Study of Factors Influencing Medical Students in Their Choice of Family Practice as a Specialty (Arizona Study)
Conducted 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
Published articles based on this research:
Senf J H, Campos-Outcalt D, Kutob R. Lessons not learned from the generalist initiatives. Acad Med 2002: 77: 774-775.
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 trend of decreasing student selection of family medicine as a specialty is persisting. In 2002, only 47.2% of family medicine residency positions were filled by U.S. seniors. This is the lowest percentage in the recent history of the specialty and continues the downward trend apparent each year since 1997. Because of the continuing trend away from family practice by U.S. medical students and the potential negative impact of this trend on the U.S. health care system, the AAFP commissioned a series of studies to identify modifiable factors in medical student specialty choice.
In an effort to explore possible reasons for the decline, the investigators compared the 12 medical schools with the greatest increase and the 12 medical schools with the greatest decrease in students entering family medicine in the years from 1998 to 2000. The first phase of the project was a review and assessment of the literature published since 1993 since the existing reviews of the literature covered the years prior to that and were published in 1995. The data from this review were then utilized in separate studies surveying graduates, department heads and family medicine faculty and comparing institutional characteristics in the designated medical schools. While there has been a significant body of research on the influence of student characteristics on specialty choice, less is known about how medical schools and their faculty help determine students' career paths.
What follows are key themes and/or new data discovered by the investigators about those factors which appear to be influencing the choice of family practice among U.S. medical students. The objective in sharing these preliminary findings is to stimulate discussion and the exchange of information within the family of family medicine. The investigators plan to report their findings and conclusions in a series of articles.
Rural background and socioeconomic status
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.
Stated career intentions prior to admission versus those indicated after admission
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.
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.
Legislative mandates and school initiatives
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.
Philosophical and financial support
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.
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. Curriculum
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. Faculty role models
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. Recruitment efforts
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. Student perceptions
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. Debt
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.
Comments or questions may be submitted to the AAFP Division of Medical Education at email@example.com