If primary care is going to be central to future reforms and renewals of heath care systems,3,6,8,9
countries embarking on these renewals will need sufficient numbers of family physicians. Given that student career choice is an important determinant of human resources in health care, an understanding of the variables present on entry into medical school that are associated with a subsequent choice of career in family medicine could allow for preferential selection of students who are likely to meet the health needs of the population.
In our study, having family medicine as a career choice on entry was the most important predictor of a student’s ultimate career choice. There may be value in a determination by admissions committees of a student’s early commitment to family medicine if they wish to increase the number of family physicians that their schools produce. A downside of asking this question at admission is that such a scenario can be “gamed” by students once applicants become aware of the desired answers to this question. By removing career interest on medical school entry from our model, we were able to retain nearly the same accuracy (only 2.6% lower) with 11 significant predictive items. Whereas demographic factors such as age and relationship status would be considered inappropriate to ask a student in many jurisdictions, a number of the other items, particularly the attitudinal items, could be used by admissions committees to identify students more likely to choose a career in family medicine.
In our study, interest in family medicine increased during the course of medical school, with switchers to family medicine accounting for 48.0% (n = 231) of the group of students applying for a family medicine residency. Students who switched to family medicine from a specialty career during medical school showed several differences from those who maintained an interest in a career not in family medicine, and shared more than half of the variables we evaluated with those who stayed with a career in family medicine. These findings support the notion of an underlying family medicine construct carried by entering medical students. Students who do not have family medicine as their top career choice but who have these attributes may be targeted by educators who wish to encourage students to switch to a career in family medicine. Students who switched from family medicine to a specialty career shared attributes with those students who stayed with a specialty career throughout medical school.
As with other studies, we found a stated preference for family medicine at medical school entry to be a strong predictor of an exit career choice in family medicine,14,22
but unlike other studies, we did not find this interest in primary care to wane after medical school admission.23–25
Some of the predictive variables we identified in our study have been described elsewhere, though the reported effects sometimes conflict. These include age,13
having a societal orientation and volunteering in a developing country.14,26
Rural origin, which has been shown by others to be predictive,27,28
was not associated with a career choice of family medicine in our study; however, it was associated with a decreased likelihood of switching career interests away from family medicine during medical school. As in our study, scope of practice has been shown in some studies to draw students toward family medicine,29
but others have shown it to lead students to reject family medicine.30
In contrast to other studies,13,14,31
the student’s sex was not found to be a significant predictor in our model. This may be due to the increasing number of women in medical school.
Our study on career interest at exit from medical school built on a previous study20
that identified predictors of a student’s career interest at medical school entry. We found that most variables were represented in both studies, given that they were derived from the same survey answers obtained from students on entry into medical school. Since each of these studies used a different outcome variable (i.e., career choice on entry into medical school versus career choice on exit), certain items not previously identified became important when looking at a student’s ultimate career choice. Relationships, volunteer work in developing nations and parental education endured as predictors throughout the process of medical education. Age, varied scope of practice and a strong societal orientation, while remaining predictive of a career interest in family medicine, were less important influences on final career choice than on entry choice, indicating that the experience of medical school may have lessened the influence of these items. A low interest in hospital care, interest in medical lifestyle and having completed high school in a smaller community were no longer significant predictors of career choice on exit from medical school.
Although the survey underwent a thorough development and validation process, other important influences may have been overlooked. Not all regions of Canada were surveyed in this study; therefore, it was not fully representative of the career choices of all Canadian students. Lack of representation from the Maritimes and, particularly, from Quebec, given its unique structure of human resources in health care, may have resulted in important associations being missed. Still, students in our study chose their careers in the same proportions as all students nationally, showing the generalizability of our cohort findings. In addition, given the nature and structure of primary care in Canada and the role of family physicians, the findings may not be directly applicable to other countries. However, given the rapid globalization of all aspects of society, including medicine, our findings (which had a high predictive value and were difficult to manipulate by applicants) provide a window into the student attitudes and demographics at medical school entry that are associated with an ultimate career choice in family medicine. Although student attitudes during the first two weeks of medical school may differ from attitudes at the time of application to medical school, it would be expected that many of the variables in this model would be unchanged and could be tested at the time of application.
Our study looked at the variables associated with the choice of a career in family medicine at exit from medical school. We can infer from our results that these variables, which we assessed at the second week of medical school, would be similarly predictive if assessed at the time of admissions interviews; but we do not know this, so it would be important to study this similarity directly. We would encourage schools with an interest in increasing the proportion of students choosing a career in family medicine to integrate some or all of the variables identified in our study into their student selection processes.