How Experiences in a Medical School Affect Medical Students’ Attitudes Toward Family Medicine as a Career Choice: A Mixed-Method Study

Abstract

Background: Family practice is the key element of a primary care system. A shortage of family physicians is an important issue in Thailand. However, Thai medical students still show low interest in pursuing a career in family medicine. The objective of this research is to study how a curriculum, an extra-curricular activity, and a hidden curriculum in a medical school affect medical students’ attitude toward family medicine as their career choice.

Methods: This research is a mixed-method study with a sequential-explanatory design. The quantitative part is an online questionnaire to obtain a distribution of interest in a career of family physician. It was distributed among 181 senior medical students of Ramathibodi medical school; out of which 64 have participated. In the qualitative part, a total of 14 students who met the inclusion criteria were chosen from the questionnaire and from a snowball sampling to participate in an in-depth interview. Thereafter, a content analysis was done to identify themes.

Results: Four out of 64 participants showed interest in a career of family physician, but only one participant was strongly interested. As the whole curriculum focuses mostly on specialty contents, only the family medicine department teaches holistic care and students find it difficult to understand. Some students perceive that a psychosocial assessment intrudes too much into a patient’s personal life and is not a physician task. The examination-based curriculum causes them to lack spare time to participate in any extra-curricular activity. The students received both positive and negative comments about family physicians from other specialists. However, this hidden curriculum does not have a direct impact on the student’s decision to choose their career path. Important factors that influence the decision are their personal interests, masteries, family factors, a work-life balance, and a humanized environment.

Conclusions: Experiences in medical school have an impact on medical students’ attitudes toward family physician as a career choice. A disease-oriented care model is still dominating Thai medical education. Therefore, the curriculum needs to be reformed to promote the importance of holistic care. This will lead to an increase in the production of Thai family physicians.

Background

The shortage of family physicians is a major concern in many countries all over the world, including Thailand. This problem is one of the barriers to establishing a good health care system.

In the past, many sectors have come up with strategies to increase the number of Thai family doctors. Many medical schools have been collaborating to find a solution since 2001. There was a suggestion from Nation Medical Education Forum that teaching family medicine in a medical school curriculum may encourage undergraduate medical students to become family doctor. Despite all the efforts, Thai medical students still show low interest in choosing family medicine as a career choice.

Previous studies have shown that experiences in medical school have an influence on medical students’ attitudes toward family medicine as a career choice. These experiences in medical school were related to three issues including a curriculum, an extra-curricular activity, and a hidden curriculum.

First, medical students were reported to have a poor idea of what family practice is if they have not been exposed to family medicine in their school curriculum.^(1-3) The length of time, quality, and learning environment of the practices were also important factors influencing students’ career choice. ^{(4, 5)}

Secondly, extra-curricular activities were also important. It had been found that experiences of volunteer works in a developing country were associated with a primary care career choice. ^{(6, 7)}

The final issue was about the hidden curriculum, which means an unwritten and unintended lesson in the school. Most of the studies showed that negative comments about family medicine from other specialties affect students’ career choice. ^{(1, 2, 8-10)} However, one study found that they have no influence at all.⁽¹¹⁾

Out of 21 medical schools in Thailand, only four medical schools have family medicine department. Ramathibodi medical school is one of those and the school family medicine department is well-known for post-graduate family medicine training. Because of that, Ramathibodi medical school is considered a rich resource to be used in investigating how a curriculum, an extra-curricular activity, and a hidden curriculum in medical school affect medical students’ interest to choose family medicine as a career choice. The results of this study might be beneficial to the production of Thai family doctors in the future.

Methods

This research is a mixed-method study with a sequential-explanatory design. A quantitative questionnaire was conducted on medical students to identify a distribution of interest in choosing family medicine as a career choice. Then, a qualitative part was done using an in-depth interview in which a content analysis was used to identify themes.

Study setting

The study was conducted in Ramathibodi hospital, which is a tertiary care hospital and a medical school located in Bangkok, the capital city of Thailand. The school provides a six-year medical curriculum. All of the 181 final-year medical students in the graduating class of 2019 were invited to participate.

Quantitative part

We developed an online questionnaire which consists of three parts, including baseline demographic characteristics, future career plans, and attitudes toward family medicine as a career choice. The attitude part is evaluated using a five-point Likert scale. A higher score represents a higher level of interest in becoming a family doctor. The questionnaire was distributed to all the final-year medical students by a medical student representative. The distribution was done three times during September 2018 with one week apart between each round.

Qualitative part

Participants were purposely selected using a snowball technique and from samplings of the quantitative data collection. Participants were classified into three groups as follows; showing interest in becoming a family physician, not showing interest, and not sure. A semi-structured in-depth interview was conducted covering three major topics; reason for entering a medical school, life in the medical school, and plan after graduation. Written informed consent was obtained before the interview. The participants were individually interviewed face-to-face. The interviews were audio-recorded and transcribed verbatim. Two of us (KH and SH) independently coded the transcriptions which later on are reviewed by the third person (SS). We then held a discussion to find a consensus. A content analysis was used to identify themes from the transcriptions.

Results

In the quantitative part, there were 64 out of 181 senior medical students (Respond rate 35.4%) who participated and submitted the answers. The demographic characteristics of the quantitative part are shown in Table 1.

Table 1: Demographic data of participants in the quantitative part

Among the participated students, 85.9 percent plan to work as a physician and 84.4 percent plan to study further in residency training in the future (Table 2-3). In the attitude part, four out of 64 participants show interest in a career of family physician, but only one participant is strongly interested.

Table 2: Participants’ future plan about their career path

Table 3: Specialty that medical students consider as their first choice for future training

In the qualitative part, a total of 14 students were chosen using a snowball sampling and from those who met inclusion criteria from the questionnaire to participate in an in-depth interview. The details of all the participants are shown in Table 4.

Table 4: Demographic data of participants in the qualitative part

F = Female, M = Male, GP = General practitioner, BMR = Bangkok Metropolitan Region, NE = North-eastern region, S = Southern region

There are many factors affecting the medical students’ attitudes toward family medicine as a career choice. The factors can be categorized into two main periods; before entering the medical school, and during the medical school. Both periods have an influence on medical students’ personal life and their attitudes toward choosing family physician as a career choice. The conceptual framework is shown in Figure 1.

Figure 1: Conceptual framework of the findings.

The factors before entering the medical school

This period is an important time for the medical students to make a decision for medical school admission. It also has an impact on their experiences during the medical school. There are four factors in this period.

1. Individual factors

The medical students share particular similar characteristics. For example, they tend to like helping other people. They also had a good high school performance and are multi-talent. They were so proud of their skills but experiences in the medical school might have mitigated the use of these skills.

 2. Family factors

Family also plays an important part in influencing students to enter a medical school. Participants who are the first child in a family with low economic status tend to choose a career path of doctor because of the job stability. Participants whose family members are medical personnel would have a chance to see beforehand what it is like to be a doctor. Some families supported their child to become a doctor. However, some did not because they did not want to lose their child to the intensive study.

3. Elementary school factors

A school-peers trend also has an influence on students’ decision. In a school that most students aim to get into a medical school, students tend to be interested in this path too because of the trend and teachers’ expectations. However, in a school without this trend, students decided on their own about their career path.

 4. Social factors

In Thai society, being a doctor is considered as having a high social status. There is a social value that a smart child should become a doctor. This has an influence on smart students’ decision to get into a medical school even though they have no inspiration to be a doctor. This value also has a negative effect on other average students to follow their dream jobs as they have to compete with smart students in an admission examination. As a result, it is more difficult for them to get into a medical school.

Factors during the medical school

The experiences during the medical school can be divided into six main themes, all of which have an influence on medical students’ attitudes toward family medicine as a career choice.

 1. The late clinical-exposure curriculum

The medical students were exposed to clinical experience only after the fourth year of the program. As a result, they could not grasp the idea of what doctors’ duties and tasks would be in the early years. This caused the 1^st-3^rd year students to have a poor understanding of how to apply the medical knowledge clinically in the later years.

“In the first three years, I had absolutely no idea how I will apply the knowledge to the practice.” Medical student #8

 2. Examination based curriculum

The medical curriculum is divided into department-based rotations such as medicine, pediatrics, and surgery. The medical students had to prepare for an examination at the end of each rotation. Some of the medical problems in the examination were rarely found in real practice. The medical students had to study just for the evaluation rather than for taking real care of patients. Moreover, they extremely gave the highest priority to their grades. Some of them believe that the scores represent their own competency.

“The second year was tough. The examinations were scheduled every two weeks. I had to study for these tests every day.” Medical student #14

 3. High competition

The environment in the medical school was very competitive. It can be seen obviously from bed-side teaching. The medical students had to compete with each other to give the correct answer to their professors’ questions. If they could get the answer right, they would look so smart. The smarter students got more acceptance from professors. The competitive environment could also be seen during an examination. This competition eventually affected students’ decision to choose a specialty to study in residency.

“It is better to choose a specialty that I am good at. There are outstanding medical students in each specialty. I cannot beat them if I choose a specialty that I am not master at.” Medical student #3

 4. Dehumanized lifestyle

A tight schedule caused the medical students to lack spare time for their own personal life. They had to be away from their families for a long time. They also did not have enough time to participate in extra-curricular activities as they had to be in the same routine activities every day.

“It was so busy during the 5^th-6^th year. I was too tired to take care of myself. I could not remember the last time I set my hair” Medical student #5

 5. Poor understanding of a role of family doctors in real life

Most of the medical students could not understand the role of family physician in reality because they were only exposed to experiences in the medical school. They thought that family doctors play an important role only in a community hospital in suburban areas. This idea is one of many reasons that discourage some medical students to become a family doctor because they do not want to live out of town. Many students had a bad impression of family medicine during their home visit session. Some of them perceived that psychosocial and family assessment are too intrusive into the personal life of a patient and are not physician tasks.

“I am not interested in family medicine because I do not want to work in a suburban area. Most of my friends agree with me especially those who live in Bangkok. We had no clue where family doctors would end up working at but at least that was what we think” Medical student #12

 6. The hidden curriculum

The medical students received both positive and negative comments on family physicians from other specialists. Most of the negative comments were about inaccurate treatments provided by family physicians. However, one student heard a positive comment on a home visit skill and competency.

The medical students were obsessed with their future specialty and tried to make their decision early before finishing the medical school. This trend had come up because of the repeated conversations about career path among medical students and with their professors. Moreover, a ‘fixed ward option’, the path that medical students can choose in advance which specialty they want to do during an internship, also plays a crucial role in this trend.

“The ‘Fixed ward option was so popular’. I would probably choose this option too. You could say that we choose an easy way out. Everyone wants to finish residency training as soon as possible so we could finally work and make money.” Medical student #5

Influence on personal life

The factors from before and during the medical school both have an effect on the medical students’ personal lives. They felt stressed and exhausted especially the final year students working on overnight duty. Some of them suffered from depression and burnout. One student told that it was like burning a candle as medical students’ lives were being destroyed day by day to make other people’s lives better.

Some of the medical students had been through experiences in the medical school that diminish their self-esteem. They doubted themselves that they might not be competent enough to be a doctor because they got a low score on their examinations.

Influence on attitudes toward family medicine as a career choice

1. Personal interest

One of the factors affecting a specialty selection is the medical students’ personal interests. For example, the medical students who hate doing procedures are usually interested in medicine, pediatrics, and family medicine. The medical students who like a wide range of knowledge tend to become generalists, such as family physicians, internists, and emergency physicians. In addition, the ones who liked holistic care are usually interested in becoming a family physician.

“I am interested in caring with heart rather than discussing complex and rare diseases” Medical student #8

 2. Mastery

The medical students prefer a specialty that they are good at. If they are not a master of preventive healthcare, they may not choose to be a family physician.

 3. Family factors

One of the barriers that discourage the medical students to choose family medicine as a career choice is a misconception about workplaces. The medical students whose hometown is Bangkok or a nearby province may not choose to be a family physician because they think that this specialist has to work in a suburban area. Their family members also do not want them to be far away from home. Another barrier is that the family members do not understand the job of a family physician. As a result, they would not support their children to choose this career path.

 “It is difficult to explain to my parents what family medicine is. I would rather choose a well-known specialty” Medical student #14

 4. Work-life balance

The medical students are interested in careers with a good work-life balance. Family medicine is one of those with such characteristic which could make it more appealing to medical students.

“One of the reasons that I want to be a family physician is a work-life balance. It is my dream to have a family full of weekend activities. It would be great to be a doctor who can spend time with family.” Medical student #7

 5. Humanized environment

A learning environment is one of the main factors affecting the medical students’ impression of each rotation. The family medicine rotation has a humanized environment that could make medical students interested in this career path.

“I have observed residences and professors in several departments including family medicine. The way family doctors talk to their patients was very nice.” Medical student #7

Discussion

This study shows that the factors before entering the medical school and the experiences during the training program have an influence on the medical students’ decision to become a family physician. This finding is similar to a result of a systematic review in 2013⁽¹²⁾ which found that these same factors affect students’ decision to be a primary care physician. Experiences in a medical school can be divided into three categories, which include a curriculum, an extra-curricular activity, and a hidden curriculum.

Based on the result of this study, the humanized environment in family medicine is one of the factors that might attract more medical students to choose this career path. In this respect, our finding is similar to a study in several countries^{(4, 13)}. In those studies, the duration, quality, and learning environment of a school curriculum have an effect on medical students’ decision to be family physicians.

In Thailand, the whole curriculum is structured based on specialty content. A department of family medicine is the only one teaching holistic care which medical students find difficult to understand. Some students perceive that psychosocial and family assessment are too intrusive into a personal business of a patient and are not a physician task.

For the extra-curricular activities, previous studies showed that having experiences in working as a volunteer in developing countries is a contributing factor for students to choose family medicine career path in the future.^{(6, 7)} On the other hand, our study reveals that the Thai examination-based curriculum caused the medical students to lack spare time to participate in such extra-curricular activities. This would result in the medical students not having enough experiences in real life to make a decision on their career path and thus, would be one of the barriers for the students to choose family medicine as a career choice

For the hidden curriculum, the medical students have heard both positive and negative comments on family physicians from other specialists. This study found that such comments do not have a direct impact on the decision to choose family medicine as a career choice. This result is similar to a qualitative study in 2008. Our study has two new findings about the hidden curriculum that had never been found in other studies before. First, there were also positive comments toward family physicians about their specializing in a home visit skill. The second finding is that a ‘fixed ward option’ can induce the medical students to feel pressured and be in a hurry to find their future specialty. This trend causes them to make the decision too early.

We found that factors that have an important influence on the students’ attitude toward a decision whether or not to become a family physician are actually their personal interests, mastery, family factors, work-life balance, and a humanized environment.

In our study, family factors play a crucial role on the medical student’s attitude. We found that, among Thai medical students, the opinions of their family members have a strong influence on them. In some families, their parents strongly disagree if the students want to work far away from their hometown. The family influence had been shown not only at the period of choosing a career path but also long before since the period of medical school admission.

Our mixed-method research provides essential information in both broad and deep detail. The limitation of this study is the low response rate in the quantitative part. This might be because of the launching time of the online questionnaire which happened near the medical students’ examination in which they needed to be in focus. However, the baseline characteristics of the participants have a normal distribution, so the results could be implied that the participants are good samples for the study.

Conclusions

Experiences in a medical school have an impact on medical students’ decision to choose family medicine as a career choice. However, their individual and family factors also play some crucial parts. Medical education in Thailand is based on subspecialties which leads to disease-oriented care. Therefore, it needs to be reformed in order to promote the importance of holistic care which would be beneficial to the development of family doctors in the future.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki, and was ethically approved by the Institutional Review Board of the Faculty of Medicine, Ramathibodi hospital, Mahidol University (protocol number: ID 06-61-50). Informed consent was obtained from all participants before the start of the data collection.

Consent for publication

Not applicable

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available to protect participant anonymity but are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

The authors declare that they have no funding

Authors’ contributions

KH, SS, and SH designed the study. KH and SS developed the online questionnaire. KH conceived the data. KH, SS, and SS analyzed the data. KH wrote the manuscript in consultation with SS and SH. All authors read and approved the final manuscript.

Acknowledgments

Not applicable

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