Where to work, what to do? Does the medical school experience influence career intentions?

Educational institutions that train health professionals are in a unique position to contribute to the improvement of a health system by aligning the curriculum to the growing burden of disease in a country and with patient needs (1). Medical graduates that are currently produced by the education system are ill-equipped to manage health challenges within their communities which can be addressed by the primary health care approach (1, 2). This misalignment of skills and needs is in part due to curricula that are disjointed and that tend to have a narrow technical focus without understanding broader contextual issues (2).

Addressing broader contextual issues that affect the delivery of health care services is one of the aims of the primary health care approach adopted by South Africa (3). The re-engineering of primary health care services in South Africa prioritizes the preventive aspect of health care, which requires a greater involvement of public health and primary care providers (3). The Health Professions Council of South Africa (HPCSA) regulation for approved training institutions also recommends that public health “feature prominently” throughout the curriculum (4). “Undergraduates should understand strategies for health promotion, methods of prevention of disease, be equipped with the skills to determine community needs and promote community participation” (4).

Despite the national prioritization of primary health care services in South Africa and the HPCSA regulation, educational institutions continue to have predominantly hospital-based training for medical students by clinical specialists in tertiary academic hospitals (2). Wits University Medical School introduced the Graduate Entry Medical Programme (GEMP) in 2003 (5). The curriculum in GEMP is based on the biopsychosocial approach and is intended to expose the students to public health and primary care disciplines as well as the traditional hospital based clinical training (5). Even with this curriculum reform annual surveys conducted at the Wits Medical School show that medical students were not interested in public health or  primary care. In fact, their attitude towards these components of the curriculum was negative, more so with public health than with primary care.

There is a growing body of research that examines how medical school experiences can shape career intentions of medical students (6). The curriculum content, placements during clinical rotations and lengths of these rotations have been shown to impact on medical student’s intentions of pursuing primary care careers (6). Studies examining primary care rotations found a positive relationship between exposure to a primary care rotation in the curriculum and the attitudes of students towards primary care (7, 8).  Students with more exposure to primary care settings were found to have a better understanding of patient care as well as the intellectual challenges and research opportunities that lie in these settings (9).

A study was conducted at Wits University in 2010 amongst the medical students in their final year of study (GEMP 4) and those in their first year (GEMP 1) with the aim of comparing career intentions between the two groups. Comparison of the two groups would provide some insight into whether the medical school experience influenced career intentions when adjustment was made for all other factors that could influence career intentions. The hypothesis was that GEMP 4 students were more likely to intend to pursue careers in primary care and in the public sector as they had had exposure to a curriculum that promoted public health and primary care. The study involved primary data collection through self-administered questionnaires. Univariate and multivariate regression models were fitted to determine which factors were associated with a career intention in primary care and in the public sector.

A total of 312 students completed the questionnaires with a response rate of 67% for GEMP 1 and 71% for GEMP 4 students. There was no difference in career intentions between the two groups of GEMP students with the majority being interested in furthering their career in specialist clinical disciplines. Although some GEMP 4 students had changed their minds about their career intentions over the course of their training, the vast majority were still interested in clinical specialist disciplines. Most students did not intend pursuing employment in the public sector beyond their specialist training. Univariate and multivariate regression models showed that students who had children were more likely to work in primary care possibly due to the lifestyle the career offers such as reduced working hours. Students who found the primary care component of their curriculum to be interesting and those who had prior degrees were more likely to work in the public sector.

The study showed that the medical school experience at the University, as it is currently, did not appear to have an influence in any way on the GEMP students into following primary care disciplines or to remain in the public sector. Knowledge of the health system and the burden of disease in the country differed in the two groups suggesting that medical school experience had an influence on knowledge. This, however, did not necessarily translate to career intentions in primary care or the public health sector where the greatest need for health professionals lies.

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I would like to acknowledge Dr Julia Moorman who was my supervisor when doing this study.

Note that the views expressed in this article are those of the author(s) and do not necessarily represent the views of PHASA.

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