertiary level education (tertiary entry). DESIGN AND METHODS: Cross-sectional study using a mail-out survey to graduates from the first 16 graduating years (1983-98 inclusive) of the University of Newcastle Medical School. RESULTS: Secondary school entrants were, on average, 8 years younger than tertiary entrants and were less likely to have received rural-based schooling. However, there were no differences with respect to gender or type of secondary school attended (public or private). Motivations for studying medicine did not generally differ according to entry type, except that more secondary students were motivated by parental expectations and more tertiary entrants were motivated by the need for professional independence and the desire to prevent disease. A greater proportion of tertiary entrants experienced stress at medical school. However, secondary students experienced more stress due to doubts about being a doctor, while tertiary entrants experienced more stress due to lack of leisure time, finances and balancing commitments. There were no significant differences between the groups in terms of academic performance (as measured by the award of medical school honours) or research outcomes (as measured by completion of a research degree during or after medical school training, publication of scientific papers or holding career posts in the research sciences). There were no differences in career positions held by clinicians, choice of general practice or another specialty as a career, practice location (rural or urban) or employment sector (public or private). CONCLUSION: There is no clear advantage, at least on the outcomes measured in this study, to limiting medical school entry to either those candidates from secondary school or those with tertiary backgrounds. Medical schools could reasonably broaden their selection criteria to include more graduate entry candidates in addition to secondary school leavers without compromising medical school and practice outcomes.     

Assessment of personal qualities in relation to admission to medical school

BACKGROUND: Recently there has been much scrutiny of the medical school admissions process by universities, the General Medical Council and the public. Improved objectivity, fairness and effectiveness of selection procedures are desirable. The ultimate outcome sought is the graduation of competent doctors who reflect the values of and are in tune with the communities they serve. METHODS: Applicants to the Scottish medical schools sat a battery of psychometric tests to measure cognitive ability, personality traits and moral/ethical reasoning (Personal Qualities Assessment, PQA). Analysis determined the potential impact of the latter variables, and those of educational background and socioeconomic class (assessed by residential 'deprivation category'), upon success in gaining a place to study medicine. RESULTS: Cognitive ability did not vary significantly as a function of gender or educational background, although there was a trend for it to be lower in individuals from more deprived backgrounds. Women as a group were more empathic, with a greater communitarian orientation, than men. There was no significant difference between individuals attending independent and state-funded schools in respect of any of the qualities measured by the PQA. Applicants from deprived backgrounds and those attending state-funded schools would not be disadvantaged by an admissions process based on the PQA. CONCLUSION: The incorporation of an assessment tool such as the PQA may have positive implications for widening access and the objective selection of suitable medical students, resulting in the training of doctors who are more representative of the community at large. A longterm follow-up of the professional careers of those medical students who completed the PQA will be undertaken.     

Why are there so few working‐class applicants to medical schools? Learning from the success stories

Objectives  Students from lower socio-economic circumstances remain under-represented in UK medical schools despite recent shifts in other demographic variables and specific policy emphasis on widening participation (WP). This study aimed to further understanding of the reasons for this.
Methods  Volunteer participants at three English medical schools took part in narrative-style, in-depth interviews examining their pathways into medicine and the relationships between these pathways and participants' socio-cultural, educational and family backgrounds. This analysis uses findings from interviews with 12 mature students from working-class backgrounds. It employs theoretical work from the wider field of education sociology that has investigated the relationship between higher education decision making and class.
Results  This study demonstrates how 'normal working-class biographies', constructed by the majority of students targeted by WP activity, result from the influences of socio-cultural context, as well as familial and institutional habitus. The resultant influence on habitus as identity and, in particular, the disjuncture between working-class perceptions of medicine and individual identities are key to understanding the reasons behind the low number of working-class applicants to medical school.
Conclusions  Interventions that aim to increase participation rates in medicine must address this disjuncture. This might be achieved by re-orienting working-class identities and perceptions of medicine as a profession. However, it should be acknowledged that 'identity conflict' is related to the elite image that medicine maintains within contemporary society and, as such, efforts to re-orient individual working-class identities may have only a limited impact on overall participation rates.