Rural exposure during medical education and student preference for future practice location - a case of Botswana

Preferences of Iranian medical students for selecting the compulsory service plan packages: A discrete choice experiment

Background and Aims

Health policymakers face challenges in designing compulsory plan packages for medical students to encourage them to work in disadvantaged regions. Using a discrete choice experiment, this study assessed the preferences of medical students for selecting the compulsory service plan packages in Guilan Province, Iran.

Methods

In total, 374 medical students responded to a survey inquiring about salary, distance from their residency city, availability of welfare amenities, work difficulty, the developmental status of their workplace, contract duration, and preference for urban or rural work settings.

Results

The study revealed that students favor a compulsory service package that provides higher salaries and shorter contract duration. They also show a preference for working within their home province over other factors. For the opportunity to serve in their city of residence, they would forgo an average of US$77.93 per month.

Conclusion

While financial incentives were the primary consideration for medical students when choosing compulsory service packages, a range of nonfinancial factors significantly influenced their decisions as well.

Increasing the availability of health workers in rural sub-Saharan Africa: a scoping review of rural pipeline programmes

INTRODUCTION

Rural pipeline approach has recently gain prominent recognition in improving the availability of health workers in hard-to-reach areas such as rural and poor regions. Understanding implications for its successful implementation is important to guide health policy and decision-makers in Sub-Saharan Africa. This review aims to synthesize the evidence on rural pipeline implementation and impacts in sub-Saharan Africa.

METHODS

We conducted a scoping review using Joanna Briggs Institute guidebook. We searched in PubMed and Google scholar databases and the grey literature. We conducted a thematic analysis to assess the studies. Data were reported following the PRISMA extension for Scoping reviews guidelines.

RESULTS

Of the 443 references identified through database searching, 22 met the inclusion criteria. Rural pipeline pillars that generated impacts included ensuring that more rural students are selected into programmes; developing a curriculum oriented towards rural health and rural exposure during training; curriculum oriented to rural health delivery; and ensuring retention of health workers in rural areas through educational and professional support. These impacts varied from one pillar to another and included: increased in number of rural health practitioners; reduction in communication barriers between healthcare providers and community members; changes in household economic and social circumstances especially for students from poor family; improvement of health services quality; improved health education and promotion within rural communities; and motivation of community members to enrol their children in school. However, implementation of rural pipeline resulted in some unintended impacts such as perceived workload increased by trainee's supervisors; increased job absenteeism among senior health providers; patients' discomfort of being attended by students; perceived poor quality care provided by students which influenced health facilities attendance. Facilitating factors of rural pipeline implementation included: availability of learning infrastructures in rural areas; ensuring students' accommodation and safety; setting no age restriction for students applying for rural medical schools; and appropriate academic capacity-building programmes for medical students. Implementation challenges included poor preparation of rural health training schools' candidates; tuition fees payment; limited access to rural health facilities for students training; inadequate living and working conditions; and perceived discrimination of rural health workers.

CONCLUSION

This review advocates for combined implementation of rural pipeline pillars, taking into account the specificity of country context. Policy and decision-makers in sub-Saharan Africa should extend rural training programmes to involve nurses, midwives and other allied health professionals. Decision-makers in sub-Saharan Africa should also commit more for improving rural living and working environments to facilitate the implementation of rural health workforce development programmes.

Medical education interventions influencing physician distribution into underserved communities: a scoping review

BACKGROUND AND OBJECTIVE

Physician maldistribution is a global problem that hinders patients' abilities to access healthcare services. Medical education presents an opportunity to influence physicians towards meeting the healthcare needs of underserved communities when establishing their practice. Understanding the impact of educational interventions designed to offset physician maldistribution is crucial to informing health human resource strategies aimed at ensuring that the disposition of the physician workforce best serves the diverse needs of all patients and communities.

METHODS

A scoping review was conducted using a six-stage framework to help map current evidence on educational interventions designed to influence physicians' decisions or intention to establish practice in underserved areas. A search strategy was developed and used to conduct database searches. Data were synthesized according to the types of interventions and the location in the medical education professional development trajectory, that influence physician intention or decision for rural and underserved practice locations.

RESULTS

There were 130 articles included in the review, categorized according to four categories: preferential admissions criteria, undergraduate training in underserved areas, postgraduate training in underserved areas, and financial incentives. A fifth category was constructed to reflect initiatives comprised of various combinations of these four interventions. Most studies demonstrated a positive impact on practice location, suggesting that selecting students from underserved or rural areas, requiring them to attend rural campuses, and/or participate in rural clerkships or rotations are influential in distributing physicians in underserved or rural locations. However, these studies may be confounded by various factors including rural origin, pre-existing interest in rural practice, and lifestyle. Articles also had various limitations including self-selection bias, and a lack of standard definition for underservedness.

CONCLUSIONS

Various educational interventions can influence physician practice location: preferential admissions criteria, rural experiences during undergraduate and postgraduate medical training, and financial incentives. Educators and policymakers should consider the social identity, preferences, and motivations of aspiring physicians as they have considerable impact on the effectiveness of education initiatives designed to influence physician distribution in underserved locations.

Interventions for managing professional isolation among health professionals in low resource environments: A scoping review

BACKGROUND

Professional isolation is viewed as a sense of isolation from ones professional peers and this has contributed to compromised quality of health service delivery as well as quality of life for health professionals in low resource environments. Professional isolation is a multidimensional concept which may be either geographic, social, and/or ideological. However, professional isolation in low resource environments remains poorly defined with a limited body of research focusing on health professionals.

AIM

To map and examine available literature on interventions for managing professional isolation among health professionals in low resource environments.

METHODS

We conducted a scoping review of the published and grey literature to examine the extent, range and nature of existing research studies relevant to professional isolation in health professionals.

RESULTS

Of the 10 articles retrieved, 70% were conducted in high income countries where the context may be different if applied to other low-income settings such as in Africa. Only 20% of the studies focused specifically on nurses or the nursing profession and only 10% were conducted on the African continent.

CONCLUSION

There is insufficient research on the definition and origins of professional isolation among health professionals including the interventions that can be employed. Rural, remote and/or isolated settings significantly predispose health professionals to professional isolation but remain poorly defined. Additional research is recommended to explore and determine the interventions for managing professional isolation among health professionals in low resource environments.

Using Design Thinking to Explore Rural Experiential Education Barriers and Opportunities

INTRODUCTION

Design thinking is a creative problem-solving framework that can be used to better understand challenges and generate solutions in health professions education, such as the barriers to rural education. Rural education experiences can benefit students, providers, and patients; however, placement in and maintenance of rural education experiences offer unique challenges. Design thinking offers strategies to explore and address these challenges.

METHODS

This study used a design thinking framework to identify barriers of student placement in rural locations; this was accomplished using strategies to empathize with users (eg, students, practitioners, and administrators) and define the problem. Data were collected from focus groups, interviews, and a design thinking workshop. Design activities promoted participant discussion by drawing pictures, discussing findings, and creating empathy maps of student experiences. Qualitative data were analyzed to identify salient barriers to rural experience selection and opportunities for support.

RESULT

Focus group (n = 6), interview (n = 13), and workshop participants (n = 18) identified substantial advantages (eg, exposure to a wider variety of patients, less bureaucracy and constraints, more time with faculty) and disadvantages (eg, isolation, lack of housing, and commuting distances) of rural experiences. Participants identified physical, emotional, and social isolation as a significant barrier to student interest in and engagement in rural experiences. Workshop participants were able to generate over 100 ideas to address the most prominent theme of isolation.

DISCUSSION

Design thinking strategies can be used to explore health professions education challenges, such as placement in rural settings. Through engagement with students, practitioners, and administrators it was identified that physical, social, and emotional isolation presents a significant barrier to student placement in rural experiences. This perspective can inform support systems for students, preceptors, and communities that participate in rural educational experiences.

Are Medical Graduates' Job Choices for Rural Practice Consistent with their Initial Intentions? A Cross-Sectional Survey in Western China

Global concerns persist regarding the shortage and misdistribution of health workers in rural and remote areas. Medical education is an important input channel of human resources for health. This study aimed to identify the association between medical graduates’ job choices for rural practice and their initial intentions when they began to look for a job in China. Data were extracted from a cross-sectional survey among medical students in ten western provinces in China in 2013. Only medical students who were in the last year of study (i.e., medical graduates) and had found a job were included in this study. Of the 482 participants, 61.04% (293) presented an initial intention of rural practice when they began to look for a job, and 68.88% (332) made a final job choice for rural practice. However, of the 332 graduates with a final job choice of rural practice, only 213 (64.55%) had an initial intention. A univariate association was identified in which medical graduates who were more likely to make final job choices for rural practice were those having initial intentions (OR: 1.59; 95% CI: 1.08–2.36); however, after adjusting for controlled variables, it became insignificant and was reduced to a 1.31-fold increase (95% CI: 0.82–2.07). The initial intentions of medical graduates are not assurance of ultimate job outcomes, and it cannot be deduced that all medical graduates who made a final job choice for rural practice had authentic desires for rural practice. Twenty years of age or below, low-income families, majoring in non-clinical medicine, and studying in a junior medical college or below were associated with medical graduates’ final job choices for rural practice. More studies are required on how to translate medical student’s intention of rural medical practice into reality and how to retain these graduates via a job choice in rural practice in the future.

Building Clinical Clerkships Capacity in a Resource-limited Setting: The Case of the Kilimanjaro Christian Medical University College in Tanzania

BACKGROUND

The shortage of medical doctors in sub-Saharan Africa (SSA) has resulted in increased enrolment in medical schools, which has not been matched with increased faculty size or physical infrastructure. This process has led to overcrowding and possibly reduced quality of training. To reduce overcrowding at its teaching hospital, the Kilimanjaro Christian Medical University College introduced eight-week peripheral clerkship rotations in 2012. We explore students' perceptions and attitudes towards peripheral hospital placements.

METHOD

The clerkship rotations were conducted in eight hospitals operating in the northern Tanzania, after evaluating each hospitals' capabilities and establishing the optimum number of students per hospital. Paper-based surveys were conducted after student rotations from 2014 to 2016.

RESULTS

Overall student satisfaction was moderate (strength of consensus measure (sCns), 77%). The three cohorts exhibited improving trends over three years with respect to satisfaction with clinical skills and attitude towards placements. student-preceptor interaction was rated highly (sCns 81-84%). The first cohort students expressed concerns about limited laboratory support, and poor access to Internet and learning resources. Specific interventions were undertaken to address these concerns.

CONCLUSIONS

Student experiences in peripheral rotations were positive with adequate satisfaction levels. Opportunities exist for medical schools in SSA to enhance clinical training and relieve overcrowding through peripheral clerkship rotations.

Association between rural clinical clerkship and medical students' intentions to choose rural medical work after graduation: A cross-sectional study in western China

Background

A large number of programs have been implemented in many countries to increase the healthcare workforce recruitment in rural and remote areas. Rural early exposure programs for medical students have been shown to be effective strategies. However, no related studies have been reported before in China. This study was carried out to determine the association between medical students’ participation in rural clinical clerkships and their intentions to choose rural medical work after graduation from western medical schools in China.

Methods

Based on a two-stage random sampling method, the cross-sectional survey was carried out in ten western provinces in China. A brief questionnaire filled in by medical students was used for data collection. A total of 4278 medical students participated in the study. The response rate was approximately 90.34%. Pearson’s chi-squared tests and binary logistic regression analyses were performed for data analyses.

Results

Approximately 52.0% of medical students disclosed intentions to work in rural medical institutions after graduation. Only one in five participants had experience with a rural clinical clerkship. Rural clinical clerkships were significantly associated with medical students’ intentions to work in rural medical institutions (OR: 1.24, 95%CI: 1.05–1.46); further analyses indicated that such clerkships only had a significant impact among the medical students with an urban background (OR: 2.10, 95%CI: 1.48–2.97). In terms of the sociodemographic characteristics, younger age, low level of parental education, majoring in general practice, and studying in low-level medical schools increased the odds of having intentions to engage in rural medical work among medical students; however, rural origins was the only positive univariate predictor. In addition, the predictors of intentions to choose rural medical work were different between medical students with a rural background and those with an urban background.

Conclusions

Rural clinical clerkship is likely to increase the odds of having intentions to work in rural medical institutions after graduation among medical students in western China, especially for those with an urban background. Related policy makers could consider developing compulsory rural clerkship programs and implement them among medical students to increase early rural exposure.

Career Choices of Medical doctors at Graduate level - A Multicenter Study

Objective:

To find out the specialty choices being taken by Final year Medical students and graduate Doctors.

Method:

This is a cross sectional survey study which was conducted over two months from 1^st November to 31^st December 2016. Final year students and house job doctors were asked for the filling of Performa, after filling the consent form. A self-developed, anonymous questionnaire was used to conduct the study using close ended type of questions. This was a multi-center study conducted at Dow International Medical College and Jinnah Medical and Dental College. An IRB approval was taken for the study. A total of 317 individuals completed the Performa. Demaographic data included information regarding the year of passing, number of family members already in the medical profession, then specific questions were asked regarding their future career choice and the reason for choosing that particular speciality. After collection of data from both the centers a single operator entered the Data on SPSS 16 version. Frequencies and chi-square test were performed and p-valves were tabulated.

Results:

A total of 317 individuals completed the Performa. Two hundred and nine participants (65.9%) were females and one hundred and eight (34.1%) were male participants. The age ranged from 22-29 years mean of 25.15 and SD of 1.348. One hundred and twenty one (38%) had a family member as a doctor in the family. Medicine and allied was the most sought after specialty 184(58%), followed by surgery and allied in 108(34%). Non-Clinical Specialty such as radiology, basic sciences was taken up by 27(7.9%).

Conclusion:

The working hours followed by passion for the chosen field were the important reasons for selecting any specialty. The next most important reason was higher income and other family responsibilities of an individual. The ladies are opting more for fields with a controllable life style.

Specialty preferences among medical students in Botswana

Background

With the establishment of a new medical college in Botswana to train generalist-doctors and specialists, we set out to explore the career preferences of medical students, factors that influence their choices and attitude to local postgraduate training.

Methods

A descriptive cross-sectional questionnaire-based study was conducted among medical students in their third to fifth year, at the Faculty of Medicine, University of Botswana. The structured, self-administered questionnaires which were hand-delivered covered demographic characteristics of responders, career choices, preferred location of specialisation and factors that influenced the choices.

Results

Of the 143 medical students approached, 116 (81.0%) returned completed questionnaires. Of the responders, 102 (87.9%) intend to pursue postgraduate specialisation against 2 (1.7%) who declined; 12 (10.3%) were undecided. The four most preferred specialties which constituted 68.1% were surgery (28.4%), paediatrics (19.0%), internal medicine (12.9%), obstetrics and gynaecology (7.2%). There was male preference for surgery (p = 0.04), while women were drawn more towards paediatrics and psychiatry (p = 0.04 and p = 0.01, respectively). Personal interest and aptitude was considered the most important factor among most responders (46.2%), followed by enjoyment of the posting (19.8%). A high proportion of responders 80 (69.0%) preferred to specialise abroad for better exposure/opportunities (48.3%), while for 15.5%, their preferred courses are not currently available locally.

Conclusion

Our findings indicated that while four major specialties are preferred, significant gender differences exist with female students leaning towards non-surgical disciplines. Students prefer specialising abroad on the pretext that foreign centres offer better training opportunities, and many specialist programmes are unavailable locally.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2523-y) contains supplementary material, which is available to authorized users.

Factors influencing medical students' motivation to practise in rural areas in low-income and middle-income countries: a systematic review

OBJECTIVES

There is a shortage of doctors working in rural areas all over the world, especially in low-income and middle-income countries. The choice to practise medicine in a rural area is influenced by many factors. Motivation developed as a medical student is one key determinant of this choice. This study explores influences on medical students' motivation to practise in rural areas of low-income and middle-income countries following graduation.

DESIGN

A systematic review was conducted to identify influences on medical students' motivation to work in rural areas in low-income and middle-income countries. Papers reporting influences on motivation were included, and content analysis was conducted to select the articles. Articles not published in English were excluded from this review.

RESULTS

A rural background (ie, being brought up in a rural area), training in rural areas with a community-based curriculum, early exposure to the community during medical training and rural location of medical school motivate medical students to work in rural areas. Perceived lack of infrastructure, high workload, poor hospital management and isolation are among the health facility factors that demotivate medical students for medical practice in rural areas.

CONCLUSIONS

Medical school selection criteria focusing on a rural background factor and medical education curriculum focusing on rural area are more relevant factors in low-income and middle-income countries. The factors identified in this review may assist the planners, medical educators and policymakers in low-income and middle-income countries in designing relevant interventions to positively influence rural choices where the shortage of rural physicians is an ongoing and increasing concern.