Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

What determines medical students’ career preference for general practice residency training?: a multicenter survey in Japan

What determines medical students’ career preference for general practice residency training?: a... Background: Few studies have systematically explored factors affecting medical students’ general practice career choice. We conducted a nationwide multicenter survey (Japan MEdical Career of Students: JMECS) to examine factors associated with students’ general practice career aspirations in Japan, where it has been decided that general practice will be officially acknowledged as a new discipline. Methods: From April to December 2015, we distributed a 21-item questionnaire to final year medical students in 17 medical schools. The survey asked students about their top three career preferences from 19 specialty fields, their demographics and their career priorities. Multivariable logistic regression was used to determine the effect of each item. Results: A total of 1264 responses were included in the analyses. The top three specialty choice were internal medi- cine: 833 (65.9%), general practice: 408 (32.3%), and pediatrics: 372 (29.4%). Among demographic factors, “plan to inherit other’s practice” positively associated with choosing general practice, whereas “having physician parent” had negative correlation. After controlling for potential confounders, students who ranked the following items as highly important were more likely to choose general practice: “clinical diagnostic reasoning (adjusted odds ratio (aOR): 1.65, 95% CI 1.40–1.94)”, “community-oriented practice (aOR: 1.33, 95% CI 1.13–1.57)”, and” involvement in preventive medi- cine (aOR: 1.18, 95% CI 1.01–1.38)”. On the contrary, “acute care rather than chronic care”, “mastering advanced proce- dures”, and “depth rather than breadth of practice” were less likely to be associated with general practice aspiration. Conclusions: Our nationwide multicenter survey found several features associated with general practice career aspirations: clinical diagnostic reasoning; community-oriented practice; and preventive medicine. These results can be fundamental to future research and the development of recruitment strategies. Keywords: General practice, Primary care, Family practice, Career choice, Medical students, Surveys and questionnaires medicine training several decades ago, whereas other Background nations have established it more recently [1]. Family medicine training in Asian countries has been Japanese physicians have been board certified by the developed mostly in partnership with other western individual society of their specialty. Although ex-spe- countries since the 1970s. Commonwealth member cialists have played a major role in Japanese primary countries like Singapore and Malaysia have started family care, there was no formal family medicine training until recently [11]. Starting in 2018, however, a new board *Correspondence: iekenya0321@gmail.com certificate system for physicians’ specialties by a third- Department of General Internal Medicine, Kawasaki Municipal Tama Hospital/St. Marianna University School of Medicine, 1-30-37 party organization will be implemented. Along with Shukugawara, Kawasaki, Kanagawa 214-8525, Japan this reform, it has been decided that general practice, Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ie et al. Asia Pac Fam Med (2018) 17:2 Page 2 of 6 including family medicine, will be officially acknowl - Measurement edged as a new basic discipline. Based on such historical The items included in the questionnaire were determined context, it is anticipated that the number of applicants based on a literature review [2–14], including our previ- for general practice will increase among medical students ous qualitative study results, and discussion among the and interns. study team. Given the paucity of existing evidence in a In Europe and North America, accumulating evidence Japanese context, we included items thought to reflect has elucidated factors associated with choosing family the uniqueness of Japanese general practice. The survey medicine and general practice as a career among medical asked students to select top three career options from students and junior doctors. Within the existing litera- 19 newly determined specialty fields as an outcome vari - ture on medical career choice, several demographic fac- able: internal medicine, pediatrics, dermatology, psy- tors have been shown to positively influence the choice chiatry, surgery, orthopedics, obstetrics and gynecology, of general practice/family medicine: being female [2–5], ophthalmology, otorhinolaryngology, urology, neuro- coming from rural background [2, 5, 6], having no fam- surgery, radiology, anesthesiology, pathology, clinical ily members in the healthcare field [6, 7]. In addition to laboratory, emergency medicine, plastic surgery, rehabili- the demographic factors, career intentions such as inter- tation, and general practice. The other explanatory vari - est in broad scope practice [7–9], interest in community- ables included participant demographics (e.g. age, sex) oriented practice [10, 11], work-life balance [11–13], and and 14 questions regarding their career intention, using societal orientation [6–8] have consistently predicted 6-point Likert scales ranging from 1 (strongly disagree) general practice/family medicine career choice. to 6 (strongly agree). All the data collected from medi- On the contrary, few studies have systematically cal students were anonymous except for the name of the explored factors affecting specialty choice of Japanese medical school. Before the data were handed over to the medical students and junior doctors, especially in general researchers, the school names were coded and de-identi- practice/family medicine. Our previous qualitative study fied by an honest broker using a linking file. revealed a range of factors affecting the choice of family medicine as their specialty including but not limited to Statistical analysis “community/rural orientedness” and “multifaceted ori- The outcome variable was dichotomized into two cat - entation” [11]. More recently, a cross-sectional study at a egories based on whether general practice was included Japanese university revealed that admission from home- in up to three choices or not. Among explanatory vari- town, intent for rural practice, and work-life balance were ables, “sex”, “job or other field experiences prior to medi - positive influences, while presence of medical relatives cal school”, “having physician parent”, and “plan to inherit and scientific orientation were negatively associated with other’s practice” were treated as binary; “birthplace” was general practice career choice [14]. To our knowledge, treated as nominal, and “age” was treated as a continuous however, no multicenter study has been conducted with a variable. The responses to the Likert scale of 14 career focus on general practice aspiration under the new board intention questions were treated as continuous, assum- certificate system. ing that the variables have interval properties. Univari- The purpose of this study was to conduct a nationwide able and multivariable logistic regression were used to multicenter survey (Japan MEdical Career of Students: examine the effect of each demographic factor and career JMECS) to examine factors associated with general prac- intentions in terms of odds ratio and 95% confidence tice career aspirations among Japanese medical students. intervals. We considered p values less than or equal to 0.05 as significant. STATA SE14.0 was used for all analy - Methods ses. Since the generation of parsimonious model was not Study population our primary objective, only the saturated model was fit - From April to December 2015, 17 medical schools (14 ted in our logistic regression analyses. Hosmer–Leme- public schools and three private schools) which were show Goodness of Fit test was applied to test the overall selected by convenience sampling and gave permission model fit. Multicollinearity was tested based on variance for study participation were included in the survey. We inflation factor with a cutoff of 10. Model discrimination distributed a 21-item questionnaire to medical students was tested using c-statistics. who had enrolled in their final year at the time of April The study protocol was approved by the Institutional 2015 in the 17 medical schools. We were able to sam- Ethical Committee of Mie University Graduate School of ple approximately 21% of 81 medical schools in Japan in Medicine (No. 1482). 2015. Ie et al. Asia Pac Fam Med (2018) 17:2 Page 3 of 6 parent, both had significant effects on students’ gen - Results eral practice career preference (Table  2). However, after A total of 1408 responses out of a possible 1903 medical adjusting for other covariates in the multivariable logis- students (74.0%) in the 17 medical schools were obtained. tic regression, “having a physician parent” and “intent to Among them, 1264 responses were included in the final inherit existing practice” had a negative association with analyses after removing invalid or insufficient responses. choosing general practice among the medical students Distribution of the participants’ sex, age, birth place, job demographics (Table 2). or other field experiences prior to medical school, phy - As for the 14 career priorities, seven positive influ - sician parent, plan to inherit other’s practice, and career ences and six negative influencers were identified in priorities are shown in Table  1. The survey participants crude (or univariate) analyses (Table  2). After adjust- had a median age of 24, 66.3% were male, 32.1% had ing for other covariates in the multivariable logistic a physician parent, and 11.3% had a positive intent to regression, three positive influencers and three nega - inherit an existing practice. Among the students with tive influencers remained significant. Medical students an intention to inherit, 92.3% had a physician parent. who ranked “clinical diagnostic reasoning”, “commu- On the contrary, only 32.5% of participants with a phy- nity-oriented practice”, and “involvement in preven- sician parent revealed their intention to inherit. The top tive medicine” as highly important were more likely five specialty fields chosen by students and their numbers to choose general practice, whereas “acute care rather were internal medicine 833 (65.9%), general practice 408 than chronic care”, “mastering advanced procedures”, (32.3%), pediatrics 372 (29.4%), surgery 344 (27.2%), and and “depth rather than breadth of practice” were less emergency medicine 244 (19.3%). likely to be associated with general practice aspiration Univariate analysis found those born in suburban areas (Table 2). compared to urban areas, and not having a physician Table 1 Characteristics of GP candidates and non-GP candidates among Japanese medical student Total (N = 1264) GP (N = 405) Non-GP (N = 846) Demographics; no. (%) of students Age, median (range), years 24 (23–58) 24 (23–58) 24 (23–52) Sex (male) 838 (66.3) 274 (67.2) 564 (65.9) Hometown Urban 267 (21.1) 72 (17.7) 195 (22.8) Relatively urban 287 (22.7) 102 (25) 185 (21.6) Relatively rural 401 (31.7) 130 (31.9) 271 (31.7) Rural 309 (24.5) 104 (25.5) 205 (24) Other academic or professional experiences prior to medical school 286 (22.6) 102 (25) 184 (21.5) Physician parent 406 (32.1) 114 (27.9) 292 (34.1) Intent to inherit existing practice 143 (11.3) 55 (13.5) 88 (10.3) Career priorities ; mean (SD) Mastering advanced procedures 4.83 (1.00) 4.60 (1.03) 4.93 (0.97) Work life balance 4.89 (0.93) 4.90 (0.89) 4.89 (0.95) Frequent patient communication 4.82 (0.89) 5.01 (0.82) 4.73 (0.91) Opening own clinic 3.33 (1.35) 3.48 (1.34) 3.26 (1.35) Involvement in preventive medicine 4.06 (1.13) 4.40 (1.04) 3.90 (1.14) Involvement in terminal care 3.77 (1.15) 4.06 (1.03) 3.63 (1.17) Acute care rather than chronic care 4.11 (1.06) 3.96 (1.02) 4.18 (1.07) Not treat patients with psychosocial problems 2.75 (1.19) 2.50 (1.14) 2.87 (1.19) Income 4.17 (1.00) 4.04 (1.08) 4.23 (0.96) Access to advanced medical fields 4.28 (0.98) 4.06 (0.97) 4.39 (0.96) Clinical diagnostic reasoning 4.31 (1.00) 4.60 (0.95) 4.17 (0.99) Depth rather than breadth of practice 3.97 (1.02) 3.64 (0.97) 4.13 (1.01) Involvement in global health 3.37 (1.13) 3.45 (1.13) 3.32 (1.12) Community-oriented practice 4.09 (1.05) 4.47 (0.98) 3.91 (1.03) Please select one of the following options which best describes your thoughts regarding your career priorities.” (1 = strongly disagree, 6 = strongly agree) Ie et al. Asia Pac Fam Med (2018) 17:2 Page 4 of 6 Table 2 Crude and adjusted odds ratio of characteristics of GP candidates among Japanese medical students (N = 1264) OR (95% CI) Crude Adjusted Demographics Sex (male) 0.94 (0.74, 1.21) 0.85 (0.64, 1.15) Hometown Urban – – Relatively urban 1.49* (1.04, 2.15) 1.45 (0.96, 2.17) Relatively rural 1.30 (0.92, 1.83) 1.24 (0.85, 1.83) Rural 1.37 (0.96, 1.97) 1.25 (0.84, 1.88) Other academic or professional experiences prior to medical school 1.22 (0.92, 1.61) 1.23 (0.90, 1.68) Physician parent 0.75* (0.58, 0.96) 0.59* (0.42, 0.83) Intent to inherit existing practice 1.36 (0.95, 1.95) 1.64* (1.01, 2.68) Career priorities Mastering advanced procedures 0.72* (0.64, 0.81) 0.75* (0.65, 0.87) Work life balance 1.02 (0.90, 1.15) 0.89 (0.76, 1.06) Frequent patient communication 1.47* (1.28, 1.70) 1.17 (0.97, 1.42) Opening own clinic 1.13* (1.03, 1.23) 1.08 (0.95, 1.22) Involvement in preventive medicine 1.51* (1.35, 1.70) 1.18* (1.01, 1.38) Involvement in terminal care 1.41 (1.26, 1.58) 1.10 (0.95, 1.28) Acute care rather than chronic care 0.82* (0.73, 0.92) 0.85* (0.74, 0.98) Not treat patients with psychosocial problems 0.76* (0.68, 0.84) 0.91 (0.80, 1.04) Income 0.83* (0.73, 0.93) 0.92 (0.79, 1.08) Access to advanced medical fields 0.70* (0.62, 0.80) 0.85 (0.71, 1.02) Clinical diagnostic reasoning 1.60* (1.40, 1.82) 1.65* (1.40, 1.94) Depth rather than breadth of practice 0.61* (0.54, 0.69) 0.69* (0.59, 0.81) Involvement in global health 1.11* (1.00, 1.23) 1.03 (0.90, 1.18) Community-oriented practice 1.77* (1.55, 2.01) 1.33* (1.13, 1.57) Dependent variable: whether general practice was included in up to three choices (1) or not (0) Adjusted pseudo R = 0.1572; AIC = 1.093329 * Statistically significant at an alpha level of 0.05 finding not common in previous literatures. In many Jap - Discussion anese medical schools, the department of general prac- The survey participants revealed a similar distribution tice or family medicine has been in charge of teaching of age and gender to a national sample of recent medical fundamental clinical reasoning skills to medical students. school graduates in Japan [15]. Among the study partici- Such context could have contributed to the strong posi- pants, general practice was selected as one of the career tive association between clinical diagnostic reasoning options by approximately 32% of medical students in and general practice choice among study participants. their final year. “Clinical diagnostic reasoning”, “commu - Two demographic factors, “having physician parent” nity-oriented practice”, and “involvement in preventive and “plan to inherit other’s practice”, were found to have medicine” were positively associated with the selection of significant association with choosing general practice, general practice. A student’s community orientation has even after controlling for other covariates. Having physi- been shown to predict primary care career preference cian parent was negatively associated with general prac- and was a factor affecting family medicine career choice tice choice, which is concordant with existing literature among Japanese physicians [11]. On the contrary, the [6, 7] from North America and Europe. One potential ranking of “acute care rather than chronic care”, “master- reason is that the perceived prestige of other medical spe- ing advanced procedures”, and “depth rather than breadth cialties among physician parents could negatively influ - of practice” as of higher importance were less likely to be ence their children’s general practice choice. On the associated with an aspiration for general practice aspira- other hand, having family or friends in general practice tion. This has been described in other studies [13]. was found to have positive association with general prac- Of 14 career priorities, “clinical diagnostic reasoning” tice career choice in a study [15]. Thus, it is possible that was the strongest predictor of general practice choice, a Ie et al. Asia Pac Fam Med (2018) 17:2 Page 5 of 6 the effect of family physicians may vary according to the generalizable to other countries. To our knowledge, how- specialty of parents. A positive association between the ever, this is the first and largest nationwide survey con - intention to inherit existing practice and general practice ducted across multiple Japanese medical schools. choice would have reflected students’ perceived useful - ness of general practice residency to develop expertise as Conclusions a future private practice owner. Our nationwide multicenter survey found several impor- Some previously known demographic factors, such as tant factors associated with general practice career being female [2–5] and coming from rural background aspirations among Japanese medical students. Clinical [2, 5, 6], had no association between students’ general diagnostic reasoning, community-oriented practice, and practice choice. In our study, participants were asked to preventive medicine were three major career priorities select the degree of rurality of their birthplace based on among students selected general practice. These results subjective judgment. This could be attributed to the het - can be fundamental to future research and the develop- erogeneity of birthplace classification, which potentially ment of recruitment strategies. could have led to a null result. In addition, the different definition of rural areas among countries should be taken Abbreviations into consideration for future research. JMECS: Japan MEdical Career of Students; OR: odds ratio. The role of gender in career choice has been well stud - Authors’ contributions ied and is known to be affected by nationality. A qualita - KI, AM, MT, MK, SI, YCT, and HO participated in the proposal’s design and data tive study explored Japanese female doctors’ perspectives collection. KI, AM, MT, MK, and SI carried out the data analyses and drafted the on specialty choice and found that they tend to make a manuscript. YCT and HO reviewed process of data analyses and manuscript writing. All authors read and approved the final manuscript. choice based on conventional gender roles where women tend to spend more time on household duties [16]. It is Author details possible that general practice, which is not well-estab- Department of General Internal Medicine, Kawasaki Municipal Tama Hospital/St. Marianna University School of Medicine, 1-30-37 Shukugawara, lished yet in Japan, could have been perceived as too Kawasaki, Kanagawa 214-8525, Japan. Department of Family Medicine, Mie unpredictable and insecure a career path. Such insecuri- University School of Medicine, 2-174 Edobashi, Tsu-shi, Mie 514-8507, Japan. ties of general practice career could have been perceived Family Practice Center of Okayama, 292-1 Toyosawa, Katsuta-gun, Nagi-cho, Okayama 708-1323, Japan. Iwakura Station Tahara Clinic, 291-1 Chuzaiji, as an unreasonable choice for female medical students. Iwakura, Sakyo-ku, Kyoto-shi, Kyoto 606-0021, Japan. Thank You All, Family While family medicine preference at entry to medical Clinic Hiratsuka, 215-3 Okazaki, Hiratsuka-shi, Kanagawa 259-1212, Japan. school is known to increase the likelihood of choosing a Department of Education and Research in Family and Community Medicine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu-shi, Mie family medicine career [7, 8], this item was not included 514-8507, Japan. International Research Center for Medical Education, Gradu- in our study as we assumed that a general practice career ate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, path had not been widely available at the time of study Tokyo 113-0033, Japan. participants’ medical school entry. Acknowledgements Our results reflect how general practice is perceived by We would like to thank the respondents of our survey for their support. We medical students, and they are a little different from that would also like to thank the faculty and staff in the 17 medical schools for their assistance with questionnaire survey, the secretariat of Japan Primary Care in other countries where general practice/family medi- Association for data management, and Nippon Foundation for their support. cine is well-established. Further studies are required to confirm factors affecting students’ career choice to deter - Competing interests The authors declare that they have no competing interests. mine strategies to facilitate general practice career choice in Japan. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Limitations Despite the thorough development of the questionnaire Consent for publication and relatively large sample size, our study has several Not applicable. limitations. First of all, our outcome measurement was Ethics approval and consent to participate career aspiration during the final year of medical school. The study protocol was approved by the Institutional Ethical Committee of u Th s, the actual enrolment in general practice residency Mie University Graduate School of Medicine (No. 1482). The IRB Committee waived the requirement to obtain a signed consent from study participants to and subsequent retention rate should also be considered avoid the potential risks of breach of confidentiality. in the future. Secondly, due to convenience sampling of medical schools, the representativeness of our study Funding This study was funded by the Japan Primary Care Association (Grant Number results to the general medical student population would 26-01-001). be limited. In addition, the study results may not be Ie et al. Asia Pac Fam Med (2018) 17:2 Page 6 of 6 8. Wright B, Scott I, Woloschuk W, Brenneis F. Career choice of new medi- Publisher’s Note cal students at three Canadian universities: family medicine versus Springer Nature remains neutral with regard to jurisdictional claims in pub- specialty medicine. CMAJ. 2004;170(13):1920–4. https://doi.org/10.1503/ lished maps and institutional affiliations. cmaj.1031111. 9. Kassebaum DG, Szenas PL. Factors influencing the specialty choices of Received: 1 May 2017 Accepted: 22 January 2018 1993 Medical School Graduates. Acad Med. 1994;69(2):164–70. 10. Whitcomb ME. Primary care medicine in the United States: where are we headed? Acad Med. 2002;77(8):759–60. 11. Ie K, Tahara M, Murata A, Komiyama M, Onishi H. Factors associated to the career choice of family medicine among Japanese physicians: the dawn References of a new era. Asia Pac Fam Med. 2014;13(1):11. https://doi.org/10.1186/ 1. Arya N, Gibson C, Ponka D, et al. Family medicine around the world: s12930-014-0011-2. overview by region: the Besrour Papers: a series on the state of family 12. Weiss YG, Zisk-Rony RY, Tandeter H, et al. Using medical specialty and medicine in the world. Can Fam Phys. 2017;63(6):436–41. selection criteria clusters to study specialty selection by Israeli medi- 2. Senf JH, Campos-Outcalt D, Kutob R. Factors related to the choice of fam- cal students. BMC Med Educ. 2017;17(1):17. https://doi.org/10.1186/ ily medicine: a reassessment and literature review. J Am Board Fam Pract. s12909-017-0854-y. 2003;16(6):502–12. https://doi.org/10.3122/jabfm.16.6.502. 13. Osborn HA, Frcsc KF, Brandt MG, Doyle PC. Primary care specialty career 3. Bland C, Meurer L, Maldonado G. Determinants of primary care specialty choice among Canadian medical students Understanding the factors choice: a non-statistical meta-analysis of the literature. Acad Med. that influence their decisions Recherche Le choix d’une carrière en 1995;70(7):620–41. médecine de première ligne chez les étudiants en médecine canadiens. 4. Kost A, Cawse-Lucas J, Evans DV, Overstreet F, Andrilla CH, Dobie S. Medi- Can Fam Phys. 2017;63:107–13. cal student participation in family medicine department extracurricular 14. Kawamoto R, Ninomiya D, Kasai Y, et al. Factors associated with the choice experiences and choosing to become a family physician. Fam Med. of general medicine as a career among Japanese medical students. Med 2015;47(10):763–9. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=ref Educ Online. 2016;21:29448. https://doi.org/10.3402/meo.v21.29448. erence&D=medl&NEWS=N&AN=26545052. 15. Deutsch T, Lippmann S, Frese T, Sandholzer H. Who wants to become 5. Gill H, McLeod S, Duerksen K, Szafran O. Factors influencing medical a general practitioner? Student and curriculum factors associated with students’ choice of family medicine: effects of rural versus urban back - choosing a GP career—a multivariable analysis with particular consid- ground. Can Fam Phys. 2012;58(11):649–57. eration of practice-orientated GP courses. Scand J Prim Health Care. 6. Avery DM, Wheat JR, Mcknight JT, Leeper JD. Factors associated with 2015;33(1):47–53. https://doi.org/10.3109/02813432.2015.1020661. choosing family medicine as a career specialty : what can we use ? Am J 16. Nakamura M. Studies on work-and-life balances and career development Clin Med. 2009;6(4):54–8. http://aapsus.org/articles/40.pdf. of Japanese physicians. Roudo Shakai-gaku Kenkyu. 2010;11:37–61. 7. Scott I, Gowans M, Wright B, Brenneis F, Banner S, Boone J. Determinants of choosing a career in family medicine. CMAJ. 2011;183(1):1–8. https:// doi.org/10.1503/cmaj.091805. Submit your next manuscript to BioMed Central and we will help you at every step: • We accept pre-submission inquiries • Our selector tool helps you to find the most relevant journal • We provide round the clock customer support • Convenient online submission • Thorough peer review • Inclusion in PubMed and all major indexing services • Maximum visibility for your research Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

What determines medical students’ career preference for general practice residency training?: a multicenter survey in Japan

Loading next page...
 
/lp/springer-journals/what-determines-medical-students-career-preference-for-general-3LwHIFG0r0
Publisher
Springer Journals
Copyright
2018 The Author(s)
eISSN
1447-056X
DOI
10.1186/s12930-018-0039-9
Publisher site
See Article on Publisher Site

Abstract

Background: Few studies have systematically explored factors affecting medical students’ general practice career choice. We conducted a nationwide multicenter survey (Japan MEdical Career of Students: JMECS) to examine factors associated with students’ general practice career aspirations in Japan, where it has been decided that general practice will be officially acknowledged as a new discipline. Methods: From April to December 2015, we distributed a 21-item questionnaire to final year medical students in 17 medical schools. The survey asked students about their top three career preferences from 19 specialty fields, their demographics and their career priorities. Multivariable logistic regression was used to determine the effect of each item. Results: A total of 1264 responses were included in the analyses. The top three specialty choice were internal medi- cine: 833 (65.9%), general practice: 408 (32.3%), and pediatrics: 372 (29.4%). Among demographic factors, “plan to inherit other’s practice” positively associated with choosing general practice, whereas “having physician parent” had negative correlation. After controlling for potential confounders, students who ranked the following items as highly important were more likely to choose general practice: “clinical diagnostic reasoning (adjusted odds ratio (aOR): 1.65, 95% CI 1.40–1.94)”, “community-oriented practice (aOR: 1.33, 95% CI 1.13–1.57)”, and” involvement in preventive medi- cine (aOR: 1.18, 95% CI 1.01–1.38)”. On the contrary, “acute care rather than chronic care”, “mastering advanced proce- dures”, and “depth rather than breadth of practice” were less likely to be associated with general practice aspiration. Conclusions: Our nationwide multicenter survey found several features associated with general practice career aspirations: clinical diagnostic reasoning; community-oriented practice; and preventive medicine. These results can be fundamental to future research and the development of recruitment strategies. Keywords: General practice, Primary care, Family practice, Career choice, Medical students, Surveys and questionnaires medicine training several decades ago, whereas other Background nations have established it more recently [1]. Family medicine training in Asian countries has been Japanese physicians have been board certified by the developed mostly in partnership with other western individual society of their specialty. Although ex-spe- countries since the 1970s. Commonwealth member cialists have played a major role in Japanese primary countries like Singapore and Malaysia have started family care, there was no formal family medicine training until recently [11]. Starting in 2018, however, a new board *Correspondence: iekenya0321@gmail.com certificate system for physicians’ specialties by a third- Department of General Internal Medicine, Kawasaki Municipal Tama Hospital/St. Marianna University School of Medicine, 1-30-37 party organization will be implemented. Along with Shukugawara, Kawasaki, Kanagawa 214-8525, Japan this reform, it has been decided that general practice, Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ie et al. Asia Pac Fam Med (2018) 17:2 Page 2 of 6 including family medicine, will be officially acknowl - Measurement edged as a new basic discipline. Based on such historical The items included in the questionnaire were determined context, it is anticipated that the number of applicants based on a literature review [2–14], including our previ- for general practice will increase among medical students ous qualitative study results, and discussion among the and interns. study team. Given the paucity of existing evidence in a In Europe and North America, accumulating evidence Japanese context, we included items thought to reflect has elucidated factors associated with choosing family the uniqueness of Japanese general practice. The survey medicine and general practice as a career among medical asked students to select top three career options from students and junior doctors. Within the existing litera- 19 newly determined specialty fields as an outcome vari - ture on medical career choice, several demographic fac- able: internal medicine, pediatrics, dermatology, psy- tors have been shown to positively influence the choice chiatry, surgery, orthopedics, obstetrics and gynecology, of general practice/family medicine: being female [2–5], ophthalmology, otorhinolaryngology, urology, neuro- coming from rural background [2, 5, 6], having no fam- surgery, radiology, anesthesiology, pathology, clinical ily members in the healthcare field [6, 7]. In addition to laboratory, emergency medicine, plastic surgery, rehabili- the demographic factors, career intentions such as inter- tation, and general practice. The other explanatory vari - est in broad scope practice [7–9], interest in community- ables included participant demographics (e.g. age, sex) oriented practice [10, 11], work-life balance [11–13], and and 14 questions regarding their career intention, using societal orientation [6–8] have consistently predicted 6-point Likert scales ranging from 1 (strongly disagree) general practice/family medicine career choice. to 6 (strongly agree). All the data collected from medi- On the contrary, few studies have systematically cal students were anonymous except for the name of the explored factors affecting specialty choice of Japanese medical school. Before the data were handed over to the medical students and junior doctors, especially in general researchers, the school names were coded and de-identi- practice/family medicine. Our previous qualitative study fied by an honest broker using a linking file. revealed a range of factors affecting the choice of family medicine as their specialty including but not limited to Statistical analysis “community/rural orientedness” and “multifaceted ori- The outcome variable was dichotomized into two cat - entation” [11]. More recently, a cross-sectional study at a egories based on whether general practice was included Japanese university revealed that admission from home- in up to three choices or not. Among explanatory vari- town, intent for rural practice, and work-life balance were ables, “sex”, “job or other field experiences prior to medi - positive influences, while presence of medical relatives cal school”, “having physician parent”, and “plan to inherit and scientific orientation were negatively associated with other’s practice” were treated as binary; “birthplace” was general practice career choice [14]. To our knowledge, treated as nominal, and “age” was treated as a continuous however, no multicenter study has been conducted with a variable. The responses to the Likert scale of 14 career focus on general practice aspiration under the new board intention questions were treated as continuous, assum- certificate system. ing that the variables have interval properties. Univari- The purpose of this study was to conduct a nationwide able and multivariable logistic regression were used to multicenter survey (Japan MEdical Career of Students: examine the effect of each demographic factor and career JMECS) to examine factors associated with general prac- intentions in terms of odds ratio and 95% confidence tice career aspirations among Japanese medical students. intervals. We considered p values less than or equal to 0.05 as significant. STATA SE14.0 was used for all analy - Methods ses. Since the generation of parsimonious model was not Study population our primary objective, only the saturated model was fit - From April to December 2015, 17 medical schools (14 ted in our logistic regression analyses. Hosmer–Leme- public schools and three private schools) which were show Goodness of Fit test was applied to test the overall selected by convenience sampling and gave permission model fit. Multicollinearity was tested based on variance for study participation were included in the survey. We inflation factor with a cutoff of 10. Model discrimination distributed a 21-item questionnaire to medical students was tested using c-statistics. who had enrolled in their final year at the time of April The study protocol was approved by the Institutional 2015 in the 17 medical schools. We were able to sam- Ethical Committee of Mie University Graduate School of ple approximately 21% of 81 medical schools in Japan in Medicine (No. 1482). 2015. Ie et al. Asia Pac Fam Med (2018) 17:2 Page 3 of 6 parent, both had significant effects on students’ gen - Results eral practice career preference (Table  2). However, after A total of 1408 responses out of a possible 1903 medical adjusting for other covariates in the multivariable logis- students (74.0%) in the 17 medical schools were obtained. tic regression, “having a physician parent” and “intent to Among them, 1264 responses were included in the final inherit existing practice” had a negative association with analyses after removing invalid or insufficient responses. choosing general practice among the medical students Distribution of the participants’ sex, age, birth place, job demographics (Table 2). or other field experiences prior to medical school, phy - As for the 14 career priorities, seven positive influ - sician parent, plan to inherit other’s practice, and career ences and six negative influencers were identified in priorities are shown in Table  1. The survey participants crude (or univariate) analyses (Table  2). After adjust- had a median age of 24, 66.3% were male, 32.1% had ing for other covariates in the multivariable logistic a physician parent, and 11.3% had a positive intent to regression, three positive influencers and three nega - inherit an existing practice. Among the students with tive influencers remained significant. Medical students an intention to inherit, 92.3% had a physician parent. who ranked “clinical diagnostic reasoning”, “commu- On the contrary, only 32.5% of participants with a phy- nity-oriented practice”, and “involvement in preven- sician parent revealed their intention to inherit. The top tive medicine” as highly important were more likely five specialty fields chosen by students and their numbers to choose general practice, whereas “acute care rather were internal medicine 833 (65.9%), general practice 408 than chronic care”, “mastering advanced procedures”, (32.3%), pediatrics 372 (29.4%), surgery 344 (27.2%), and and “depth rather than breadth of practice” were less emergency medicine 244 (19.3%). likely to be associated with general practice aspiration Univariate analysis found those born in suburban areas (Table 2). compared to urban areas, and not having a physician Table 1 Characteristics of GP candidates and non-GP candidates among Japanese medical student Total (N = 1264) GP (N = 405) Non-GP (N = 846) Demographics; no. (%) of students Age, median (range), years 24 (23–58) 24 (23–58) 24 (23–52) Sex (male) 838 (66.3) 274 (67.2) 564 (65.9) Hometown Urban 267 (21.1) 72 (17.7) 195 (22.8) Relatively urban 287 (22.7) 102 (25) 185 (21.6) Relatively rural 401 (31.7) 130 (31.9) 271 (31.7) Rural 309 (24.5) 104 (25.5) 205 (24) Other academic or professional experiences prior to medical school 286 (22.6) 102 (25) 184 (21.5) Physician parent 406 (32.1) 114 (27.9) 292 (34.1) Intent to inherit existing practice 143 (11.3) 55 (13.5) 88 (10.3) Career priorities ; mean (SD) Mastering advanced procedures 4.83 (1.00) 4.60 (1.03) 4.93 (0.97) Work life balance 4.89 (0.93) 4.90 (0.89) 4.89 (0.95) Frequent patient communication 4.82 (0.89) 5.01 (0.82) 4.73 (0.91) Opening own clinic 3.33 (1.35) 3.48 (1.34) 3.26 (1.35) Involvement in preventive medicine 4.06 (1.13) 4.40 (1.04) 3.90 (1.14) Involvement in terminal care 3.77 (1.15) 4.06 (1.03) 3.63 (1.17) Acute care rather than chronic care 4.11 (1.06) 3.96 (1.02) 4.18 (1.07) Not treat patients with psychosocial problems 2.75 (1.19) 2.50 (1.14) 2.87 (1.19) Income 4.17 (1.00) 4.04 (1.08) 4.23 (0.96) Access to advanced medical fields 4.28 (0.98) 4.06 (0.97) 4.39 (0.96) Clinical diagnostic reasoning 4.31 (1.00) 4.60 (0.95) 4.17 (0.99) Depth rather than breadth of practice 3.97 (1.02) 3.64 (0.97) 4.13 (1.01) Involvement in global health 3.37 (1.13) 3.45 (1.13) 3.32 (1.12) Community-oriented practice 4.09 (1.05) 4.47 (0.98) 3.91 (1.03) Please select one of the following options which best describes your thoughts regarding your career priorities.” (1 = strongly disagree, 6 = strongly agree) Ie et al. Asia Pac Fam Med (2018) 17:2 Page 4 of 6 Table 2 Crude and adjusted odds ratio of characteristics of GP candidates among Japanese medical students (N = 1264) OR (95% CI) Crude Adjusted Demographics Sex (male) 0.94 (0.74, 1.21) 0.85 (0.64, 1.15) Hometown Urban – – Relatively urban 1.49* (1.04, 2.15) 1.45 (0.96, 2.17) Relatively rural 1.30 (0.92, 1.83) 1.24 (0.85, 1.83) Rural 1.37 (0.96, 1.97) 1.25 (0.84, 1.88) Other academic or professional experiences prior to medical school 1.22 (0.92, 1.61) 1.23 (0.90, 1.68) Physician parent 0.75* (0.58, 0.96) 0.59* (0.42, 0.83) Intent to inherit existing practice 1.36 (0.95, 1.95) 1.64* (1.01, 2.68) Career priorities Mastering advanced procedures 0.72* (0.64, 0.81) 0.75* (0.65, 0.87) Work life balance 1.02 (0.90, 1.15) 0.89 (0.76, 1.06) Frequent patient communication 1.47* (1.28, 1.70) 1.17 (0.97, 1.42) Opening own clinic 1.13* (1.03, 1.23) 1.08 (0.95, 1.22) Involvement in preventive medicine 1.51* (1.35, 1.70) 1.18* (1.01, 1.38) Involvement in terminal care 1.41 (1.26, 1.58) 1.10 (0.95, 1.28) Acute care rather than chronic care 0.82* (0.73, 0.92) 0.85* (0.74, 0.98) Not treat patients with psychosocial problems 0.76* (0.68, 0.84) 0.91 (0.80, 1.04) Income 0.83* (0.73, 0.93) 0.92 (0.79, 1.08) Access to advanced medical fields 0.70* (0.62, 0.80) 0.85 (0.71, 1.02) Clinical diagnostic reasoning 1.60* (1.40, 1.82) 1.65* (1.40, 1.94) Depth rather than breadth of practice 0.61* (0.54, 0.69) 0.69* (0.59, 0.81) Involvement in global health 1.11* (1.00, 1.23) 1.03 (0.90, 1.18) Community-oriented practice 1.77* (1.55, 2.01) 1.33* (1.13, 1.57) Dependent variable: whether general practice was included in up to three choices (1) or not (0) Adjusted pseudo R = 0.1572; AIC = 1.093329 * Statistically significant at an alpha level of 0.05 finding not common in previous literatures. In many Jap - Discussion anese medical schools, the department of general prac- The survey participants revealed a similar distribution tice or family medicine has been in charge of teaching of age and gender to a national sample of recent medical fundamental clinical reasoning skills to medical students. school graduates in Japan [15]. Among the study partici- Such context could have contributed to the strong posi- pants, general practice was selected as one of the career tive association between clinical diagnostic reasoning options by approximately 32% of medical students in and general practice choice among study participants. their final year. “Clinical diagnostic reasoning”, “commu - Two demographic factors, “having physician parent” nity-oriented practice”, and “involvement in preventive and “plan to inherit other’s practice”, were found to have medicine” were positively associated with the selection of significant association with choosing general practice, general practice. A student’s community orientation has even after controlling for other covariates. Having physi- been shown to predict primary care career preference cian parent was negatively associated with general prac- and was a factor affecting family medicine career choice tice choice, which is concordant with existing literature among Japanese physicians [11]. On the contrary, the [6, 7] from North America and Europe. One potential ranking of “acute care rather than chronic care”, “master- reason is that the perceived prestige of other medical spe- ing advanced procedures”, and “depth rather than breadth cialties among physician parents could negatively influ - of practice” as of higher importance were less likely to be ence their children’s general practice choice. On the associated with an aspiration for general practice aspira- other hand, having family or friends in general practice tion. This has been described in other studies [13]. was found to have positive association with general prac- Of 14 career priorities, “clinical diagnostic reasoning” tice career choice in a study [15]. Thus, it is possible that was the strongest predictor of general practice choice, a Ie et al. Asia Pac Fam Med (2018) 17:2 Page 5 of 6 the effect of family physicians may vary according to the generalizable to other countries. To our knowledge, how- specialty of parents. A positive association between the ever, this is the first and largest nationwide survey con - intention to inherit existing practice and general practice ducted across multiple Japanese medical schools. choice would have reflected students’ perceived useful - ness of general practice residency to develop expertise as Conclusions a future private practice owner. Our nationwide multicenter survey found several impor- Some previously known demographic factors, such as tant factors associated with general practice career being female [2–5] and coming from rural background aspirations among Japanese medical students. Clinical [2, 5, 6], had no association between students’ general diagnostic reasoning, community-oriented practice, and practice choice. In our study, participants were asked to preventive medicine were three major career priorities select the degree of rurality of their birthplace based on among students selected general practice. These results subjective judgment. This could be attributed to the het - can be fundamental to future research and the develop- erogeneity of birthplace classification, which potentially ment of recruitment strategies. could have led to a null result. In addition, the different definition of rural areas among countries should be taken Abbreviations into consideration for future research. JMECS: Japan MEdical Career of Students; OR: odds ratio. The role of gender in career choice has been well stud - Authors’ contributions ied and is known to be affected by nationality. A qualita - KI, AM, MT, MK, SI, YCT, and HO participated in the proposal’s design and data tive study explored Japanese female doctors’ perspectives collection. KI, AM, MT, MK, and SI carried out the data analyses and drafted the on specialty choice and found that they tend to make a manuscript. YCT and HO reviewed process of data analyses and manuscript writing. All authors read and approved the final manuscript. choice based on conventional gender roles where women tend to spend more time on household duties [16]. It is Author details possible that general practice, which is not well-estab- Department of General Internal Medicine, Kawasaki Municipal Tama Hospital/St. Marianna University School of Medicine, 1-30-37 Shukugawara, lished yet in Japan, could have been perceived as too Kawasaki, Kanagawa 214-8525, Japan. Department of Family Medicine, Mie unpredictable and insecure a career path. Such insecuri- University School of Medicine, 2-174 Edobashi, Tsu-shi, Mie 514-8507, Japan. ties of general practice career could have been perceived Family Practice Center of Okayama, 292-1 Toyosawa, Katsuta-gun, Nagi-cho, Okayama 708-1323, Japan. Iwakura Station Tahara Clinic, 291-1 Chuzaiji, as an unreasonable choice for female medical students. Iwakura, Sakyo-ku, Kyoto-shi, Kyoto 606-0021, Japan. Thank You All, Family While family medicine preference at entry to medical Clinic Hiratsuka, 215-3 Okazaki, Hiratsuka-shi, Kanagawa 259-1212, Japan. school is known to increase the likelihood of choosing a Department of Education and Research in Family and Community Medicine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu-shi, Mie family medicine career [7, 8], this item was not included 514-8507, Japan. International Research Center for Medical Education, Gradu- in our study as we assumed that a general practice career ate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, path had not been widely available at the time of study Tokyo 113-0033, Japan. participants’ medical school entry. Acknowledgements Our results reflect how general practice is perceived by We would like to thank the respondents of our survey for their support. We medical students, and they are a little different from that would also like to thank the faculty and staff in the 17 medical schools for their assistance with questionnaire survey, the secretariat of Japan Primary Care in other countries where general practice/family medi- Association for data management, and Nippon Foundation for their support. cine is well-established. Further studies are required to confirm factors affecting students’ career choice to deter - Competing interests The authors declare that they have no competing interests. mine strategies to facilitate general practice career choice in Japan. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Limitations Despite the thorough development of the questionnaire Consent for publication and relatively large sample size, our study has several Not applicable. limitations. First of all, our outcome measurement was Ethics approval and consent to participate career aspiration during the final year of medical school. The study protocol was approved by the Institutional Ethical Committee of u Th s, the actual enrolment in general practice residency Mie University Graduate School of Medicine (No. 1482). The IRB Committee waived the requirement to obtain a signed consent from study participants to and subsequent retention rate should also be considered avoid the potential risks of breach of confidentiality. in the future. Secondly, due to convenience sampling of medical schools, the representativeness of our study Funding This study was funded by the Japan Primary Care Association (Grant Number results to the general medical student population would 26-01-001). be limited. In addition, the study results may not be Ie et al. Asia Pac Fam Med (2018) 17:2 Page 6 of 6 8. Wright B, Scott I, Woloschuk W, Brenneis F. Career choice of new medi- Publisher’s Note cal students at three Canadian universities: family medicine versus Springer Nature remains neutral with regard to jurisdictional claims in pub- specialty medicine. CMAJ. 2004;170(13):1920–4. https://doi.org/10.1503/ lished maps and institutional affiliations. cmaj.1031111. 9. Kassebaum DG, Szenas PL. Factors influencing the specialty choices of Received: 1 May 2017 Accepted: 22 January 2018 1993 Medical School Graduates. Acad Med. 1994;69(2):164–70. 10. Whitcomb ME. Primary care medicine in the United States: where are we headed? Acad Med. 2002;77(8):759–60. 11. Ie K, Tahara M, Murata A, Komiyama M, Onishi H. Factors associated to the career choice of family medicine among Japanese physicians: the dawn References of a new era. Asia Pac Fam Med. 2014;13(1):11. https://doi.org/10.1186/ 1. Arya N, Gibson C, Ponka D, et al. Family medicine around the world: s12930-014-0011-2. overview by region: the Besrour Papers: a series on the state of family 12. Weiss YG, Zisk-Rony RY, Tandeter H, et al. Using medical specialty and medicine in the world. Can Fam Phys. 2017;63(6):436–41. selection criteria clusters to study specialty selection by Israeli medi- 2. Senf JH, Campos-Outcalt D, Kutob R. Factors related to the choice of fam- cal students. BMC Med Educ. 2017;17(1):17. https://doi.org/10.1186/ ily medicine: a reassessment and literature review. J Am Board Fam Pract. s12909-017-0854-y. 2003;16(6):502–12. https://doi.org/10.3122/jabfm.16.6.502. 13. Osborn HA, Frcsc KF, Brandt MG, Doyle PC. Primary care specialty career 3. Bland C, Meurer L, Maldonado G. Determinants of primary care specialty choice among Canadian medical students Understanding the factors choice: a non-statistical meta-analysis of the literature. Acad Med. that influence their decisions Recherche Le choix d’une carrière en 1995;70(7):620–41. médecine de première ligne chez les étudiants en médecine canadiens. 4. Kost A, Cawse-Lucas J, Evans DV, Overstreet F, Andrilla CH, Dobie S. Medi- Can Fam Phys. 2017;63:107–13. cal student participation in family medicine department extracurricular 14. Kawamoto R, Ninomiya D, Kasai Y, et al. Factors associated with the choice experiences and choosing to become a family physician. Fam Med. of general medicine as a career among Japanese medical students. Med 2015;47(10):763–9. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=ref Educ Online. 2016;21:29448. https://doi.org/10.3402/meo.v21.29448. erence&D=medl&NEWS=N&AN=26545052. 15. Deutsch T, Lippmann S, Frese T, Sandholzer H. Who wants to become 5. Gill H, McLeod S, Duerksen K, Szafran O. Factors influencing medical a general practitioner? Student and curriculum factors associated with students’ choice of family medicine: effects of rural versus urban back - choosing a GP career—a multivariable analysis with particular consid- ground. Can Fam Phys. 2012;58(11):649–57. eration of practice-orientated GP courses. Scand J Prim Health Care. 6. Avery DM, Wheat JR, Mcknight JT, Leeper JD. Factors associated with 2015;33(1):47–53. https://doi.org/10.3109/02813432.2015.1020661. choosing family medicine as a career specialty : what can we use ? Am J 16. Nakamura M. Studies on work-and-life balances and career development Clin Med. 2009;6(4):54–8. http://aapsus.org/articles/40.pdf. of Japanese physicians. Roudo Shakai-gaku Kenkyu. 2010;11:37–61. 7. Scott I, Gowans M, Wright B, Brenneis F, Banner S, Boone J. Determinants of choosing a career in family medicine. CMAJ. 2011;183(1):1–8. https:// doi.org/10.1503/cmaj.091805. Submit your next manuscript to BioMed Central and we will help you at every step: • We accept pre-submission inquiries • Our selector tool helps you to find the most relevant journal • We provide round the clock customer support • Convenient online submission • Thorough peer review • Inclusion in PubMed and all major indexing services • Maximum visibility for your research Submit your manuscript at www.biomedcentral.com/submit

Journal

Asia Pacific Family MedicineSpringer Journals

Published: Dec 1, 2018

References