The present study identified several medical student characteristics associated with interest in a primary care residency and those interested in a residency in the periphery among 5th year students at the Hadassah-Hebrew University Medical School.
Primary care
There were many differences between 5th-year Israeli medical students interested and not interested in a primary care residency. Students inclined toward primary care were more interested in lifestyle: spending time with their families, working limited hours and working only during the daytime. This importance of lifestyle was more pronounced in female than male students. Students inclined toward primary care were less interested in academic pursuits, such as being academic faculty members. Reduced interest in academic activities was also observed among Japanese medical students with preferences for family medicine [12]. Lack of interest in academic endeavors is problematic since it reduces the number of family medicine faculty members able to serve as medical student mentors. This lack of mentors might decrease the ability to attract students to the specialty.
It is important to note that the query on the questionnaire was about the broader area of primary care and not specifically about family medicine. Unlike a previous study where we found a female-predominance among 6th year Israeli medical students interested in family medicine, in the present study we did not find such predominance [13]. Furthermore, the proportion of women medical students interested and not interested in primary care was comparable. Similarly, upon multiple regression analysis, interest in primary care was not associated with being female. We thus failed to prove our hypothesis that interest in primary care would be greater among women than men medical students. This variance with our previous studies is attributable to primary care incorporating general internal medicine, general pediatrics and some aspects of obstetrics/gynecology, in addition to family medicine. We previously found that In Israel, internal medicine and obstetrics/gynecology residencies attract many male students [13]. When asked which specialties they were considering, students interested in primary care listed pediatrics and internal medicine more frequently than family medicine.
In many countries, attracting medical students to primary care careers is a daunting task [14]. The reasons for this difficulty differ between countries [15]. In the United States, the proportion of medical students selecting primary care specialties dropped from 73% in 1996 to 44% in 2008, although subsequently there has been some stabilization [16]. Moreover, more internal medicine and pediatric residents are choosing to subspecialize, reducing the numbers entering general internal medicine and pediatric practices [17]. The major reasons cited for the dearth of students entering primary care in the United States are relatively low incomes in the face of high student debt burdens, many administrative tasks and time pressures [16]. Many medical schools have instituted programs to attract more students to primary care, with a multi-year exposure to primary care being more successful than adding a single primary care course to a conventional curriculum [18]. Other countries face similar problems. In Vietnam less than a third of commune (collective farming communities) health stations are staffed by a physician even though the number of medical school graduates almost tripled between 2004 and 2011 [19]. The reasons include poor working conditions, low income and lack of opportunities for career development [19]. In a survey of 9499 South Korean medical students only 2.2% expressed interest in family medicine [20].
Shortages of primary care physicians are generally attributed to low salaries, lack of prestige and glamor; long hours with frequent on-call responsibilities; and lack of a controllable lifestyle [21, 22]. The situation in Israel differs from other countries in that primary care physicians mainly work in health maintenance clinics, receive salaries comparable to other physicians, have few on-call obligations and have set hours [8]. This was reflected in our previous study where Israeli 6th-year students rated family medicine and pediatrics as specialties with controllable lifestyles and positive relationships between controllable lifestyle and remuneration [13]. This was also found in the present study, where compared to 5th-year students not interested in primary care, those interested in primary care wanted a specialty with time for family involving only daytime work and practice in the community (i.e. outside the hospital). This interest profile was similarly demonstrated by their greater interest in short (in years) residency programs with limited hours and with much time spent in clinics. This grouping of interests indicates a desire for positive life/work balance, something that Israeli non-hospital primary care practice provides. A recent study of Israeli family medicine residents reported similar findings. Specifically, more than 85% of residents reported that factors that positively influence their choice included the ability to combine work, family, and free time; direct, meaningful contact with patients; the diversity of patients and medical conditions; and attractive working conditions [23]. This interest profile is similar to those reported from other countries among students interested in primary care and family medicine [12, 24]. However, primary care in isolated Israeli rural village has been reported to lead to unclear boundaries between private life and physician roles leading to problems with life/work balance [25]. This may be among the reasons for the shortage of primary care practitioners in the country’s periphery.
Rural (periphery) workforce
Worldwide, rural areas often suffer physician shortages. Therefore, in many countries with large rural areas, such as the United States, Canada and Australia, emphasis has been placed on encouraging more medical students to become rural primary care physicians [26, 27]. To attract students to rural areas, medical schools have programs that expose students to rural practice and have increased the recruitment of students from rural areas [28]. The current study showed that of the more than 500 5th-year Israeli students studied, 8.9% were considering residency in the country’s periphery. This percentage is greater than that reported in our previous study of 5th year students (4.6%) and might be attributable to the recent introduction of monetary incentives (one-time grants and salary increases) for physicians choosing to train and practice in the periphery. Shortages of rural physicians frequently includes a lack of primary care physicians; a situation also present in Israel. Among students interested in primary care, 19% would choose a residency in the periphery. Alternately, among students considering a residency in the periphery, 42% were interested in primary care. This attraction to primary care among students interested in living in rural areas was also observed among Japanese medical students [29]. However, when we examined our overall student sample, only 3.7% of the 5th-year students reported interest in both primary care and peripheral residencies.
Regression analysis showed that attending high school in Israel’s south and north was associated with interest in residency in the same regions. Notably, significantly more students interested in residencies in the periphery reported that the locale of their family was an important criterion for choosing a residency program. Furthermore, among students who responded to the question concerning the effects of one-time monetary incentives to do a residency in the periphery, “I already plan to do a residency in the periphery”, 63% had gone to high school in the northern or southern areas. Therefore, we confirmed the hypothesis that interest in residencies in peripheral areas is greater among students who attended high school in peripheral regions. Similar observations were made in Kenya, United States, Japan and Australia where students of rural origin were more interested in rural practice [2, 11, 28, 29]. These results have potential healthcare policy implications. Firstly, they can contribute to decisions about whether to admit more medical school applicants residing in the periphery in an attempt to reduce the shortage of physicians practicing there. Secondly, the results can also contribute to decisions about whether to include rural medicine rotations during the clinical years to provide all students with exposure to such medical practice [30].
The characteristics of students considering a residency in the periphery were similar to those interested in a primary care residency. Although this may be partially attributable to the many students interested in a primary care residency, it also likely reflects that those interested in residencies in the periphery are more interested in life-work balance and are less interested in a residency in a large hospital and in a leading department.
Incentives
The last four years of the study provided an opportunity to explore the student’s thoughts about the monetary incentives for rural residency included in the 2011 union contract [7]. Although only 6% were already planning to do a residency in the periphery, 30% indicated that the incentives induced them to consider a residency there. Fifty-three percent of the latter students reported that they did not yet know where they wished to do their residency as opposed to 22% among those not interested in the incentives. Moreover, there were more differences between the two groups. Students interested in the incentives were more interested in primary care residencies, specialties dealing with social issues, specialties providing family time and residencies affording controllable lifestyles. Alternately, they were less interested in research opportunities, a rapidly advancing specialty and a residency in a leading department in a large hospital. For medical educators and healthcare leaders these results point to a group with distinct characteristics who might be encouraged to join residency programs in the periphery. The challenge is to better characterize this student group, identify them early during their specialty/residency program decision process and provide positive information and counseling about residency programs and lifestyle in the periphery. Thirty percent of the residents working in Israel’s periphery reported that the incentives had influenced them greatly, even though initially they had intended to work there [23]. Previous studies have shown that Israeli primary care practitioners in the periphery are more satisfied and had a broader scope of practice than urban practitioners [29, 31, 32]. While the aim is to market residency programs in the periphery to the students, the results of this study show that a third of the students reported that the influence of family was an important part of their residency selection process. Therefore, consideration should be given to including spouses in recruitment efforts.
Strengths and limitations
The strength of this study is that the large number of students studied allowed us to examine subgroups, such as those interested in primary care. A further strength was its multi-year design showing that the proportion of students interested in primary care and peripheral hospitals remained steady throughout the study.
The major limitation is that the study was performed in a single institution that is located in the center of the country and is focused on academic medicine. Hence the findings are not automatically generalizable to the entire Israeli medical student population, and parallel studies should be carried out at additional Israeli medical schools.Footnote 1
Another limitation is that the study only included Israeli medical students when half the medical internship workforce is comprised of Israeli who graduated from foreign medical schools and immigrants and 58% of the family medicine residents graduated from such schools [23]. Yet, unlike the foreign graduates who only enter the Israeli healthcare system as interns, having had exposure to the various specialties in foreign healthcare systems during medical school, the Israeli medical students are part of the Israeli healthcare system while they are medical students providing the Israeli healthcare leadership the opportunity to directly expose them to Israeli primary and rural practices early in their clinical experience.
A further limitation is that there might be selection criteria that were not included in the questionnaire. However, both the factor and cluster analyses showed few factors and clusters indicating that a wide-variety of topics were queried.