We found no evidence of an association between socioeconomic factors and the NRE rank. However, passing the first-year medical exam at the first attempt and enrollment in the NRE preparatory lectures during the sixth year of medical training were significantly associated with the NRE rank.
Few studies have evaluated success in the NRE as a function of the socioeconomic status of a student’s parents. The NRE has been in place since 2004 for all medical students. Before this, students chose whether or not to sit competitive exams for internship training. One study assessed the predictors of success in the NRE between 2004 and 2008 in 473 students selected from an administrative database at the Créteil Faculty of Medicine (9). The factors independently associated with the NRE rank were having to repeat the first-year medical examination, the rank in the faculty exams in the first, third, and fourth years of medical training, and failure to pass the mock NRE. So, the performance in the NRE was highly associated with previous performances from the first year of medical studies. This study also showed that the NRE rank was better when the student's father was a chief executive or when the student lived in a high income residential area (9). These socioeconomic factors were no longer significant in multivariate analysis and only the educational factors were correlated with higher NRE rank. However, one bias was the possible association between the socioeconomic level of the parents and exam success during successive years of medical studies. In a 2011 study of the predictors of ranking in the top 500 students in the NRE, Karila et al (3) found that the factors of success were being under 25 years of age, being from the Paris-Île-de-France region, passing the first year medical school exams at the first attempt, and being in the top 20% of students in the year. Our results are therefore in agreement with literature reports since we found that passing the first-year medical examination at the first attempt was correlated with a higher NRE rank. However, we did not study the other factors during the medical studies, notably passing the faculty exams.
We found that the proportion of students neither of whose parents belonged to a high socio-professional category was relatively low (about 20%). These students were usually those who had a grant awarded on the basis of social criteria and who had a student job during their studies. Previous studies have highlighted a difference in access to medical studies as a function of the socioeconomic status of the students (6,10,11). Karila et al showed that students who undertook medical studies were generally from a high socioeconomic background (6). Of the 4307 students in their study, most had parents of high socio-professional status . The authors concluded that there is unequal access to medical studies as a function of parental socio-professional status . A Danish study found similar results for students studying at the University of Copenhagen between 1992 and 2007 (10). The distribution of social categories among medical students differed from that of the rest of the Danish population. The medical faculty recruited more students from higher socioeconomic backgrounds than the other departments of the University of Copenhagen. A study in Taiwan compared the socioeconomic status of the parents of 227 medical students with that of 181 students in other university departments (11). The parents of the medical students had a higher socioeconomic status than the parents of the students of the control group (11). So, although there may be differences between countries, in particular concerning the process of selection used for medical studies, there seems to be a social selection of medical students.
We found that the population of medical students is selected, with overrepresentation of students from a high socio-professional background. This suggests that when students take the first-year medical examination there has already been prior selection based on social criteria. Since a massive selection occurs after the first-year medical examination in France, the remaining population of students is very specific, and the socio-economic background is likely to have a major impact at this stage. During the remaining years of the curriculum, one would expect the intrinsic motivation to have a major impact, which would corroborate the hypothesis of a weakening of the impact of the socio-economics status.
Our study has some limitations. It was a one-year study in a smallish study population at a single center, the Paris-Sud Faculty of Medicine in the Paris-Ile-de-France region. Now, there are disparities between medical faculties within and outside the Paris-Île-de-France region. One study has shown that the proportion of students with parents of high socioeconomic status was higher in medical faculties in the Paris-Île-de-France region (6). Also, there are disparities between medical faculties within the Paris-Île-de-France region, notably in terms of hospital and university staff and training (12). The number of certified lecturers differs greatly from one medical school to another, with a higher ratio of university hospital lecturers with regard to a variable numerus clausus that favors medical schools within the city of Paris (12). In terms of training, the NRE results constitute the indicator used to compare medical schools. Between 2006 and 2008, the same schools regularly had more than 10% of their medical students in the top 500 and over 20% in the top 1000 (Paris 5, Paris 6, Paris-Île-de-France-Ouest) (12). Another limitation of our study was the posteriori exclusion of ten students because their NRE rank was unavailable, as they decided not to sit the NRE. However, the comparison of these students with other ranked students revealed no difference in their characteristics. A good result in the NRE was defined as being in the top 1500 students, but this was an arbitrary choice, based on a previously established national ranking (2). This Rank 1500 cut-off allows students to have whatever the choice they want about the specialty and where in France to study it. A good result could also be defined by the match before and after the NRE between the choice of specialty and place of study. Finally, the proportion of students whose parents were of low socio-professional status was small. This is interesting in itself, but does constitute a limitation in meeting the objective of our study. Certain factors were not evaluated, notably the students' study hours, social and emotional dimensions, and stress. Nonetheless, ours is the first study to evaluate prospectively the socioeconomic factors involved in success in the NRE, with a non-negligible response rate of 65%.
As this study is a single-cohort single-site observational study, it would be interesting to do a larger-scale study of several medical schools in France as a whole. Study of the factors of success in the NRE would enable us to identify those students who are in difficulty and may need support during their studies. Moreover, the reform of medical studies, notably of the first-year selection, could improve the demographic, in particular the socioeconomic status of medical students.