The ideal job

The number of medical students choosing family medicine as a career has steadily declined in the past decade. Rural practice has seen a similar trend. Yasmina Dadi investigates why today’s medical students find hospitals and cities more appealing

I don’t like it! I hate it, and I demand to leave… Well that is because you are not the one who is supposed to spend the next four years of his life in this Godforsaken hole,” complained Dr Joel Fleischman, played by Rob Morrow on the American hit show Northern Exposure, which was broadcast all over the world in the early 90s. Dr Fleischman owed $125,000 (£70,000, a100,000) to Columbia University and was forced to repay his scholarship by working as a general practitioner for four years in the remote town of Cicely, Alaska.

Of course, this case is fictional, but it seems to describe the worst nightmare of many medical students. The wishes of medical students vary, but one thing seems quite common: only a few students want to work in rural or remote areas after graduation. Ask today’s medical students to describe their ideal job and you will probably get an answer that includes the words “hospital” and “city.”

Indeed, a recent study from the University of Helsinki found that less than 15% of its medical students want to work in rural areas after graduation. Furthermore, 60% want to stay and work in the Finnish capital. The same study also found that only 10% of women and 6% of men wanted to work as general practitioners in a community health centre. And the problem affects not only Finland—a similar trend is seen around the world.¹

Attraction of working in cities
But why do medical students want to settle in metropolitan, suburban, or other non-rural areas after graduation? Eero Lahelma, professor of medical sociology at the University of Helsinki and the author of the Finnish study explains: “Obviously, students find more career opportunities and possibilities to specialise in big cities. It is only natural for them to move where the jobs are.”

Furthermore, many young doctors feel that they do not yet have the extended clinical skills that are needed in rural practice. The first years of any doctor’s career are often the hardest ones, and life in remote communities can be lonely for a graduate in a personal as well as in a professional sense.

Bad name
In addition to the more practical reasons, there are also negative myths and expectations that may scare students away from family and rural medicine. Rural and family practice are often perceived as less glamorous and are not appreciated as much as other specialties or hospital posts.

Walter W Rosser, professor and chair of the department of family medicine at the Queen’s University, Canada, puts it this way: “Students hear complaints from family physicians themselves about physician shortages, excessive workloads, increased difficulty ‘keeping up,’ and declining financial rewards compared with those of specialists. Thus, most medical students buy into the myth that family medicine is an amalgam of all specialties and is impossible to practice competently given the overwhelming information load. These misunderstandings lead to negative comments about family physicians and their style of work”.²

Personal reasons
Students’ personal characteristics also contribute to their career choice. A study conducted in three Canadian universities found that first year medical students who identified family medicine as their first career option were more likely to demonstrate a social orientation and desire to pursue a more varied practice. Furthermore, these students tended to be older and to have lived in smaller communities at the time of completing high school.³

Besides personal interest, money has a considerable influence on students’ career choices. Recent studies indicate that students with high levels of debt are less likely to choose family medicine. Furthermore, the students who do choose family medicine expect to earn less than students who intend to specialise.^{4 5}

Future problems
Eero Lahelma says: “When medical students enter medicine they say they are ready to work where they are needed, but in reality they are far keener to work in hospitals and in non-rural areas. In future, there may be problems finding enough doctors to fill countryside offices and family practices.”

Studies have shown that more than 60% of doctors in countries such as Finland, the UK, the Netherlands, Germany, Norway, and Italy were employed in the career that was their first choice at the time of graduation from medical school one year after qualification, and 80% after three years. Clearly, that the reluctance of medical students to work in family and rural practice should not be overlooked.⁶

What can be done?
 In many countries, measures have been taken to tackle the issue. For example, many states in the United States offer to pay part of a medical student’s loan if, in turn, he or she serves in a medically underserved area. In Australia, almost all medical schools have special programmes that offer students training in rural medicine. In Finland, there has even been discussion in the media about whether there should be a special government scheme to make doctors work in family medicine and rural areas.

From the students’ point of view, forcing them is no way to make them go. But what can be done? There have been suggestions that medical school admission policies should be changed. Since medical students seem to favour working in communities similar to those in which they were raised, should we encourage more students from rural backgrounds to enter medicine? Or should we provide special incentives for students who are willing to commit themselves to working in rural communities after graduation?

A study conducted in six US medical schools found that a quarter of fourth year students who planned to go into non-primary care would change to a primary care specialty with appropriate adjustments in income, hours worked, or loan repayment. Appreciable changes in economic and lifestyle factors might therefore attract more students to family medicine.⁷

itv/tpc/rex
So you want to follow in the footsteps of Peak Practice’s Dr Jack Kerruish?

A special attraction
Matias Kallio, a third year student at the University of Helsinki, suggests a way to make family and rural medicine more attractive that no government scheme could plan for: “Well, I could only consider moving to rural areas if I met a special girl who lived there. In the past I have dated a few country girls and I believe I could be very happy being a town doctor if I had a good reason to be there.”

And in case you wonder what happened to Dr Fleischman, he too met someone special—a courier pilot played by co-star Janine Turner. He grew fond of Cicely and even attempted to retreat further from modern day society. In the end, however, as so often in real life, the high life beckoned and Dr Fleischman returned to New York.

1. Lahelma E, Broms U, Karisto A. Pienestä pitäen olen halunnut lääkäriksi. Lääketieteen opiskelijoiden tausta ja suuntautuminen. Lääkärilehti 2003;58(44):4491-6.
2. Rosser W. The decline of family medicine as a career choice. Can Med J Assoc 2002;166:11.
3. Wright B, Scott I, Woloschuk W, Brenneis F, Bradley J. Career choice of new medical students at three Canadian universities: family medicine versus specialty medicine. Can Med J Assoc 2004;170:1920-4.
4. Rosenthal MP, Marquette PA, Diamond JJ. Trends along the debt-income axis: implications for medical students’ selections of family practice careers. Acad Med 1996;71:675-7.
5. Rosenthal MP, Turner TN, Diamond J, Rabinowitz HK. Income expectations of first-year students at Jefferson Medical College as a predictor of family practice specialty choice. Acad Med 1992;67:328-31.
6. Soethout MBM, ten Cate ThJ, van der Wal G. Factors associated with the nature, timing and stability of the specialty career choices of recently graduated doctors in European countries: a literature review. Medical Education Online 2004;9:24.
7. Rosenthal MP, Diamond JJ, Rabinowitz HK, et al. Influence of income, hours worked, and loan repayment on medical students’ decision to pursue a primary care career. JAMA 1994;271:914-7.