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1.  The College of Medicine in the Republic of Malawi: towards sustainable staff development 
Background
Malawi has a critical human resources problem particularly in the health sector. There is a severe shortage of doctors; there are only few medical specialists. The College of Medicine (COM) is the only medical school and was founded in 1991. For senior staff it heavily depends on expatriates. In 2004 the COM started its own postgraduate training programme (Master of Medicine) in the clinical specialties.
Methods
We explore to what extent a brain drain took place among the COM graduates by investigating their professional development and geographical distribution. Using current experience with the postgraduate programme, we estimate at what point all senior academic positions in the clinical departments could be filled by Malawians. We demonstrate the need for expatriate staff for its most senior academic positions in the interim period and how this can be phased out. Lastly we reflect on measures that may influence the retention of Malawian doctors.
Results
Since the start of the COM 254 students have graduated with an average of 17 students per year. Most (60%) are working in Malawi. Of those working abroad, 60% are in various postgraduate training programmes.
In 2015, adequate numbers of Malawi senior academics should be available to fill most senior positions in the clinical departments, taking into account a 65% increase in staff to cope with increasing numbers of students.
Conclusion
There seems to be no significant brain drain among graduates of the COM. The postgraduate programme is in place to train graduates to become senior academic staff. In the interim, the COM depends heavily upon expatriate input for its most senior academic positions. This will be necessary at least until 2015 when sufficient numbers of well trained and experienced Malawian specialists may be expected to be available. Improved pay structure and career development perspectives will be essential to consolidate the trend that most doctors will remain in the country.
doi:10.1186/1478-4491-5-10
PMCID: PMC1863431  PMID: 17433100
2.  Career choices and what influences Nepali medical students and young doctors: a cross-sectional study 
Background
Nepal, as a nation with limited resources and a large number of poor people, needs far more well-trained, committed general practitioners. The aim of this study was to understand medical career choices and the factors that influence medical students’ and young doctors’ career choices in Nepal and to understand what would encourage them to work in rural areas as generalists.
Methods
This was a cross-sectional study of 1137 medical students (first and final year) and young doctors (interns and residents) from six medical colleges in Nepal who completed a voluntary questionnaire, with some also participating in structured focus groups – 170 first years, 77 final years and 80 graduates – with an additional 28, 44 and 49 written responses respectively.
Results
Without selective admissions policies, 41.7% (464/1112) of respondents had a rural background – most significant in Year 1 students, males and in colleges outside of Kathmandu. Of the respondents, 569 (50.9%) had a specialty choice starting medical school – the greatest proportion in Year 1. Medicine (especially cardiology) and surgery (particularly among males) were most significant choices at all stages. Only five participants initially and four during their course chose general practice. There appears no interest in, recognition of, significant exposure to, or role models in general practice.
Serving the sick, personal interest and social prestige were the most significant influencing factors – consistent across all groups. Course availability was also a factor. To attract doctors to work in rural areas most respondents affirmed the need for a good salary, infrastructure and facilities, scholarships and career development opportunities.
Conclusions
Challenges include raising generalists’ profiles within the medical community, government and patient community; changing undergraduate curricula to include greater exposure to good models of rural generalist practice; and providing incentives and attractions for post-graduate training and service.
doi:10.1186/1478-4491-11-5
PMCID: PMC3599062  PMID: 23394308
Career choice; Medical students; Generalists; General practitioners
3.  Analysis of a survey on young doctors' willingness to work in rural Hungary 
Background
The severe shortage of qualified healthcare staff in Hungary cannot be quickly or easily overcome. There is not only a lack of human resources for health, but significant inequalities are widespread, including in geographical distribution. This disparity results in severe problems regarding access to and performance of health care services. In this context, this report, based on research carried out in 2008, deals with a particularly relevant matter: the willingness of young doctors to work outside Budapest (the capital of Hungary).
Methods
We conducted a survey with voluntary questionnaires and focus group interviews at each of the four Hungarian medical schools, concerning career plans and related incentives among young medical doctors. In all, 524 residents responded to the question concerning their willingness to work in rural areas, and there were seven focus group interviews, with 3-7 participants in each group. The number of residents' places in Hungary were 832, 682, and 785 in 2006/2007, 2007/2008, and 2008/2009, respectively.
Results
The majority of those surveyed would like to work in Budapest or a large town. Fewer than 7% were willing to work in a town with less than 50 000 inhabitants. Most young doctors would like to work in a teaching hospital (i.e. an accredited training site for medical students and postgraduate trainees) or a major regional hospital.
Conclusions
The current system of medical training in Hungary tends to produce doctors who want to live in big cities and work in central hospitals. Rural regions and non-in-patient service alternatives seem either not to be targeted or seen as unattractive work places.
More doctors would be willing to work in smaller towns and villages if in-hospital training was altered and if doctors were offered adequate incentives as part of a comprehensive human resource strategy (high salaries, high professional standards, good working environment, reasonable workload). If these changes do not occur, the existing geographical and structural imbalances will not be improved.
doi:10.1186/1478-4491-8-13
PMCID: PMC2887778  PMID: 20482779
4.  Future career plans of Malawian medical students: a cross-sectional survey 
Background
Malawi has one of the lowest physician densities in the world, at 1.1 doctors per 100,000 population. Undergraduate training of doctors at the national medical school has increased considerably in recent years with donor support. However, qualified doctors continue to leave the public sector in order to work or train abroad. We explored the postgraduate plans of current medical students, and the extent to which this is influenced by their background.
Methods
A self-administered questionnaire was developed after discussion with students and senior staff. This included questions on background characteristics, education before medical school, and future career plans. This was distributed to all medical and premedical students on campus over 1 week and collected by an independent researcher. One reminder visit was made to each class. Chi-squared tests were performed to investigate the relationship of student characteristics with future career plans.
Results
One hundred and forty-nine students completed the questionnaire out of a student body of 312, a response rate of 48%. When questioned on their plans for after graduation, 49.0% of students plan to stay in Malawi. However, 38.9% plan to leave Malawi immediately. Medical students who completed a ‘premedical’ foundation year at the medical school were significantly more likely to have immediate plans to stay in Malawi compared to those who completed A-levels, an advanced school-leaving qualification (P = 0.037). Current premedical students were slightly more likely to have immediate plans to work or train in Malawi compared to medical students (P = 0.049). However, a trend test across all the years was not significant. When asked about future plans, nearly half of students intend to work or train outside Malawi.
Conclusions
The majority of respondents plan to leave Malawi in the future. The effectiveness of the substantial upscaling of medical education in Malawi may be diminished unless more medical students plan to work in Malawi after graduation.
doi:10.1186/1478-4491-10-29
PMCID: PMC3465242  PMID: 22971119
Human resources for health; Physicians; Medical education; Migration; Malawi
5.  Career Destinations of University of Ghana Medical School Graduates of Various Year Groups 
Ghana Medical Journal  2013;47(2):87-91.
Summary
Background
To report on the current career destination of the University of Ghana Medical School (UGMS) qualified doctors in the year groups, 1998, 2000, 2003, 2005 and 2008.
Design
Interview of doctors from each year group currently working at the Korle-Bu Teaching Hospital corroborated by phone calls to the doctors.
Subjects
All Ghanaian doctors from each graduating year group.
Main Outcome Measures
1. Current location of employment in Ghana or abroad, 2. Gender ratios of the doctors retained in Ghana
Results
Three hundred and seventy-two (372) UGMS doctors consisting of 353 Ghanaians and 19 foreign students graduated over the five year groups. Of the 353 Ghanaians, 113 emigrated, while all but one of the 240 living in Ghana, practice medicine. The retention rate improved from 54.2% in 1998 to 86.3% in 2008. The overall retention rate however is 68.0% while the retention rates for the male and female doctors were 69.3% and 64.6% respectively. Of the 177 doctors practicing in Ghana from the first 4 year-groups (i.e. 1998, 2000, 2003 and 2005,) 139 (i.e. 31, 31, 34 and 43 from the respective year groups) have either completed postgraduate training or are in the residency training programme. Thus 78.5% of these doctors working in Ghana have opted for postgraduate training.
Conclusion
The establishment of the GCPS and to a lesser extent the introduction of the ADHA before it appear to have slowed down the medical brain drain as more and more doctors avail themselves of the local opportunities. The GCPS therefore needs supporting effectively in order to continue to be a strong incentive for the retention of doctors in Ghana, apart from helping to staff district general hospitals with specialists.
PMCID: PMC3743114  PMID: 23966746
Career destinations; University of Ghana; Ghanaian doctors; specialist training; medical emigration
6.  The training and professional expectations of medical students in Angola, Guinea-Bissau and Mozambique 
Background
The purpose of this paper is to describe and analyze the professional expectations of medical students during the 2007-2008 academic year at the public medical schools of Angola, Guinea-Bissau and Mozambique, and to identify their social and geographical origins, their professional expectations and difficulties relating to their education and professional future.
Methods
Data were collected through a standardised questionnaire applied to all medical students registered during the 2007-2008 academic year.
Results
Students decide to study medicine at an early age. Relatives and friends seem to have an especially important influence in encouraging, reinforcing and promoting the desire to be a doctor.
The degree of feminization of the student population differs among the different countries.
Although most medical students are from outside the capital cities, expectations of getting into medical school are already associated with migration from the periphery to the capital city, even before entering medical education.
Academic performance is poor. This seems to be related to difficulties in accessing materials, finances and insufficient high school preparation.
Medical students recognize the public sector demand but their expectations are to combine public sector practice with private work, in order to improve their earnings. Salary expectations of students vary between the three countries.
Approximately 75% want to train as hospital specialists and to follow a hospital-based career. A significant proportion is unsure about their future area of specialization, which for many students is equated with migration to study abroad.
Conclusions
Medical education is an important national investment, but the returns obtained are not as efficient as expected. Investments in high-school preparation, tutoring, and infrastructure are likely to have a significant impact on the success rate of medical schools. Special attention should be given to the socialization of students and the role model status of their teachers.
In countries with scarce medical resources, the hospital orientation of students' expectations is understandable, although it should be associated with the development of skills to coordinate hospital work with the network of peripheral facilities. Developing a local postgraduate training capacity for doctors might be an important strategy to help retain medical doctors in the home country.
doi:10.1186/1478-4491-9-9
PMCID: PMC3079608  PMID: 21473778
7.  The graduate entry generation: a qualitative study exploring the factors influencing the career expectations and aspirations of a graduating cohort of graduate entry dental students in one London institution 
BMC Oral Health  2011;11:25.
Background
Dentistry in the UK has a number of new graduate-entry programmes. The aim of the study was to explore the motivation, career expectations and experiences of final year students who chose to pursue a dental career through the graduate entry programme route in one institution; and to explore if, and how, their intended career expectations and aspirations were informed by this choice.
Method
In-depth interviews of 14 graduate entry students in their final year of study. Data were transcribed verbatim and analysed using framework analysis.
Results
There were three categories of factors influencing students' choice to study dentistry through graduate entry: 'push', 'pull' and 'mediating'. Mediating factors related to students' personal concerns and circumstances, whereas push and pull factors related to features of their previous and future careers and wider social factors. Routes to Graduate Entry study comprised: 'early career changers', 'established career changers' and those pursuing 'routes to specialisation'. These routes also influenced the students' practice of dentistry, as students integrated skills in their dental studies, and encountered new challenges.
Factors which students believed would influence their future careers included: vocational training; opportunities for specialisation or developing special interests and policy-related issues, together with wider professional and social concerns.
The graduate entry programme was considered 'hard work' but a quick route to a professional career which had much to offer. Students' felt more could have been made of their pre-dental studies and/or experience during the programme. Factors perceived as influencing students' future contribution to dentistry included personal and social influences. Overall there was strong support for the values of the NHS and 'giving back' to the system in their future career.
Conclusion
Graduate entry students appear to be motivated to enter dentistry by a range of factors which suit their preferences and circumstances. They generally embrace the programme enthusiastically and seek to serve within healthcare, largely in the public sector. These students, who carry wider responsibilities, bring knowledge, skills and experience to dentistry which could be harnessed further during the programme. The findings suggest that graduate entry students, facilitated by varied career options, will contribute to an engaged workforce.
doi:10.1186/1472-6831-11-25
PMCID: PMC3201891  PMID: 21942994
dental; graduate; graduate-entry; career; motivation; workforce
8.  Understanding the 'four directions of travel': qualitative research into the factors affecting recruitment and retention of doctors in rural Vietnam 
Background
Motivation and retention of health workers, particularly in rural areas, is a question of considerable interest to policy-makers internationally. Many countries, including Vietnam, are debating the right mix of interventions to motivate doctors in particular to work in remote areas. The objective of this study was to understand the dynamics of the health labour market in Vietnam, and what might encourage doctors to accept posts and remain in-post in rural areas.
Methods
This study forms part of a labour market survey which was conducted in Vietnam in November 2009 to February 2010. The study had three stages. This article describes the findings of the first stage - the qualitative research and literature review, which fed into the design of a structured survey (second stage) and contingent valuation (third stage). For the qualitative research, three tools were used - key informant interviews at national and provincial level (6 respondents); in-depth interviews of doctors at district and commune levels (11 respondents); and focus group discussions with medical students (15 participants).
Results
The study reports on the perception of the problem by national level stakeholders; the motivation for joining the profession by doctors; their views on the different factors affecting their willingness to work in rural areas (including different income streams, working conditions, workload, equipment, support and supervision, relationships with colleagues, career development, training, and living conditions). It presents findings on their overall satisfaction, their ranking of different attributes, and willingness to accept different kinds of work. Finally, it discusses recent and possible policy interventions to address the distribution problem.
Conclusions
Four typical 'directions of travel' are identified for Vietnamese doctors - from lower to higher levels of the system, from rural to urban areas, from preventive to curative health and from public to private practice. Substantial differences in income from formal and informal sources all reinforce these preferences. While non-financial attributes are also important for Vietnamese doctors, the scale of the difference of opportunities presents a considerable policy challenge. Significant salary increases for doctors in hard-to-staff areas are likely to have some impact. However, addressing the differentials is likely to require broader market reforms and regulatory measures.
doi:10.1186/1478-4491-9-20
PMCID: PMC3169448  PMID: 21849045
9.  Doctors’ views about training and future careers expressed one year after graduation by UK-trained doctors: questionnaire surveys undertaken in 2009 and 2010 
BMC Medical Education  2014;14(1):270.
Background
The UK medical graduates of 2008 and 2009 were among the first to experience a fully implemented, new, UK training programme, called the Foundation Training Programme, for junior doctors. We report doctors’ views of the first Foundation year, based on comments made as part of a questionnaire survey covering career choices, plans, and experiences.
Methods
Postal and email based questionnaires about career intentions, destinations and views were sent in 2009 and 2010 to all UK medical graduates of 2008 and 2009. This paper is a qualitative study of ‘free-text’ comments made by first-year doctors when invited to comment, if they wished, on any aspect of their work, education, training, and future.
Results
The response rate to the surveys was 48% (6220/12952); and 1616 doctors volunteered comments. Of these, 61% wrote about their first year of training, 35% about the working conditions they had experienced, 33% about how well their medical school had prepared them for work, 29% about their future career, 25% about support from peers and colleagues, 22% about working in medicine, and 15% about lifestyle issues. When concerns were expressed, they were commonly about the balance between service provision, administrative work, and training and education, with the latter often suffering when it conflicted with the needs of medical service provision. They also wrote that the quality of a training post often depended on the commitment of an individual senior doctor. Service support from seniors was variable and some respondents complained of a lack of team work and team ethic. Excessive hours and the lack of time for reflection and career planning before choices about the future had to be made were also mentioned. Some doctors wrote that their views were not sought by their hospital and that NHS management structures did not lend themselves to efficiency. UK graduates from non-UK homes felt insecure about their future career prospects in the UK. There were positive comments about opportunities to train flexibly.
Conclusions
Although reported problems should be considered in the wider context, in which the majority held favourable overall views, many who commented had been disappointed by aspects of their first year of work. We hope that the concerns raised by our respondents will prompt trainers, locally, to determine, by interaction with junior staff, whether or not these are concerns in their own training programme.
Electronic supplementary material
The online version of this article (doi:10.1186/s12909-014-0270-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s12909-014-0270-5
PMCID: PMC4302441  PMID: 25528260
Medical careers; Junior doctors; Medical education; Foundation training
10.  GP recruitment and retention: a qualitative analysis of doctors' comments about training for and working in general practice. 
BACKGROUND AND AIMS: General practice in the UK is experiencing difficulty with medical staff recruitment and retention, with reduced numbers choosing careers in general practice or entering principalships, and increases in less-than-full-time working, career breaks, early retirement and locum employment. Information is scarce about the reasons for these changes and factors that could increase recruitment and retention. The UK Medical Careers Research Group (UKMCRG) regularly surveys cohorts of UK medical graduates to determine their career choices and progression. We also invite written comments from respondents about their careers and the factors that influence them. Most respondents report high levels of job satisfaction. A noteworthy minority, however, make critical comments about general practice. Although their views may not represent those of all general practitioners (GPs), they nonetheless indicate a range of concerns that deserve to be understood. This paper reports on respondents' comments about general practice. ANALYSIS OF DOCTORS' COMMENTS: Training Greater exposure to general practice at undergraduate level could help to promote general practice careers and better inform career decisions. Postgraduate general practice training in hospital-based posts was seen as poor quality, irrelevant and run as if it were of secondary importance to service commitments. In contrast, general practice-based postgraduate training was widely praised for good formal teaching that met educational needs. The quality of vocational training was dependent upon the skills and enthusiasm of individual trainers. Recruitment problems Perceived deterrents to choosing general practice were its portrayal, by some hospital-based teachers, as a second class career compared to hospital medicine, and a perception of low morale amongst current GPs. The choice of a career in general practice was commonly made for lifestyle reasons rather than professional aspirations. Some GPs had encountered difficulties in obtaining posts in general practice suited to their needs, while others perceived discrimination. Newly qualified GPs often sought work as non-principals because they felt too inexperienced for partnership or because their domestic situation prevented them from settling in a particular area. Changes to general practice The 1990 National Health Service (NHS) reforms were largely viewed unfavourably, partly because they had led to a substantial increase in GPs' workloads that was compounded by growing public expectations, and partly because the two-tier system of fund-holding was considered unfair. Fund-holding and, more recently, GP commissioning threatened the GP's role as patient advocate by shifting the responsibility for rationing of health care from government to GPs. Some concerns were also expressed about the introduction of primary care groups (PCGs) and trusts (PCTs). Together, increased workload and the continual process of change had, for some, resulted in work-related stress, low morale, reduced job satisfaction and quality of life. These problems had been partially alleviated by the formation of GP co-operatives. Retention difficulties Loss of GPs' time from the NHS workforce occurs in four ways: reduced working hours, temporary career breaks, leaving the NHS to work elsewhere and early retirement. Child rearing and a desire to pursue interests outside medicine were cited as reasons for seeking shorter working hours or career breaks. A desire to reduce pressure of work was a common reason for seeking shorter working hours, taking career breaks, early retirement or leaving NHS general practice. Other reasons for leaving NHS general practice, temporarily or permanently, were difficulty in finding a GP post suited to individual needs and a desire to work abroad. CONCLUSIONS: A cultural change amongst medical educationalists is needed to promote general practice as a career choice that is equally attractive as hospital practice. The introduction of Pre-Registration House Officer (PRHO) placements in general practice and improved flexibility of GP vocational training schemes, together with plans to improve the quality of Senior House Officer (SHO) training in the future, are welcome developments and should address some of the concerns about poor quality GP training raised by our respondents. The reluctance of newly qualified GPs to enter principalships, and the increasing demand from experienced GPs for less-than-full-time work, indicates a need for a greater variety of contractual arrangements to reflect doctors' desires for more flexible patterns of working in general practice.
PMCID: PMC2560447  PMID: 12049026
11.  Specialist training in Fiji: Why do graduates migrate, and why do they remain? A qualitative study 
Background
Specialist training was established in the late 1990s at the Fiji School of Medicine. Losses of graduates to overseas migration and to the local private sector prompted us to explore the reasons for these losses from the Fiji public workforce.
Methods
Data were collected on the whereabouts and highest educational attainments of the 66 Fiji doctors who had undertaken specialist training to at least the diploma level between 1997 and 2004. Semistructured interviews focusing on career decisions were carried out with 36 of these doctors, who were purposively sampled to include overseas migrants, temporary overseas trainees, local private practitioners and public sector doctors.
Results
120 doctors undertook specialist training to at least the diploma level between 1997 and 2004; 66 of the graduates were Fiji citizens or permanent residents; 54 originated from other countries in the region. Among Fiji graduates, 42 completed a diploma and 24 had either completed (21) or were enrolled (3) in a master's programme. Thirty-two (48.5%) were working in the public sectors, four (6.0%) were temporarily training overseas, 30.3% had migrated overseas and the remainder were mostly in local private practice. Indo-Fijian ethnicity and non-completion of full specialist training were associated with lower retention in the public sectors, while gender had little impact. Decisions to leave the public sectors were complex, with concerns about political instability and family welfare predominating for overseas migrants, while working conditions not conducive to family life or frustrations with career progression predominated for local private practitioners. Doctors remaining in the public sectors reported many satisfying aspects to their work despite frustrations, though 40% had seriously considered resigning from the public service and 60% were unhappy with their career progression.
Conclusion
Overall, this study provides some support for the view that local or regional postgraduate training may increase retention of doctors. Attention to career pathways and other sources of frustration, in addition to encouragement to complete training, should increase the likelihood of such programmes' reaching their full potentials.
doi:10.1186/1478-4491-7-9
PMCID: PMC2652983  PMID: 19216766
12.  Migration of Sri Lankan medical specialists 
Background
The migration of health-care workers contributes to the shortage of health-care workers in many developing countries. This paper aims to describe the migration of medical specialists from Sri Lanka and to discuss the successes and failures of strategies to retain them.
Methods
This paper presents data on all trainees who have left Sri Lanka for postgraduate training through the Post Graduate Institute of Medicine, University of Colombo, from April 1980 to June 2009. In addition, confidential interviews were conducted with 30 specialists who returned following foreign training within the last 5 years and 5 specialists who opted to migrate to foreign countries.
Results
From a total of 1,915 specialists who left Sri Lanka for training, 215 (11%) have not returned or have left the country without completing the specified bond period. The majority (53%) migrated to Australia. Of the specialists who left before completion of the bond period, 148 (68.8%) have settled or have started settling the bond. All participants identified foreign training as beneficial for their career. The top reasons for staying in Sri Lanka were: job security, income from private practice, proximity to family and a culturally appropriate environment. The top reasons for migration were: better quality of life, having to work in rural parts of Sri Lanka, career development and social security.
Conclusions
This paper attempts to discuss the reasons for the low rates of emigration of specialists from Sri Lanka. Determining the reasons for retaining these specialists may be useful in designing health systems and postgraduate programs in developing countries with high rates of emigration of specialists.
doi:10.1186/1478-4491-11-21
PMCID: PMC3664600  PMID: 23693092
Migration of health-care workers; Health-care worker shortage; Training of medical specialists
13.  Student perception about working in rural Nepal after graduation: a study among first- and second-year medical students 
Background
The Federal Democratic Republic of Nepal is a developing country in South Asia with a population of 29.8 million. In September 2011, there were 18 medical schools with 14 being in the private sector. KIST Medical College is a private school in Lalitpur district. The present study was conducted to obtain information on student perceptions about working in rural Nepal after graduation.
Methods
The study was conducted among first- and second-year undergraduate medical students using a semi-structured questionnaire developed by the authors using inputs from the literature and their experiences of teaching medical students. Year of study, gender, method of financing of medical education, place of family residence and occupation of parents were noted. Participant responses were analysed, grouped together and the number of respondents stating a particular response was noted.
Results
Of the 200 students, 185 (92.5%) participated with 95 being from the first year and 90 from the second. Most students were self-financing and from urban areas. Regarding the question of working in rural Nepal after graduation, 134 (72.4%) said they will work after their undergraduate course. Students preferred to work in the government or nongovernmental sector. Student felt doctors are reluctant to serve in rural Nepal due to inadequate facilities, low salary, less security, problems with their professional development, less equipment in health centres, decreased contact with family and difficulties in communicating with an illiterate, rural population. About 43% of respondents felt medical education does not adequately prepare them for rural service. Repeated rural exposure, postings in rural hospitals and health centres, and training students to diagnose and treat illness with less technology were suggested. The median monthly salary expected was 60 000 Nepalese rupees (US$ 820) and was significantly higher among first-year students.
Conclusions
The majority of respondents were in favour of working in rural Nepal after graduation. They wanted facilities in rural areas and health centres to be improved. Changes in the education system were suggested. Providing relatively better facilities for rural doctors compared with urban doctors and reorienting medical education for producing doctors for rural Nepal can be considered. Further studies are required in other private medical schools.
doi:10.1186/1478-4491-10-27
PMCID: PMC3464161  PMID: 22938089
Curriculum changes; Developing countries; Financing; Medical students; Nepal; Rural service; Scholarship; Self-financing
14.  Views of junior doctors about whether their medical school prepared them well for work: questionnaire surveys 
BMC Medical Education  2010;10:78.
Background
The transition from medical student to junior doctor in postgraduate training is a critical stage in career progression. We report junior doctors' views about the extent to which their medical school prepared them for their work in clinical practice.
Methods
Postal questionnaires were used to survey the medical graduates of 1999, 2000, 2002 and 2005, from all UK medical schools, one year after graduation, and graduates of 2000, 2002 and 2005 three years after graduation. Summary statistics, chi-squared tests, and binary logistic regression were used to analyse the results. The main outcome measure was the level of agreement that medical school had prepared the responder well for work.
Results
Response rate was 63.7% (11610/18216) in year one and 60.2% (8427/13997) in year three. One year after graduation, 36.3% (95% CI: 34.6, 38.0) of 1999/2000 graduates, 50.3% (48.5, 52.2) of 2002 graduates, and 58.2% (56.5, 59.9) of 2005 graduates agreed their medical school had prepared them well. Conversely, in year three agreement fell from 48.9% (47.1, 50.7) to 38.0% (36.0, 40.0) to 28.0% (26.2, 29.7). Combining cohorts at year one, percentages who agreed that they had been well prepared ranged from 82% (95% CI: 79-87) at the medical school with the highest level of agreement to 30% (25-35) at the lowest. At year three the range was 70% to 27%. Ethnicity and sex were partial predictors of doctors' level of agreement; following adjustment for them, substantial differences between schools remained. In years one and three, 30% and 34% of doctors specified that feeling unprepared had been a serious or medium-sized problem for them (only 3% in each year regarded it as serious).
Conclusions
The vast knowledge base of clinical practice makes full preparation impossible. Our statement about feeling prepared is simple yet discriminating and identified some substantial differences between medical schools. Medical schools need feedback from graduates about elements of training that could be improved.
doi:10.1186/1472-6920-10-78
PMCID: PMC3020650  PMID: 21070622
15.  Specialization training in Malawi: a qualitative study on the perspectives of medical students graduating from the University of Malawi College of Medicine 
Background
There is a critical shortage of healthcare workers in sub-Saharan Africa, and Malawi has one of the lowest physician densities in the region. One of the reasons for this shortage is inadequate retention of medical school graduates, partly due to the desire for specialization training. The University of Malawi College of Medicine has developed specialty training programs, but medical school graduates continue to report a desire to leave the country for specialization training. To understand this desire, we studied medical students’ perspectives on specialization training in Malawi.
Methods
We conducted semi-structured interviews of medical students in the final year of their degree program. We developed an interview guide through an iterative process, and recorded and transcribed all interviews for analysis. Two independent coders coded the manuscripts and assessed inter-coder reliability, and the authors used an “editing approach” to qualitative analysis to identify and categorize themes relating to the research aim. The University of Pittsburgh Institutional Review Board and the University of Malawi College of Medicine Research and Ethics Committee approved this study and authors obtained written informed consent from all participants.
Results
We interviewed 21 medical students. All students reported a desire for specialization training, with 12 (57%) students interested in specialties not currently offered in Malawi. Students discussed reasons for pursuing specialization training, impressions of specialization training in Malawi, reasons for staying or leaving Malawi to pursue specialization training and recommendations to improve training.
Conclusions
Graduating medical students in Malawi have mixed views of specialization training in their own country and still desire to leave Malawi to pursue further training. Training institutions in sub-Saharan Africa need to understand the needs of the country’s healthcare workforce and the needs of their graduating medical students to be able to match opportunities and retain graduating students.
doi:10.1186/1472-6920-14-2
PMCID: PMC3884020  PMID: 24393278
Medical education; Postgraduate medical education; Specialization training; Medical migration; Sub-Saharan Africa; Qualitative research
16.  Scaling up specialist training in developing countries: lessons learned from the first 12 years of regional postgraduate training in Fiji – a case study 
Background
In 1997, regional specialist training was established in Fiji, consisting of one-year Postgraduate Diplomas followed by three-year master’s degree programs in anesthesia, internal medicine, obstetrics/gynecology, pediatrics and surgery. The evolution of these programs during the first 12 years is presented.
Case description
A case study utilizing mixed methods was carried out, including a prospective collection of enrolment and employment data, supplemented by semi-structured interviews. Between 1997 and 2009, 207 doctors (113 from Fiji and 94 from 13 other countries or territories in the Pacific) trained to at least the Postgraduate Diploma level. For Fiji graduates, 29.2% migrated permanently to developed countries, compared to only 8.5% for regional graduates (P <0.001). Early years of the program were characterized by large intakes and enthusiasm, but also uncertainty. Many resignations took place following a coup d’etat in 2000. By 2005, interviews suggested a dynamic of political instability initially leading to resignations, leading to even heavier workloads, compounded by academic studies that seemed unlikely to lead to career benefit. This was associated with loss of hope and downward spirals of further resignations. After 2006, however, Master’s graduates generally returned from overseas placements, had variable success in career progression, and were able to engage in limited private practice. Enrolments and retention stabilized and increased.
Discussion and evaluation
Over time, all specialties have had years when the viability and future of the programs were in question, but all have recovered to varying degrees, and the programs continue to evolve and strengthen. Prospective clarification of expected career outcomes for graduates, establishment of career pathways for diploma-only graduates, and balancing desires for academic excellence with workloads that trainees were able to bear may have lessened ongoing losses of trainees and graduates.
Conclusions
Despite early losses of trainees, the establishment of regional postgraduate training in Fiji is having an increasingly positive impact on the specialist workforce in the Pacific. With forethought, many of the difficulties we encountered may have been avoidable. Our experiences may help others who are establishing or expanding postgraduate training in developing countries to optimize the benefit of postgraduate training on their national and regional workforces.
doi:10.1186/1478-4491-10-48
PMCID: PMC3543231  PMID: 23270525
Education; Medical; Postgraduate; Developing countries; Pacific Islands; Human resources for health; Professional satisfaction; Case study; Qualitative research; Medical migration; Mixed methods research
17.  Why do doctors emigrate from Sri Lanka? A survey of medical undergraduates and new graduates 
BMC Research Notes  2014;7:918.
Background
Migration of medical professionals is a long recognized problem in Sri Lanka, but it has not been studied in depth. Undergraduate and postgraduate medical education in Sri Lanka is state sponsored, and loss of trained personnel is a loss of investment. This study assessed the intention to migrate among medical students and newly passed out graduates from the largest medical school in Sri Lanka.
Methods
A cross sectional descriptive study was conducted in the Faculty of Medicine, University of Colombo in September 2013 with the participation of first and fourth year medical students and pre-intern medical graduates. Data was collected using a self administered, pre-tested questionnaire that collected data on socio-demographic details, intention to migrate and factors influencing a decision for or against migration.
Results
There were 374 respondents, 162 from first year (females; 104, 64.2%), 159 from fourth year (females; 85, 53.5%) and 53 pre interns (females; 22, 41.5%). Of the entire sample, 89 (23.8%) had already decided to migrate while another 121 (32.3%) were not sure of their decision. The most cited reasons for migration were a perceived better quality of life, better earnings and more training opportunities in the host country. There were no socio-demographic characteristics that had a significant association with the intention to migrate, indicating that it is a highly individualized decision.
Conclusions
The rate of intention to migrate in this sample is low when compared to international studies from Africa and South Asia, but is still significant. The core reasons which prompt doctors to migrate should be addressed by a multipronged approach to prevent brain drain.
doi:10.1186/1756-0500-7-918
PMCID: PMC4320633  PMID: 25514970
18.  Views of senior UK doctors about working in medicine: questionnaire survey 
JRSM Open  2014;5(11):2054270414554049.
Summary
Objectives
We surveyed the UK medical qualifiers of 1993. We asked closed questions about their careers; and invited them to give us comments, if they wished, about any aspect of their work. Our aim in this paper is to report on the topics that this senior cohort of UK-trained doctors who work in UK medicine raised with us.
Design
Questionnaire survey
Participants
3479 contactable UK-trained medical graduates of 1993.
Setting
UK.
Main outcome measures
Comments made by doctors about their work, and their views about medical careers and training in the UK.
Method
Postal and email questionnaires.
Results
Response rate was 72% (2507); 2252 were working in UK medicine, 816 (36%) of whom provided comments. Positive comments outweighed negative in the areas of their own job satisfaction and satisfaction with their training. However, 23% of doctors who commented expressed dissatisfaction with aspects of junior doctors’ training, the impact of working time regulations, and with the requirement for doctors to make earlier career decisions than in the past about their choice of specialty. Some doctors were concerned about government health service policy; others were dissatisfied with the availability of family-friendly/part-time work, and we are concerned about attitudes to gender and work-life balance.
Conclusions
Though satisfied with their own training and their current position, many senior doctors felt that changes to working hours and postgraduate training had reduced the level of experience gained by newer graduates. They were also concerned about government policy interventions.
doi:10.1177/2054270414554049
PMCID: PMC4228924  PMID: 25408920
physicians; career choice; medical staff; attitude of health personnel
19.  Brain Drain: Post Graduation Migration Intentions and the influencing factors among Medical Graduates from Lahore, Pakistan 
BMC Research Notes  2011;4:417.
Background
The increasing migration of health professionals to affluent countries is not a recent phenomenon and has been addressed in literature. However the various facets of physician migration from Pakistan, the third leading source of International medical graduates has not been rigorously evaluated. The objective of the current study was to survey final year students and recent medical graduates in Lahore, Pakistan about their intentions to train abroad, their post training plans as well as to identify the factors responsible for their motivation for international migration.
Method
A self administered structured questionnaire was developed to collect respondents' demographic and educational characteristics, intention to train abroad, their preferred destination & post training intentions of returning to Pakistan. Various influencing factors which impact on medical graduate's motivation to train abroad or stay in Pakistan were explored using a 10 point scale. SPSS software was used for data entry and analysis.
Results
Of the 400 eligible respondents, 275 responded (response rate 68.7%). One hundred and sixty six respondents (60.4%) intended to train abroad either for a specialty (54.9%) or a subspecialty (5.5%) The United States and United Kingdom were the most preferred destination. While 14.2% intended to return to Pakistan immediately after training, a significant percentage (10%) never intended to return to Pakistan or wished to stay abroad temporarily (37%). Professional excellence and establishing quickly in the competitive market were the most important goal to be achieved by the respondents for intention for postgraduate training abroad. The most common reasons cited for training abroad were the impact of residency training on future career (mean score 8.20 ± 2.3), financial conditions of doctors (mean score 7.97 ± 2.37) and job opportunities (mean score7.90 ± 2.34).
Conclusion
An alarming percentage of medical graduates from Lahore, Pakistan intend to migrate for post graduate training, mainly to United States. A significant proportion wished to stay in the host country either temporarily or indefinitely. Impact of residency abroad on future career, financial conditions of doctors, job opportunities and better working conditions were some of the motivating factors behind the migration.
doi:10.1186/1756-0500-4-417
PMCID: PMC3206860  PMID: 22005296
20.  The influence of rural clinical school experiences on medical students’ levels of interest in rural careers 
Human Resources for Health  2014;12(1):48.
Background
Australian Rural Clinical School (RCS) programmes have been designed to create experiences that positively influence graduates to choose rural medical careers. Rural career intent is a categorical evaluation measure and has been used to assess the Australian RCS model. Predictors for rural medical career intent have been associated with extrinsic values such as students with a rural background. Intrinsic values such as personal interest have not been assessed with respect to rural career intent. In psychology, a predictor of the motivation or emotion for a specific career or career location is the level of interest. Our primary aims are to model over one year of Australian RCS training, change in self-reported interest for future rural career intent. Secondary aims are to model student factors associated with rural career intent while attending an RCS.
Methods
The study participants were medical students enrolled in a RCS in the year 2013 at the University of New South Wales (UNSW) and who completed the newly developed self-administered UNSW Undergraduate Destinations Study (UDS) questionnaire. Data were collected at baseline and after one year of RCS training on preferred location for internship, work and intended specialty. Interest for graduate practice location (career intent) was assessed on a five-variable Likert scale at both baseline and at follow-up. A total of 165 students completed the UDS at baseline and 150 students after 1 year of follow-up.
Results
Factors associated with intent to practise in a rural location were rural background (χ2 = 28.4, P < 0.001), two or more previous years at an RCS (χ2 = 9.0, P = 0.003), and preference for a rural internship (χ2 = 17.8, P < 0.001). At follow-up, 41% of participants who originally intended to work in a metropolitan location at baseline changed their preference and indicated a preference for a rural location. The level of interest in intended practice location was significantly higher for those intending to work in a rural area than those with intention to work in a metropolitan (urban area) location (t = -3.1, P = 0.002). Initial rural career location intention was associated with increased interest levels after 1 year of follow-up (paired t = -2.3, P = 0.02).
Conclusion
When evaluating the success of RCS outcomes with respect to rural workforce destination, both rural practice intentions and level of interest are key factors related to projected career destination. RCS experience can positively influence practice intent (toward rural practice) and interest levels (toward greater interest in rural practice).
doi:10.1186/1478-4491-12-48
PMCID: PMC4159525  PMID: 25169650
Rural career intention; Interest level; Australian Rural Clinical School (RCS)
21.  Academic career in medicine – requirements and conditions for successful advancement in Switzerland 
Background
Within the framework of a prospective cohort study of Swiss medical school graduates a sample of young physicians aspiring to an academic career were surveyed on their career support and barriers experienced up to their sixth year of postgraduate training.
Methods
Thirty-one junior academics took part in semi-structured telephone interviews in 2007. The interview guideline focused on career paths to date, career support and barriers experienced, and recommendations for junior and senior academics. The qualitatively assessed data were evaluated according to Mayring's content analysis. Furthermore, quantitatively gained data from the total cohort sample on person- and career-related characteristics were analyzed in regard to differences between the junior academics and cohort doctors who aspire to another career in medicine.
Results
Junior academics differ in terms of instrumentality as a person-related factor, and in terms of intrinsic career motivation and mentoring as career-related factors from cohort doctors who follow other career paths in medicine; they also show higher scores in the Career-Success Scale. Four types of career path could be identified in junior academics: (1) focus on basic sciences, (2) strong focus on research (PhD programs) followed by clinical training, (3) one to two years in research followed by clinical training, (4) clinical training and research in parallel. The interview material revealed the following categories of career-supporting experience: making oneself out as a proactive junior physician, research resources provided by superior staff, and social network; statements concerning career barriers encompassed interference between clinical training and research activities, insufficient research coaching, and personality related barriers. Recommendations for junior academics focused on mentoring and professional networking, for senior academics on interest in human resource development and being role models.
Conclusion
The conditions for an academic career in medicine in Switzerland appear to be difficult especially for those physicians combining research with clinical work. For a successful academic career it seems crucial to start with research activities right after graduation, and take up clinical training later in the career. Furthermore, special mentoring programs for junior academics should be implemented at all medical schools to give trainees more goal-oriented guidance in their career.
doi:10.1186/1472-6963-9-70
PMCID: PMC2685793  PMID: 19402885
22.  Attitudes of undergraduate medical students of Addis Ababa University towards medical practice and migration, Ethiopia 
BMC Medical Education  2012;12:68.
Background
The health care system of Ethiopia is facing a serious shortage of health workforce. While a number of strategies have been developed to improve the training and retention of medical doctors in the country, understanding the perceptions and attitudes of medical students towards their training, future practice and intent to migrate can contribute in addressing the problem. This study was carried out to assess the attitudes of Ethiopian medical students towards their training and future practice of medicine, and to identify factors associated with the intent to practice in rural or urban settings, or to migrate abroad.
Methods
A cross-sectional study was conducted in June 2009 among 600 medical students (Year I to Internship program) of the Faculty of Medicine at Addis Ababa University in Ethiopia. A pre-tested self-administered structured questionnaire was used for data collection. Descriptive statistics were used for data summarization and presentation. Degree of association was measured by Chi Square test, with significance level set at p < 0.05. Bivariate and multivariate logistic regression analyses were used to assess associations.
Results
Only 20% of the students felt ‘excellent’ about studying medicine; followed by ‘very good’ (19%), ‘good’ (30%), ‘fair’ (21%) and ‘bad’ (11%). About 35% of respondents responded they felt the standard of medical education was below their expectation. Only 30% of the students said they would like to initially practice medicine in rural settings in Ethiopia. However, students with rural backgrounds were more likely than those with urban backgrounds to say they intended to practice medicine in rural areas (adjusted OR = 2.50, 95% CI = 1.18-5.26). Similarly, students in clinical training program preferred to practice medicine in rural areas compared to pre-clinical students (adjusted OR = 1.83, 95% CI = 1.12-2.99). About 53% of the students (57% males vs. 46% females, p = 0.017) indicated aspiration to emigrate following graduation, particularly to the United States of America (42%) or European countries (15%). The attitude towards emigration was higher among Year IV (63%) and Internship (71%) students compared to Year I to Year III students (45-54%). Male students were more likely to say they would emigrate than females (adjusted OR = 1.57, 95% CI = 1.10-2.29). Likewise, students with clinical training were more likely to want to emigrate than pre-clinical students, although the difference was marginally significant (adjusted OR = 1.58, 95% CI = 1.00-2.49).
Conclusions
The attitudes of the majority of Ethiopian medical students in the capital city towards practicing medicine in rural areas were found to be poor, and the intent to migrate after completing medical training was found to be very high among the study participants, creating a huge potential for brain drain. This necessitates the importance of improving the quality of education and career choice satisfaction, creating conducive training and working conditions including retention efforts for medical graduates to serve their nation. It follows that recruiting altruistic and rural background students into medical schools is likely to produce graduates who are more likely to practice medicine in rural settings.
doi:10.1186/1472-6920-12-68
PMCID: PMC3492144  PMID: 22867022
23.  Postgraduate education for Chinese medicine practitioners: a Hong Kong perspective 
Background
Despite Hong Kong government's official commitment to the development of traditional Chinese medicine (TCM) over the last ten years, there appears to have been limited progress in public sector initiated career development and postgraduate training (PGT) for public university trained TCM practitioners. Instead, the private TCM sector is expected to play a major role in nurturing the next generation of TCM practitioners. In the present study we evaluated TCM graduates' perspectives on their career prospects and their views regarding PGT.
Method
Three focus group discussions with 19 local TCM graduates who had worked full time in a clinical setting for fewer than 5 years.
Results
Graduates were generally uncertain about how to develop their career pathways in Hong Kong with few postgraduate development opportunities; because of this some were planning to leave the profession altogether. Despite their expressed needs, they were dissatisfied with the current quality of local PGT and suggested various ways for improvement including supervised practice-based learning, competency-based training, and accreditation of training with trainee involvement in design and evaluation. In addition they identified educational needs beyond TCM, in particular a better understanding of western medicine and team working so that primary care provision might be more integrated in the future.
Conclusion
TCM graduates in Hong Kong feel let down by the lack of public PGT opportunities which is hindering career development. To develop a new generation of TCM practitioners with the capacity to provide quality and comprehensive care, a stronger role for the government, including sufficient public funding, in promoting TCM graduates' careers and training development is suggested. Recent British and Australian experiences in prevocational western medicine training reform may serve as a source of references when relevant program for TCM graduates is planned in the future.
doi:10.1186/1472-6920-9-10
PMCID: PMC2652456  PMID: 19228379
24.  Career pathways and destinations 18 years on among doctors who qualified in the United Kingdom in 1977: postal questionnaire survey 
BMJ : British Medical Journal  1998;317(7170):1425-1428.
Objective
To determine the career destinations, by 1995, of doctors who qualified in the United Kingdom in 1977; the relation between their destinations and early career choice; and their intentions regarding retirement age.
Design
Postal questionnaire.
Setting
United Kingdom.
Subjects
All (n=3135) medical qualifiers of 1977.
Main outcome measures
Current employment; year by year trends in the percentage of doctors who worked in the NHS, in other medical posts in the United Kingdom, abroad, in non-medical posts, outside medicine, and in part time work; intentions regarding retirement age.
Results
After about 12 years the distribution of respondents by type of employment, and, for women, the percentage of doctors in part time rather than full time medical work, had stabilised. Of all 2997 qualifiers from medical schools in Great Britain, 2399 (80.0% (95% confidence interval 79.5% to 80.6%)) were working in medicine in the NHS in Great Britain 18 years after qualifying. Almost half the women (318/656) worked in the NHS part time. Of 1714 doctors in the NHS, 1125 intended to work in the NHS until normal retirement age, 392 did not, and 197 were undecided. Of the 1548 doctors for whom we had sufficient information, career destinations at 18 years matched the choices made at 1, 3, and 5 years in 58.9% (912), 78.2% (1211), and 86.6% (1341) of cases respectively.
Conclusions
Planning for the medical workforce needs to be supported by information about doctors’ career plans, destinations, and whole time equivalent years of work. Postgraduate training needs to take account of doctors’ eventual choice of specialty (and the timing of this choice).
Key messagesA large scale national study in the United Kingdom followed doctors from qualification to mid-career and beyondMost doctors had made their choice of eventual career—at least in terms of broadly defined specialty—within 5 years of qualifyingEighteen years on, 80% of the doctors were working in the NHS and nearly half of women doctors were working part timeAlmost a quarter of NHS doctors planned to retire early
PMCID: PMC28721  PMID: 9822395
25.  Current dilemmas in overseas doctors' training 
Postgraduate Medical Journal  2005;81(952):79-82.
International medical graduates (IMGs) are a remarkably successful professional group in the United Kingdom making up to 30% of the NHS work force. Their very success and media publicity about general practice and consultant shortages, has led to a large influx of inexperienced doctors seeking training opportunities in competitive specialties. In 2003 a record 15 549 doctors joined the medical register of which 9336 doctors were non-European Economic Area citizens. The number of candidates sitting PLAB part 1 and part 2 in 2003 rose by 267% and 283% respectively compared with 2001. Changes to Department of Health, Home Office, and deanery regulations with expansion of medical schools, implementation of European Working Time Directive, Modernising Medical Careers, and the future role of the Postgraduate Medical Education and Training Board, will have an important impact on IMGs' training. Dissemination of realistic information about postgraduate training opportunities is important as the NHS for some time will continue to rely on IMGs.
doi:10.1136/pgmj.2004.024547
PMCID: PMC1743197  PMID: 15701736

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