The main aim of this study was to identify factors associated with medical students’ perception of their career choice, satisfaction with their education, and intentions to practice medicine. The study revealed mixed feelings of the students towards low levels of satisfaction related to their career choice and quality of medical education. In this study we found that about one-third of the students were dissatisfied with studying medicine and felt the standard of medical education was below their expectation. Furthermore, about one-third of them were equivocal about the role model and class attendance of their instructors during lectures and practical sessions.
Quality of education and career choice satisfaction are the main factors associated with the success of medical training. Poor learning and working conditions for the students and faculty may be one of the factors that discourage them with their learning-teaching processes. The fact that medical profession is a prestigious choice, studies indicate that medical students have reservations about medicine as a career [22
]. Students’ attitudes toward medical profession and practice can be influenced during training, and these attitudes can affect their intentions of practice after graduation. In Uganda, poor working conditions and inadequate compensations were the major factors affecting job satisfaction and morale of health workers [23
]. Similar factors are also affecting job satisfaction and morale of faculty at medical schools, particularly in low-income countries like Ethiopia [3
]. Faculty may be discouraged with inadequate payment at public medical schools and engaged in private works to get better income, which can result in poor preparedness and dissatisfaction towards teaching. Improving students’ expectations through better learning-teaching processes, improving working conditions, updating of curricula and staff development are needed to counteract the decline in faculty attitudes and students’ expectations toward medical career and practice.
In our study, about 44% of the medical students expressed a preference to practice in the public sector than the private sector (6%) upon graduation. The public sector is the main employer of health workers in Ethiopia, and most of the new graduates of medicine face an obligation to serve the public to compensate for their training expenses. It has become usual that most of the experienced medical specialists and even general practitioners move to the private sector and NGOs following the completion of the obligation mainly due to low payment levels in the public sector. For example, 66% of clinical specialists and 85% of general practitioners were lost from public health institutions in Ethiopia between 1987 and 2006 [3
]. The migration of skilled health professionals from public to private or NGO sector in the country is similar with that of other countries in sub-Saharan Africa [24
]. Consequently, the public sector suffers from a shortage of experienced and skilled health professionals.
Similar to our findings, the overwhelming majority of students in health profession in Uganda preferred to initially practice in the public sector over the private sector [12
]. The main reason for health professionals to stay in the public sector may be for future training, academic aspect and gaining experience before joining the private sector [25
]. A study in South Africa indicated that private sector nurses were more satisfied than those in the public sector due to their low payment, workload and shortage of resources at the later [26
]. Other studies also indicate that achievements, remuneration and job attributes are the main motivators of health care professionals [27
We found 30% of medical students in our study would like to initially practice medicine in rural areas after graduation, while 20% were willing to serve anywhere. Most junior medical practitioners in the country start their career in rural areas and then gradually move to the most urbanized areas, leading to a high staff turnover and under staffing in rural and remote areas. The Ministry of Health reported that 43% of the physicians (general practitioners and clinical specialists) in the country worked in Addis Ababa in 2009/10 [4
], where only 3.7% of the population resides. The medical doctors profile study in the country also revealed similar pattern of accumulation of medical doctors in Addis Ababa [3
In Hungary, the majority of the young doctors preferred to work in large cities or major teaching/central hospitals due to high salary, availability of professional standards, satisfactory working environment, access to skilled colleagues and modern equipment [30
]. A study conducted in Uganda indicated that 80% of the nursing students preferred to work in urban than rural areas [12
], which was higher than our findings. Likewise, 40% of the medical and nursing students in Australia showed a preference for working in large urban centers within one year, but would consider moving to a more rural location later in life [10
We found 40% of clinical students compared to 26% of pre-clinical students preferred to initially practice medicine in rural areas of the country. Exposure to rural areas through rural attachment may be one reason why students’ intentions to work in rural areas was higher for clinical students over pre-clinical students. In the FoM at AAU, medical students undertake a rural community based training for six weeks at the 4th
year during clinical training. A study from Australia also indicated that rural placements in the undergraduate health training programs have a predominantly positive influence on students’ intention to work in rural areas after graduation [31
]. A similar study also revealed that exposure of urban background students to rural practice generates an interest among the students to serve in rural areas [33
]. Studies affirm the importance of rural training as part of a strategy to maintain and build a rural health professional workforce [32
]. A training program consisting of clinical skills, community health, practice management and communication skills for newly placed rural doctors in Mali significantly contributed to their retention in rural areas [34
We found that students with rural backgrounds are more likely to practice medicine in rural areas over students with urban backgrounds. Various literatures identified rural background as the strongest variable associated with the retention of health professionals in rural communities [18
]. In part, this association can be explained by the familiarity that rural background students have with rural setting and cultural norms. We also identified students aged 20 or more preferred to initially practice medicine in rural settings. Studies confirm the substantial changes in attitude and maturity of medical students towards clinical and ethical practice during the course of medical education [35
The findings from this study indicate that 53% of the medical students intended to migrate out of Ethiopia after completing their medical school training, and the intent increased from pre-clinical to internship. In Uganda, most (70%) of the nursing students would like to work outside the country [12
]. Similarly, 52% of Nepali medical students said they would like to practice medicine abroad [11
]. Emigration of health care professionals from low- and middle-income countries to high-income ones is becoming a serious global agenda, negatively affecting the health systems of source countries [15
Large numbers of African–trained physicians migrate to high-income countries upon completion of their medical school training [16
]. Our findings indicate that 42% of those who intended to migrate cited US as a final destination, followed by European countries (15%). More than 265 physicians in the US and Canada in the year 2002 were originally trained in Ethiopia and the number of physicians remaining at home for the same year was 1564 [40
], representing 15% of Ethiopia’s potential medical workforce without even considering those who migrated to other countries. Of Ethiopian physicians who lived in the US or Canada in 2002, 75% of them were graduates of AAU medical school. About 23-28% of physicians in the US, UK, Canada and Australia are international medical graduates mostly coming from low-income countries, and Ghana, South Africa, Ethiopia, Uganda and Nigeria are the countries in sub-Saharan Africa with the highest physician emigration factors in the world [41
One limitation of this study is that the sample consisted of more pre-clinical students than clinical ones and, therefore, may have had a less proportion of students who were exposed to a rural training program or to senior colleagues, resulting in underestimation of the intention to practice medicine in rural areas or to migrate outside Ethiopia. This is because of the recent government initiatives to increase the intake of students into medical schools in the country. The other limitation of the study was the low response rate of clinical students compared to pre-clinical ones due to the engagement of the former in practicum trainings at different hospitals, underestimating the responses than the typical. Finally, this study was based on self-reported data and possibly affected by a recall bias. However, all the above limitations may not have a detrimental effect on the validity of the findings, and data can be used for planning cost-effective and sustainable interventions to bring about positive changes in the attitudes of medical students towards medical practice and migration.