Challenges to the Israeli healthcare system: attracting medical students to primary care and to the periphery

Challenges to the Israeli healthcare system: attracting medical students to primary care and to... Background: The greatest challenges facing healthcare systems include ensuring a sufficient supply of primary care physicians and physicians willing to work in rural or peripheral areas. Especially challenging is enticing young physicians to practice primary care in rural/peripheral areas. Identifying medical students interested in primary care and in residencies in Israel’s periphery should aid the healthcare leadership. It may be particularly importanttodosoduringtheclinical years, as this is the stage at which many future physicians begin to crystallize their specialty and location preferences. Methods: Questionnaires, distributed to 6 consecutive 5th-year classes of the Hebrew University – Hadassah School of Medicine, from 2010 to 2016, elicited information on criteria for choosing a career specialty, criteria for choosing a residency program and whether one-time monetary grants authorized in the 2011 physicians’ union contract would attract students to residencies in the periphery. Results: Completed questionnaires were returned by 511 of 740 (69%) students. Ninety-eight (19%) were interested in a primary care residency, 184 (36%) were unsure and 229 (45%) were not interested. Students interested in primary care were significantly less interested in specialties that perform procedures/surgeries and in joining a medical school faculty, while being more inclined towards specialties dealing with social problems, controllable lifestyles and working limited hours. The percentage of students interested in primary care was stable during the study period. Forty-eight of the students indicated interest in residencies in the country’s periphery, and 42% of them were also interested in primary care residencies. Overall, only 3.7% of students were interested in both a primary care residency and a residency in the periphery. Thirty percent of the students indicated that the monetary incentives tempted them to consider a residency in the periphery. Fifty-three percent of these students reported that they did not yet know the geographic area where they wished to do their residency, as compared to only 22% among those not interested in incentives. (Continued on next page) * Correspondence: charles@hadassah.org.il Department of Anesthesiology and Critical Care Medicine, Hadassah-Hebrew University Medical Center, Hebrew University – Hadassah School of Medicine, Kiryat Hadassah, POB 12000, 91120 Jerusalem, Israel Full list of author information is available at the end of the article © The Author(s). 2018 Open Access 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. Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 2 of 17 (Continued from previous page) Conclusions: This study provides the healthcare leadership with information on the characteristics of the students at a centrally-located medical school who tend to be more interested in primary care and in working in the periphery. Specifically, the study found that students interested in primary care desire a positive life/work balance, something that Israeli non-hospital primary care practice provides. Students considering residencies in the periphery were similarly inclined. Moreover, about a third of students had positive thoughts about monetary incentivesfor residenciesinperipheral hospitals. These students should be identified early during their clinical experience so that attempts to recruit them to the periphery can commence before their specialty and location preferences have fully crystallized. Parallel studies should be performed at additional Israeli medical schools. Keywords: Medical students, Medical education, Residency, Medical specialty selection, Career choice Background specialists and pediatricians, especially in the county’s The greatest challenges facing healthcare systems in- peripheral areas. This shortage is predicted to clude providing sufficient numbers of primary care increase as the population grows, ages, and life spans and rural physicians [1]. Especially challenging is en- lengthen. Furthermore, the primary care physician ticing young physicians to establish primary care population is aging as many physicians who emigrated practices in rural areas [1, 2]. Among the counties from the former Soviet Union in the 1990’sare reach- where such challenges exist are the United States, ing retirement age [8]. Therefore, it is necessary to at- Australia and Canada [1, 3, 4]. Israel suffers from a tract more medical students to primary care similar problem with shortages of family medicine residencies. To increase recruitment it is important specialists in peripheral areas of the country. The lat- that the medical education and healthcare system ter include the northern and southern regions of the leadership better understand the characteristics of stu- country which encompass the majority of the dents interested in pursuing primary care and how county’s rural districts. These areas chronically suffer they differ from those without such interests. The from physician shortages, greater infant mortality and leadership needs similar information on students in- lowerlifeexpectancy than the rest of thecountry terested in residency positions in the county’s [5]. In an attempt to remedy this maldistribution, the periphery. physicians’ union contract of 2011 included both pay The present study compared the characteristics of increases for practicing in the periphery and one- Israeli 5th-year (out of 6 years) medical students time monetary incentives for moving and committing interested in primary care residencies and residencies to work in the periphery [6, 7]. This programs also in peripheral areas with those without such interests. provided incentives for medical students interested in The dataset used was collected over a 6-year period residencies in specialties suffering workforce short- from a single Israeli medical school and includes over ages. The original program excluded family medicine 500 students. The two hypotheses tested were that residentsfromboththe incentivesfor workin the the student interest in primary care would be greater periphery and the incentives to work in distressed among women medical students and that interest in specialties. However, in 2015 the Israel Ministry of Health residencies in peripheral areas would be greater began to provide financial incentives to family medicine among students who attended high school in the residents willing to train in peripheral areas. northern and southern regions. We also explored The Israeli healthcare system is dependent on whether the one-time monetary grants approved in primary care physicians to provide comprehensive the 2011 physicians’ union contract would encourage out-patient care and to serve along with community spe- students to consider a residency in a peripheral hospital. cialists and internal Health Maintenance Organization The ultimate goal was to provide the medical education regulations and pre-authorization systems as gate- and healthcare leaderships with the attributes that typify keepers for secondary and tertiary care. These students interested in primary care and/or rural practice. primary care physicians, family medicine specialists, Fifth-year students were studied since our previous study pediatricians, internists and general practitioners, are revealed that most had already begun the process of based in health maintenance organization clinics. deciding on a specialty [9]. In order for the healthcare Despite family medicine and pediatrics being popular leadership to influence specialty decisions, it is important specialties among Israeli medical students, there is to be cognizant of the thought patterns of the students still a nationwide shortage of family medicine early in their decision process. Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 3 of 17 Methods included the two points representing positive This study included students from 6 consecutive tendencies; Group 2 included the neutral point; and 5th-year classes of the Hebrew University – Hadassah Group 3 the two points representing negative School of Medicine in Jerusalem (2010–2016). It tendencies. This permitted us to compare students utilized a questionnaire to examine various aspects interested and not interested in a primary care resi- of the medical specialty selection process. The ques- dency, while also examining those who were unsure. tionnaire was based on the results of factor analysis The results from each of the 6 school-years were from a questionnaire used previously [9]. This per- compared to determine whether there were differ- mitted us to reduce repeat Likert scale questions ences between years. thus providing space for new ones that investigated additional issues. Among the new topics examined were the influence of family and colleagues on specialty Rural (periphery) workforce and residency program decisions as well as the interests of Initial data analysis showed that a significant number thestudentsinacademicpursuits. Thequestionnaire of students interested in primary care were inter- included multiple choice questions, free-text queries ested in a residency in the county’s periphery. There- and 5-point Likert scales. In addition to demographic fore, a post-hoc examination was made of the information, the questionnaire elicited information characteristics of students interested in a residency about: (1) Whether the student had already consid- in the country’s periphery. The dataset was divided ered a specialty for their residency, which specialty or into two groups based on the answer to the 5-point specialties they were considering (free-text), when Likert scale question: “Are you interested in a resi- they had first considered a specialty and whether and dency in the country’speriphery?” Group A included when (prior to beginning medical school or when the two points representing positive tendencies while during the first 5 years of medical school) they had Group B included the two points representing nega- changed their mind; (2) The criteria for choosing a tive tendencies. career specialty {20 items, 10 new, 5-point Likert scale}; (3) The criteria for choosing a residency pro- gram {20 items, 9 new, 5-point Likert scale}; and (4) The importance of interest in a specific specialty Incentives when choosing a residency {3 new items, multiple The data set was divided into three groups as per the choice}. (5) Whether the one-time monetary grants responses to the multiple- choice query “As the result authorized in the 2011 physicians’ union contract of the union contract of 2011, residents in peripheral would attract them to a residency in a peripheral hospitals receive a one-time monetary incentive and hospital (1 new item, final 4 classes). higher salaries: (1) These incentives attract me to a After two small (15 students) preliminary studies residency in the periphery (2) I already plan to do a designed to identify problems and test the question- residencyintheperiphery(3) Theincentivesdonot naire’s user-friendliness, the questionnaires were attract me to a residency in the periphery”.The distributed to the 5th year classes of the Hebrew differences between the characteristics of the three University – Hadassah School of Medicine in groups were determined. Jerusalem during the 2010–2011, 2011–2012, 2012– Based on prior research demonstrating significant 2013, 2013–2014, 2014–2015 and 2015–2016 school- gender differences associated with specialty selection years. A parallel article examining medical student an a priori decision was made to separately analyze subgroups also utilized this dataset [10]. and compare the male and female data [11]. Responses to multiple choice questions are pre- sented as frequency distributions. When the Likert Data analysis Scale results were considered continuous variables, Data were entered into Microsoft Excel (Redmond, WA) statistical analyses were performed using all 5 points. spreadsheets and analyses were performed with Systat When presented as categorical variables the Likert 12 (San Jose CA). Scale results were compressed into three categories, (the two points representing negative tendencies and the two points representing positive tendencies were Primary care each combined). The percentages of total responses The dataset was divided into three groups based on for each of the three categories (positive tendency, the answer to the 5-point Likert scale question: “Are middle point and negative tendency) were then you interested in a primary care residency?” Group 1 computed. Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 4 of 17 For continuous data, differences between the groups primary care. Among the latter, none were consider- were analyzed using analysis of variance with Tukey ing family medicine (Table 1). post-hoc tests. Categorical data were analyzed using As can be seen in Tables 1 and 2 (Appendix A), χ or Fisher exact tests, as appropriate. A p value < 0. there was similar interest in a primary care residency 05 was assumed to represent statistical significance. between female (17%) and male (21%) students. Com- Univariate linear regression analysis was used to parisons between men and women students interested examine the association between the answers to two in primary care showed that women rated lifestyle is- queries. Backward multivariate and logistic regression sues, such as family time, more highly than men and analyses were performed with the dependent variable were more interested in pediatrics (Tables 1 and 2, being either interest in a residency in primary care or Appendix A). a peripheral hospital. The independent variables were the demographic parameters and specialty and resident selection criteria. Rural (periphery) workforce Criteria for specialty and residency program Differences between students expressing and not selection were subjected to factor analysis (principal interested in a residency in the country’s periphery are components analysis) using varimax rotation with set found in Table 4 (Appendix B). Results of multivariate eigenvalues of ≥1.0. Thedatawerealsoanalyzedwith and logistic regression analyses are in Table 3. hierarchal cluster analysis. Interactions between the replies to the questions The Institutional Review Board of the Hadassah “Are you interested in a residency in the country’s Medical Organization approved this study. Completion periphery?” and “Are you interested in a primary care of the questionnaire by the student was considered tacit residency?” revealed that 4% of all the students were consent. interested in both a primary care residency and a residency in the periphery (Appendix C). Results Incentives Completed questionnaires were returned by 511 of 740 Responses to the query about monetary incentives (69%) 5th-year medical students. for a residency in peripheral hospitals are in Tables 5 (Appendix D). Thirty percent of the students reported that the incentives interested them, while Primary care another 6% had already decided to do a residency in Ninety-eight (19%) students were interested in the periphery. The relationships between the pursuing a primary care residency, 184 (36%) were responses to this question and those to the query unsure and 229 (45%) were not interested. Demo- “are you interested in a residency in the country’s graphic information is found in Table 1. Interest in periphery?” revealed that 82% of the students who primary care among 5th-year students was stable replied they were not attracted by the incentives over the 6-year study period ranging from 17%–21% indicated that they were not interested in a residency annually. in the periphery while those that reported that the Compared to students not interested in primary incentives interested them showed less aversion (20% care, those interested in primary care were signifi- negative tendency and 54% positive tendency) to a cantly less interested in a specialty with procedures/ residency in the periphery. surgeries and becoming “members of a medical school faculty”, while being more inclined towards a specialty dealing with social problems (Tables 2 and 3). When Discussion choosing a residency program, students attracted to The present study identified several medical student primary care were more interested than their characteristics associated with interest in a primary care colleagues in a residency in the country’s periphery. residency and those interested in a residency in the per- Alternately, 42% of the 48 students who indicated iphery among 5th year students at the Hadassah-Hebrew interest in a residency program in the country’s University Medical School. periphery were also interested in a primary care residency (Table 2). When asked about specialties they were considering, students interested in primary Primary care care expressed significantly more interest in family There were many differences between 5th-year Israeli medicine and pediatrics than those not interested in medical students interested and not interested in a Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 5 of 17 Table 1 Primary care - demographic and other information Primary Undecided No primary Primary care vs Primary care Females care care no primary care vs males Females Males N 98 184 229 41 57 Female 42% 51% 49% Male 58% 50% 51% NS Age (years) 18–20 0% 0% 0.4% 0% 0% 21–23 25% 14% 17% 27% 23% 24–26 19% 31% 29% 34% 9% 27–29 37% 42% 39% 27% 44% 30–32 14% 10% 12% 10% 18% +32 5% 4% 3% NS 2% 7% p < 0.01 Marital status Single 70% 63% 73% 66% 72% Married 30% 36% 26. % 34% 26% Divorced 1% 1% 0.4% NS 0% 2% NS Thought of a specialty when started Yes 85% 79% 82% 85% 84% No 15% 21% 18% NS 15% 16% NS When did you start thinking of a specialty? Pre - med school 25% 29% 26% 27% 23% Year 1 4% 4% 4% 6% 2% Year 2 4% 4% 2% 3% 4% Year 3 4% 3% 5% 0% 6% Year 4 56% 42% 48% 62% 51% Year 5 9% 19% 16% NS 3% 13% NS Have you changed your mind? Yes 61% 59% 63% 59% 62% No 40% 41% 38% NS 41% 38% NS When did you change your mind? Year 1 0% 0% 2% 0% 0% Year 2 0% 3% 1% 0% 0% Year 3 2% 1% 2% 0% 4% Year 4 41% 44% 42% 35% 46% Year 5 57% 52% 54% NS 65% 50% NS Specialties under consideration Family medicine 16% 2% 0% 14% 17% Pediatrics 41% 42% 24% 54% 30% Internal med 26% 30% 32% 26% 26% Ob/Gyn 19% 20% 22% 34% 7% Emergency med 4% 0% 2% 0% 7% Surgical* 20% 31% 31% 9% 30% Other 22% 44% 39% p < 0.01 20% 30% p < 0.01 High school location Israel 97% 97% 96% 95% 98% Other 3% 3% 4% NS 5% 2% NS High school location in israel Jerusalem 32% 25% 23% 26% 36% Central 29% 37% 44% 31% 29% North 26% 28% 23% 33% 21% South 13% 9% 10% 10% 14% Other 0% 1% 1% NS 0% 0% NS Future residency location Israel 98% 98% 99% 97% 98% Other 2% 2% 1% NS 3% 2% NS Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 6 of 17 Table 1 Primary care - demographic and other information (Continued) Primary Undecided No primary Primary care vs Primary care Females care care no primary care vs males Females Males Perferred residency location in Israel Jerusalem 28% 18% 23% 23% 31% Central 22% 32% 34% 13% 29% North 17% 11% 9% 23% 12% South 1% 1% 2% 3% 0% Don’t know 33% 39% 32% p < 0.05 39% 29% p < 0.01 *Surgical specialties primary care residency. Students inclined toward male students. Students inclined toward primary care primary care were more interested in lifestyle: spend- were less interested in academic pursuits, such as ing time with their families, working limited hours being academic faculty members. Reduced interest in and working only during the daytime. This import- academic activities was also observed among ance of lifestyle was more pronounced in female than Japanese medical students with preferences for Table 2 Primary care - selection criteria Primary Undecided No primary Primary care vs Primary care Females vs males care care no primary Females Males N 98 184 229 41 57 98 Criteria for choosing a specialty Time with family (1) 76% 73% 65% p < 0.03 85% 68% p < 0.05 Specialty with team work 57% 54% 45% p < 0.04 56% 58% NS Influence of spouse 43% 43% 31% p < 0.007 49% 39% p < 0.05 Specialty that deals with social issues (3) 42% 35% 22% p < 0.001 51% 35% p < 0.009 Daytime work only (1) 26% 29% 16% p < 0.03 34% 19% p < 0.03 Work only in the community 9% 3% 4% p < 0.001 12% 7% NS Procedures/surgery 43% 41% 57% p < 0.01 34% 49% p < 0.02 High salary 36% 48% 51% p < 0.002 34% 38% NS Opportunity for research (2) 34% 37% 44% p < 0.05 27% 39% NS Academic faculty member 19% 26% 30% p < 0.05 24% 16% NS Criteria for choosing a residency Much supervision by senior physicians 53% 45% 37% p < 0.001 68% 42% p < 0.04 Limited work hours 29% 30% 17% p < 0.001 33% 27% NS Short residency (<4.5. years) 28% 15% 12% p < 0.001 29% 26% NS Much clinic time (2) 23% 16% 5% p < 0.001 20% 25% NS Hospital in the periphery (3) 19% 7% 6% p < 0.001 20% 19% NS Leading department (1) 67% 77% 79% p < 0.03 71% 65% NS Large hospitial 52% 55% 62% p < 0.04 59% 47% NS Family living location 78% 75% 64% NS 88% 70% p < 0.05 Making clinical decisions on your own 66% 50% 55% NS 56% 74% p < 0.05 Pre-determined work hours (2) 47% 48% 35% NS 59% 39% p < 0.05 Influence of family 42% 37% 31% NS 54% 33% p < 0.01 Many on-call shifts 10% 11% 12% NS 5% 14% p < 0.03 Percent of "agree" and "agree much" responses on 5-point Likert Scale Numbers in parenthesis are the results of factor analysis clusters per cluster analysis Bold result indicates the higher value in a statistically significant pair Weissman et al. Israel Journal of Health Policy Research _#####################_ Page 7 of 17 Table 3 Regression analysis Demographics/criteria Multivariable Backward Backward logistic regression regression p Odds ratio 95% confidence limits P coefficient Interest in a primary care residency r = 0.43 Male gender 0.264 0.015 2.251 1.195–4.241 0.012 Criteria for choosing a specialty Opportunity for research −0.096 0.033 0.755 0.578–0.987 0.04 High salary −0.207 0.002 0.580 0.376–0.893 0.013 Influency of spouse 0.122 0.018 Specialty that deals with social issues 0.146 0.004 1.442 1.079–1.927 0.013 Work only in the community 0.278 0.001 Wide range of medical problems 1.512 1.004–2.277 0.048 Criteria for choosing a residency program r = 0.45 Leading department −0.125 0.053 0.581 0.395–0.854 0.006 Influence of family 0.094 0.026 1.414 1.083–1.847 0.011 Short residency (< 4.5 years) 0.159 0.001 1.524 1.122–2.069 0.007 Peripheral hospital 0.188 0.001 Much supervision by senior physicians 0.202 0.001 1.836 1.340–2.515 0.001 Much clinic time 0.207 0.001 1.495 1.110–2.013 0.008 Interest in a residency in a peripheral hospital r = 0.43 Older age 0.157 0.004 1.732 1.144–2.621 0.009 Have considered a specialty −0.234 0.048 High school location (periphery) 0.138 0.002 1.546 1.089–2.193 0.015 Criteria for choosing a specialty Wide range of medical problems 0.144 0.008 Time with family 0.145 0.009 1.686 1.001–2.839 0.049 Work only in the community 0.178 0.002 1.701 1.147–2.524 0.008 Influence of spouse 1.488 1.019–2.173 0.039 Private practice −0.109 0.012 Specialty that deals with social issues 0.123 0.003 Narrow range of medical problems 0.298 0.001 2.156 1.377–3.376 0.001 Criteria for choosing a residency program r = 0.52 Specific location in Israel −0.106 0.031 Leading department −0.280 0.001 0.480 0.091–0.791 0.004 Limited work hours 0.108 0.031 Family living location 0.115 0.046 Many on-call shifts 0.121 0.011 Teaching students 0.144 0.001 1.563 1.061–2.304 0.024 Physical challenge 0.157 0.001 Primary care 0.168 0.002 Much clinic time 0.198 0.003 1.893 1.288–2.783 0.001 Much supervision by senior physicians 0.045 1.010–2.455 0.045 Influence of family 1.430 1.030–1.986 0.022 Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 8 of 17 Table 3 Regression analysis (Continued) Demographics/criteria Multivariable Backward Backward logistic regression regression p Odds ratio 95% confidence limits P coefficient Monetary incentives for residency in the periphery r - 0.58 Opportunity for research −0.126 0.047 0.580 0.360–0.933 0.025 Specialty advancing rapidly −0.143 0.022 0.620 0.393–0.90 0.041 Specific location −0.204 0.001 0.428 0.275–0.667 0.001 Primary care 0.115 0.023 Specialty that deals with social issues 0.126 0.008 1.530 1.044–2.242 0.029 Peripheral hospital 0.258 0.001 2.835 1.782–4.511 0.001 family medicine [12]. Lack of interest in academic entering general internal medicine and pediatric endeavors is problematic since it reduces the number practices [17]. The major reasons cited for the dearth of family medicine faculty members able to serve as of students entering primary care in the United medical student mentors. This lack of mentors might States are relatively low incomes in the face of high decrease the ability to attract students to the student debt burdens, many administrative tasks and specialty. time pressures [16]. Many medical schools have in- It is important to note that the query on the stituted programs to attract more students to pri- questionnaire was about the broader area of primary mary care, with a multi-year exposure to primary care and not specifically about family medicine. care being more successful than adding a single pri- Unlike aprevious studywherewefound afemale- mary care course to a conventional curriculum [18]. predominance among 6th year Israeli medical Other countries face similar problems. In Vietnam students interested in family medicine, in the present less than a third of commune (collective farming study we did not find such predominance [13]. communities) health stations are staffed by a phys- Furthermore, the proportion of women medical ician even though the number of medical school students interested and not interested in primary care graduates almost tripled between 2004 and 2011 was comparable. Similarly, upon multiple regression [19]. The reasons include poor working conditions, analysis, interest in primary care was not associated low income and lack of opportunities for career de- with being female. We thus failed to prove our velopment [19]. In a survey of 9499 South Korean hypothesis that interest in primary care would be medical students only 2.2% expressed interest in greater among women than men medical students. family medicine [20]. This variance with our previous studies is attributable Shortages of primary care physicians are generally to primary care incorporating general internal attributed to low salaries, lack of prestige and medicine, general pediatrics and some aspects of ob- glamor; long hours with frequent on-call responsibil- stetrics/gynecology, in addition to family medicine. ities; and lack of a controllable lifestyle [21, 22]. The We previously found that In Israel, internal medicine situation in Israel differs from other countries in that and obstetrics/gynecology residencies attract many primary care physicians mainly work in health main- male students [13]. When asked which specialties tenance clinics, receive salaries comparable to other they were considering, students interested in primary physicians, have few on-call obligations and have set care listed pediatrics and internal medicine more fre- hours [8]. This was reflected in our previous study quently than family medicine. where Israeli 6th-year students rated family medicine In many countries, attracting medical students to and pediatrics as specialties with controllable life- primary care careers is a daunting task [14]. The styles and positive relationships between controllable reasons for this difficulty differ between countries lifestyle and remuneration [13]. This was also found [15]. In the United States, the proportion of medical in the present study, wherecompared to 5th-year students selecting primary care specialties dropped students not interested in primary care, those inter- from 73% in 1996 to 44% in 2008, although subse- ested in primary care wanted a specialty with time quently there has been some stabilization [16]. More- for family involving only daytime work and practice over, more internal medicine and pediatric residents in the community (i.e. outside the hospital). This are choosing to subspecialize, reducing the numbers interest profile was similarly demonstrated by their Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 9 of 17 Table 4 Residency in a peripheral hospital Table 4 Residency in a peripheral hospital (Continued) Periphery No Periphery Periphery No Periphery periphery vs no periphery vs no Periphery Periphery N 48 382 Work only in the 19% 3% p < 0.001 community Gender Female 45% 48% Narrow range of 10% 2% p < 0.001 Male 55% 52% NS medical problems Age (years) 18–20 0% 0.3% Advancing rapidly 48% 62% p < 0.05 21–23 17% 18% Opportunity for 29% 41% p < 0.03 research 24–26 19% 30% Criteria for choosing a residency program 27–29 42% 39% Family living location 81% 69% p < 0.04 30–32 17% 10% Teaching students 57% 40% p < 0.05 +32 6% 3% NS Pre-determined work 56% 41% p < 0.05 Marital status Single 63% 71% hours Married 38% 29% Influence of family 52% 33% p < 0.02 Divorced 0% 1% NS Much supervision 50% 42% p < 0.03 High school location Israel 100% 97% bysenior physicians Other 0% 3% NS Primary care 42% 15% p < 0.0004 High school location in Jerusalem 17% 27% Limited work hours 42% 21% p < 0.03 Israel Central 31% 42% Much clinic time 33% 8% p < 0.001 North 38% 22% Leading department 58% 79% p < 0.0001 South 15% 8% Large hosptial 47% 60% p < 0.003 Other 0% 1% p < 0.05 Percent of “agree” and “agree much” responses on 5-point Likert Scale Residency location Israel 100% 98% Other 0% 2% NS greater interest in short (in years) residency programs Future residency location Jerusalem 13% 26% in Israel with limited hours and with much time spent in Central 16% 36% clinics. This grouping of interests indicates a desire North 40% 7% for positive life/work balance, something that Israeli South 13% 1% non-hospital primary care practice provides. A recent Don’t know 18% 31% p < 0.01 study of Israeli family medicine residents reported Specialties under Family 0% 2% similar findings. Specifically, more than 85% of resi- consideration medicne dents reported that factors that positively influence Pediatrics 46% 30% their choice included the ability to combine work, family, and free time; direct, meaningful contact with Internal 24% 32% medicine patients; the diversity of patients and medical condi- Ob/Gyn 15% 21% tions; and attractive working conditions [23]. This interest profile is similar to those reported from other Emergency 5% 1% medicine countries among students interested in primary care and family medicine [12, 24]. However, primary care Surgical 32% 30% specialties in isolated Israeli rural village has been reported to Other 32% 35% p < 0.05 lead to unclear boundaries between private life and specialties physician roles leading to problems with life/work Criteria for choosing a specialty balance [25]. This may be among the reasons for the shortage of primary care practitioners in the country’s Time with family 85% 66% p < 0.001 periphery. Controllable lifestyle 75% 65% p < 0.04 Influency of spouse 56% 37% p < 0.01 Specialty that deals 46% 27% p < 0.004 Rural (periphery) workforce with social issues Worldwide, rural areas often suffer physician short- ages. Therefore, in many countries with large rural Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 10 of 17 Table 5 Incentives - residency in periphery 1. Incentive 2. Plan peripheral 3. Incentives don’t 1vs3 1 vs2 2vs 3 interests me residency interest me N 106 20 223 Percent 30% 6% 64% Gender Female 48% 47% 50% Male 52% 53% 50% NS NS NS Age (years) 18–20 0% 0% 0% 21–23 22% 20% 19% 24–26 27% 15% 31% 27–29 36% 50% 35% 30–32 10% 10% 11% +32 5% 5% 3% NS NS p < 0.02 Marital status Single 68% 60% 72% Married 30% 40% 27% Divorced 2% 0% 1% NS p< 0.05 p < 0.02 High school location in Israel Jerusalem 27% 5% 25% Central 36% 32% 40% South 10% 26% 10% Other 1% 0% 1% NS p < 0.01 NS Future residency location in Israel Jerusalem 14% 10% 29% Central 20% 0% 41% North 14% 55% 8% South 0% 20% 1% Don’t know 53% 15% 22% p< 0.03 p < 0.01 p< 0.01 Specialties under consideration Pediatrics 39% 31% 31% Internal medicine 21% 6% 35% Ob/Gyn 29% 19% 15% Emergency medicine 0% 13% 1% Surgical specialties 32% 31% 29% Other specialties 31% 31% 37% p < 0.04 p < 0.01 p < 0.02 Criteria for choosing a specialty Time with family (1) 78% 60% 63% p < 0.004 p < 0.04 NS Specialty that deals with social issues (3) 35% 35% 25% p < 0.02 NS NS Advancing rapidly (2) 51% 45% 69% p < 0.0007 NS p < 0.04 Opportunity for research (2) 29% 5% 47% p < 0.0001 p < 0.04 p < 0.0001 Controllable lifestyle (1) 74% 50% 66% NS NS NS Independent practice 54% 40% 51% NS p < 0.03 p < 0.03 High salary 51% 20% 45% NS p < 0.006 p < 0.01 Procedures/surgery 45% 32% 51% NS NS p < 0.04 Private practice 37% 10% 404% NS p < 0.008 p < 0.009 Criteria for choosing a residency Controllable lifestyle 73% 45% 58% p < 0.04 p < 0.03 NS Primary care 27% 32% 15% p < 0.001 NS p < 0.002 Hospital in the periphery (3) 8% 55% 4% p < 0.001 p < 0.0007 p < 0.001 Intellectual challenge (1) 8% 60% 87% p < 0.004 NS p < 0.007 Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 11 of 17 Table 5 Incentives - residency in periphery (Continued) 1. Incentive 2. Plan peripheral 3. Incentives don’t 1vs3 1 vs2 2vs 3 interests me residency interest me Leading department (1) 69% 45% 85% p < 0.0002 p < 0.004 p < 0.0009 Specific location 51% 68% 70% p < 0.0001 NS NS Large hospitial 50% 26% 68% p < 0.005 p < 0.04 p < 0.0006 Opportunity for research 17% 5% 29% p < 0.02 p < 0.01 p < 0.0005 Much supervision by senior physicians 44% 20% 46% NS NS p < 0.04 Percent of “agree” and “agree much” responses on 5-point Likert Scale Numbers in parenthesis are the results of factor analysis Clusters per cluster analysis Bold result indicares the higher value in a statistically significant pair areas, such as the United States, Canada and the periphery”, 63% had gone to high school in the Australia, emphasis has been placed on encouraging northern or southern areas. Therefore, we confirmed more medical students to become rural primary care the hypothesis that interest in residencies in periph- physicians [26, 27]. To attract students to rural areas, eral areas is greater among students who attended medical schools have programs that expose students high school in peripheral regions. Similar observa- to rural practice and have increased the recruitment tions were made in Kenya, United States, Japan and of students from rural areas [28]. The current study Australia where students of rural origin were more showed that of the more than 500 5th-year Israeli interested in rural practice [2, 11, 28, 29]. These students studied, 8.9% were considering residency in results have potential healthcare policy implications. the country’s periphery. This percentage is greater Firstly, they can contribute to decisions about than that reported in our previous study of 5th year whether to admit more medical school applicants students (4.6%) and might be attributable to the re- residing in the periphery in an attempt to reduce the cent introduction of monetary incentives (one-time shortage of physicians practicing there. Secondly, the grants and salary increases) for physicians choosing to results can also contribute to decisions about train and practice in the periphery. Shortages of rural whether to include rural medicine rotations during physicians frequently includes a lack of primary care the clinical years to provide all students with expos- physicians; a situation also present in Israel. Among ure to such medical practice [30]. students interested in primary care, 19% would The characteristics of students considering a choose a residency in the periphery. Alternately, residencyintheperipheryweresimilar to those among students considering a residency in the periph- interested in a primary care residency. Although this ery, 42% were interested in primary care. This attrac- may be partially attributable to the many students tion to primary care among students interested in interested in a primary care residency, it also likely living in rural areas was also observed among reflects that those interested in residencies in the per- Japanese medical students [29]. However, when we iphery are more interested in life-work balance and examined our overall student sample, only 3.7% of are less interested in a residency in a large hospital the 5th-year students reported interest in both and in a leading department. primary care and peripheral residencies. Regression analysis showed that attending high school in Israel’s south and north was associated with Incentives interest in residency in the same regions. Notably, The last four years of the study provided an oppor- significantly more students interested in residencies tunity to explore the student’s thoughts about the in the periphery reported that the locale of their monetary incentives for rural residency included in family was an important criterion for choosing a the 2011 union contract [7]. Although only 6% were residency program. Furthermore, among students already planning to do a residency in the periphery, who responded to the question concerning the effects 30% indicated that the incentives induced them to of one-time monetary incentives to do a residency in consider a residency there. Fifty-three percent of the the periphery, “Ialreadyplantodoaresidencyin latter students reported that they did not yet know Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 12 of 17 wheretheywishedtodotheir residencyasopposed from such schools [23]. Yet, unlike the foreign to 22% among those not interested in the incentives. graduates who only enter the Israeli healthcare sys- Moreover, there were more differences between the tem as interns, having had exposure to the various two groups. Students interested in the incentives were specialties in foreign healthcare systems during med- more interested in primary care residencies, special- ical school, the Israeli medical students are part of ties dealing with social issues, specialties providing the Israeli healthcare system while they are medical family time and residencies affording controllable life- students providing the Israeli healthcare leadership styles. Alternately, they were less interested in re- the opportunity to directly expose them to Israeli search opportunities, a rapidly advancing specialty primary and rural practices early in their clinical and a residency in a leading department in a large experience. hospital. For medical educators and healthcare leaders A further limitation is that there might be selection these results point to a group with distinct character- criteria that were not included in the questionnaire. istics who might be encouraged to join residency pro- However, both the factor and cluster analyses showed grams in the periphery. The challenge is to better few factors and clusters indicating that a wide-variety characterize this student group, identify them early of topics were queried. during their specialty/residency program decision process and provide positive information and counsel- ing about residency programs and lifestyle in the per- Conclusions iphery. Thirty percent of the residents working in The characteristics of students showing interest in Israel’s periphery reported that the incentives had in- primary care and practice inperipheralareas,that fluenced them greatly, even though initially they had were delineated by this study, should aid department intended to work there [23]. Previous studies have heads and residency program directors in identifying shown that Israeli primary care practitioners in the potential residents. Moreover, the present study re- periphery are more satisfied and had a broader scope vealed that for Israeli medical students the 5th-year is of practice than urban practitioners [29, 31, 32]. an important juncture in their choice of a medical While the aim is to market residency programs in specialty. Eighty percent had already considered vari- the periphery to the students, the results of this ous specialties. Although, about a quarter had begun study show that a third of the students reported that their considerations before beginning medical school, the influence of family was an important part of themajorityhad begunduringtheir 4thand 5th- their residency selection process. Therefore, years. Furthermore, 60% of those who had begun the consideration should be given to including spouses thought process had already changed their minds. in recruitment efforts. Therefore, the 4th and 5th years of medical school appear to be an opportune time to market the various specialties to medical students and might also be the Strengths and limitations time to begin informing them about residency pro- The strength of this study is that the large number of grams. Since the students’ decisions as to specialty students studied allowed us to examine subgroups, and residency program decisions have major influ- such as those interested in primary care. A further ences on the composition and geographic distribution strength was its multi-year design showing that the of the future physician workforce, it is for the health- proportion of students interested in primary care and care leadership to take the initiative and provide the peripheral hospitals remained steady throughout the students with direction, counseling and information study. to help them with their choices. The major limitation is that the study was performed in a single institution that is located in the center of the country and is focused on academic Endnote medicine. Hence the findings are not automatically Our hypothesis is that the findings for the other generalizable to the entire Israeli medical student medical schools will be similar to what we found for population, and parallel studies should be carried out Hebrew University-Hadassah. This is because a) Des- at additional Israeli medical schools. pite its location in the center of the country, the Another limitation is that the study only included Hebrew University- Hadassah Medical School draws Israeli medical students when half the medical in- students from across the country; b) Earlier studies of ternship workforce is comprised of Israeli who grad- family medicine specialty preferences found similar- uated from foreign medical schools and immigrants ities between this medical school and the total for all and 58% of the family medicine residents graduated Israeli medical schools [23]. Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 13 of 17 Appendix A Table 6 Primary care - selection criteria Primary Undecided No primary Primary care vs Primary care Females care care no primary vs males Females Males N 98 184 229 41 Criteria for choosing a specialty Time with family (1) 75.51% 72.68% 65.07% p < 0.03 85.37% 68.42% p < 0.05 Specialty with team work 57.14% 53.80% 44.98% p < 0.04 56.10% 57.89% NS Influence of spouse 42.55% 42.62% 31.14% p < 0.007 48.65% 38.60% p < 0.05 Specialty that deals with social issues (3) 41.84% 34.62% 21.93% p < 0.001 51.22% 35.09% p < 0.009 Daytime work only (1) 25.51% 28.73% 16.23% p < 0.03 34.15% 19.30% p < 0.03 Work only in the community 9.18% 2.73% 3.51% p < 0.001 12.20% 7.02% NS Procedures/surgery 42.86% 40.98% 56.58% p < 0.01 34.15% 49.12% p < 0.02 High salary 36.08% 48.09% 51.09% p < 0.002 34.15% 37.50% NS Opportunity for research (2) 33.67% 37.16% 43.67% p < 0.05 26.83% 38.60% NS Academic faculty member 19.39% 25.68% 30.26% p < 0.05 24.39% 15.79% NS Bedside specialty 93.88% 92.93% 92.07% NS 92.68% 94.74% NS Wide range of medical problems 79.38% 71.04% 68.12% NS 75.61% 82.14% NS Controllable lifestyle (1) 69.39% 73.91% 64.19% NS 78.05% 63.16% NS Advancing rapidly (2) 56.12% 61.41% 58.77% NS 51.22% 59.65% NS Independent practice 51.02% 60.11% 52.40% NS 56.10% 47.37% NS Private practice 39.80% 36.96% 42.48% NS 41.46% 38.60% NS Influence of family 12.37% 9.78% 8.81% NS 15.00% 10.53% NS Specialty that my coleagues choose 2.06% 1.64% 0.00% NS 0.00% 3.57% NS Influence of classmates 2.06% 1.63% 0.44% NS 0.00% 3.57% NS Narrow range of medical problems 2.04% 3.26% 3.49% NS 0.00% 3.51% NS Criteria for choosing a residency Much supervision by senior physicians 53.06% 45.11% 36.68% p < 0.001 68.29% 42.11% p < 0.04 Limited work hours 29.17% 29.89% 16.67% p < 0.001 32.50% 26.79% NS Short residency (< 4.5. Years) 27.55% 15.30% 11.79% p < 0.001 29.27% 26.32% NS Much clinic time (2) 22.45% 16.30% 4.82% p < 0.001 19.51% 24.56% NS Hospital in the periphery (3) 19.39% 6.52% 6.11% p < 0.001 19.51% 19.30% NS Leading department (1) 67.35% 77.17% 79.04% p < 0.03 70.73% 64.91% NS Large hospitial 52.04% 54.64% 61.84% p < 0.04 58.54% 47.37% NS Intellectual challenge (1) 83.67% 82.07% 83.41% NS 87.80% 80.70% NS Family living location 77.55% 74.86% 63.76% NS 87.80% 70.18% p < 0.05 Controllable lifestyle 69.39% 70.49% 60.70% NS 73.17% 66.67% NS Making clinical decisions on your own 66.33% 49.46% 55.02% NS 56.10% 73.68% p < 0.05 Specific location in Israel 65.31% 64.48% 63.88% NS 68.29% 63.16% NS Much “action” 52.04% 33.15% 46.49% NS 51.22% 52.63% NS Pre-determined work hours (2) 46.94% 48.37% 35.37% NS 58.54% 38.60% p < 0.05 Physical challenge 47.96% 36.96% 46.93% NS 41.46% 52.63% NS Teaching students 43.88% 43.48% 43.42% NS 39.02% 47.37% NS Influence of family 41.84% 37.16% 31.00% NS 53.66% 33.33% p < 0.01 Opportunity for research 20.41% 25.00% 27.95% NS 19.51% 21.05% NS Many on-call shifts 10.20% 11.41% 11.79% NS 4.88% 14.04% p < 0.03 Percent of “agree” and “agree much” responses on 5-point Likert Scale Numbers in parenthesis are the results of factor analysis Clusters per cluster analysis Bold results representthe higher value of a statistically significant pair Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 14 of 17 Appendix B Table 7 Residency in a peripheral hospital Periphery No periphery Periphery vs no periphery N 48 382 Criteria for choosing a specialty Time with family 85.42% 66.23% p < 0.001 Controllable lifestyle 75.00% 65.01% p < 0.04 Influency of spouse 56.25% 37.40% p < 0.01 Specialty that deals with social issues 45.83% 27.03% p < 0.004 Work only in the community 18.75% 2.62% p < 0.001 Narrow range of medical problems 10.42% 1.83% p < 0.001 Advancing rapidly 47.92% 62.30% p < 0.05 Opportunity for research 29.17% 40.94% p < 0.03 Bedside specialty 91.67% 93.10% NS Wide rangeof medical problems 62.50% 72.44% NS Independent practice 60.42% 55.24% NS Specialty with teamwork 54.17% 47.52% NS Procedures/surgery 50.00% 47.24% NS High salary 50.00% 47.64% NS Private practice 47.92% 41.05% NS Daytime work only 27.08% 21.78% NS Influence of family 14.89% 10.76% NS Academic faculty member 18.75% 28.61% NS Influence of classmate 4.17% 1.31% NS Specialty that my coleagues choose 2.08% 0.79% NS Criteria for choosing a residency Family living location 81.25% 68.59% p < 0.04 Teaching students 56.25% 40.05% p < 0.05 Pre-determined work hours 56.25% 40.73% p < 0.05 Influence of family 52.08% 32.98% p < 0.02 Much supervision by senior physicians 50.00% 42.15% p < 0.03 Primary care 42.22% 14.72% p < 0.0004 Limited work hours 41.67% 21.26% p < 0.03 Much clinic time 33.33% 8.38% p < 0.001 Leading department 58.33% 78.59% p < 0.0001 Large hosptial 46.81% 60.05% p < 0.003 Intellectual challenge 77.08% 82.77% NS Controllable lifestyle 77.08% 61.56% NS Specific location 75.00% 65.79% NS Making clinical decisions on your own 62.50% 53.26% NS Much “action” 43.75% 40.31% NS Physical challenge 41.67% 41.10% NS Short residency 22.92% 15.18% NS Opportunity for research 20.83% 25.85% NS Many on-call shifts 16.67% 9.14% NS Percent of “agree” and “agree much” responses on 5-point Likert Scale Numbers in parenthesis are the results of factor analysis Clusters per cluster analysis Bold results represent the higher value of a statisitcally significant pair Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 15 of 17 Appendix C Table 8 In “residency in the periphery” and “primary care residency” Residency in the periphery Not intersted Neutral Interested Total Primary Not interested 37.4% 4.7% 2.7% 44.8% Care Neutral 22.7% 11.0% 2.3% 36.0% Residency Interested 10.4% 5.1% 3.7% 19.2% Total 70.5% 20.7% 8.8% Appendix D Table 9 Primary care - selection criteria 1 2 3 1vs3 1vs2 2vs 3 Incentive Plan peripheral Incentives don’t interests me residency interest me N 106 20 223 Criteria for choosing a specialty Time with family (1) 78.30% 60.00% 63.39% p < 0.004 p < 0.04 NS Specialty that deals with social issues (3) 35.24% 35.00% 25.11% p < 0.02 NS NS Advancing rapidly (2) 51.43% 45.00% 68.75% p < 0.0007 NS p < 0.04 Opportunity for research (2) 29.25% 5.00% 46.64% p < 0.0001 p < 0.04 p < 0.0001 Bedside specialty 95.28% 95.00% 92.79% NS NS NS Wide range of medical problems 73.58% 63.16% 73.66% NS NS NS Controllable lifestyle (1) 73.58% 50.00% 66.07% NS NS NS Independent practice practice 53.77% 40.00% 51.28% NS p < 0.03 p < 0.03 High salary 50.48% 20.00% 45.09% NS p < 0.006 p < 0.01 Specialty with team work 48.11% 55.00% 50.89% NS NS NS Procedures/surgery 45.28% 31.58% 50.67% NS NS p < 0.04 Influence of spouse 41.35% 45.00% 34.84% NS NS NS Private practice 36.79% 10.00% 39.64% NS p < 0.008 p < 0.009 Daytime work only (1) 23.30% 21.05% 19.20% NS NS NS Academic faculty member 22.86% 10.53% 31.25% NS NS NS Influence of family 9.43% 10.00% 11.21% NS NS NS Work only in the community 4.72% 10.00% 3.14% NS NS NS Narrow range of medical problems 4.72% 5.00% 2.68% NS NS NS Specialty that my coleagues choose 1.90% 5.00% 0.90% NS NS NS Influence of classmates 0.95% 0.00% 1.34% NS NS NS Criteria for choosing a residency Controllable lifestyle 73.33% 45.00% 58.12% p < 0.04 p < 0.03 NS Primary care 27.18% 31.58% 15.32% p < 0.001 NS p < 0.002 Hospital in the periphery (3) 7.55% 55.00% 3.85% p < 0.001 p < 0.0007 p < 0.001 Intellectual challenge (1) 80.19% 60.00% 87.05% p < 0.004 NS p < 0.007 Leading department (1) 68.87% 45.00% 84.82% p < 0.0002 p < 0.004 p < 0.0009 Specific location 50.94% 68.42% 69.82% p < 0.0001 NS NS Large hospitial 50.00% 26.32% 67.71% p < 0.005 p < 0.04 p < 0.0006 Opportunity for research 16.98% 5.00% 29.02% p < 0.02 p < 0.01 p < 0.0005 Family living location 68.87% 70.00% 69.06% NS NS NS Making clinical decisions on your own 49.06% 50.00% 58.04% NS NS NS Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 16 of 17 Table 9 Primary care - selection criteria (Continued) 1 2 3 1vs3 1vs2 2vs 3 Incentive Plan peripheral Incentives don’t interests me residency interest me Much “action” 45.28% 40.00% 43.75% NS NS NS Much supervision by senior physicians 43.81% 20.00% 46.43% NS NS p < 0.04 Limited work hours 43.40% 30.00% 40.18% NS NS NS Physical challenge 42.45% 30.00% 41.70% NS NS NS Teaching students 38.10% 50.00% 48.21% NS NS NS Influence of family 32.38% 30.00% 34.38% NS NS NSb Pre-determined work hours (2) 25.71% 25.00% 20.72% NS NS NS Short residency 15.09% 10.00% 16.52% NS NS NS Much clinic time (2) 13.33% 20.00% 9.38% NS NS NS Many on-call shifts 12.26% 10.00% 10.71% NS NS NS Percent of “agree” and “agree much” responses on 5-point Likert Scale Numbers in parenthesis are the results of factor analysis Clusters per cluster analysis Bold results represent the higher value of a statistically significant pair Jerusalem, Israel. Department of Family Medicine, Ben Gurion University Acknowledgements Joyce and Irving Goldman School of Medicine, Be’er Sheva, Israel. The authors thank the many students who participated in this study. Received: 15 November 2017 Accepted: 25 April 2018 Funding Israel National Institute for Health Policy Research. Availability of data and materials References The datasets used and/or analyzed during the current study are available 1. Allen SM, Ballweg RA, Cosgrove EM, Engle KA, Robinson LR, Rosenblatt RA, from the corresponding author on reasonable request. Skillman SM, Wenrich MD. Challenges and opportunities in building a sustainable rural primary care workforce in alignment with the Affordable Authors’ contributions Care Act: the WWAMI program as a case study. Acad Med. 2013;88:1862–9. CW – Designed study, collected and analyzed data, wrote and edited 2. Duffrin C, Diaz S, Cashion M, Watson R, Cummings D, Jackson N. Factors manuscript. 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Isr J Med Sci. 1996;32:545–50. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Israel Journal of Health Policy Research Springer Journals

Challenges to the Israeli healthcare system: attracting medical students to primary care and to the periphery

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Medicine & Public Health; Medicine/Public Health, general; Health Administration; Health Promotion and Disease Prevention; Social Policy
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2045-4015
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10.1186/s13584-018-0218-z
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Abstract

Background: The greatest challenges facing healthcare systems include ensuring a sufficient supply of primary care physicians and physicians willing to work in rural or peripheral areas. Especially challenging is enticing young physicians to practice primary care in rural/peripheral areas. Identifying medical students interested in primary care and in residencies in Israel’s periphery should aid the healthcare leadership. It may be particularly importanttodosoduringtheclinical years, as this is the stage at which many future physicians begin to crystallize their specialty and location preferences. Methods: Questionnaires, distributed to 6 consecutive 5th-year classes of the Hebrew University – Hadassah School of Medicine, from 2010 to 2016, elicited information on criteria for choosing a career specialty, criteria for choosing a residency program and whether one-time monetary grants authorized in the 2011 physicians’ union contract would attract students to residencies in the periphery. Results: Completed questionnaires were returned by 511 of 740 (69%) students. Ninety-eight (19%) were interested in a primary care residency, 184 (36%) were unsure and 229 (45%) were not interested. Students interested in primary care were significantly less interested in specialties that perform procedures/surgeries and in joining a medical school faculty, while being more inclined towards specialties dealing with social problems, controllable lifestyles and working limited hours. The percentage of students interested in primary care was stable during the study period. Forty-eight of the students indicated interest in residencies in the country’s periphery, and 42% of them were also interested in primary care residencies. Overall, only 3.7% of students were interested in both a primary care residency and a residency in the periphery. Thirty percent of the students indicated that the monetary incentives tempted them to consider a residency in the periphery. Fifty-three percent of these students reported that they did not yet know the geographic area where they wished to do their residency, as compared to only 22% among those not interested in incentives. (Continued on next page) * Correspondence: charles@hadassah.org.il Department of Anesthesiology and Critical Care Medicine, Hadassah-Hebrew University Medical Center, Hebrew University – Hadassah School of Medicine, Kiryat Hadassah, POB 12000, 91120 Jerusalem, Israel Full list of author information is available at the end of the article © The Author(s). 2018 Open Access 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. Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 2 of 17 (Continued from previous page) Conclusions: This study provides the healthcare leadership with information on the characteristics of the students at a centrally-located medical school who tend to be more interested in primary care and in working in the periphery. Specifically, the study found that students interested in primary care desire a positive life/work balance, something that Israeli non-hospital primary care practice provides. Students considering residencies in the periphery were similarly inclined. Moreover, about a third of students had positive thoughts about monetary incentivesfor residenciesinperipheral hospitals. These students should be identified early during their clinical experience so that attempts to recruit them to the periphery can commence before their specialty and location preferences have fully crystallized. Parallel studies should be performed at additional Israeli medical schools. Keywords: Medical students, Medical education, Residency, Medical specialty selection, Career choice Background specialists and pediatricians, especially in the county’s The greatest challenges facing healthcare systems in- peripheral areas. This shortage is predicted to clude providing sufficient numbers of primary care increase as the population grows, ages, and life spans and rural physicians [1]. Especially challenging is en- lengthen. Furthermore, the primary care physician ticing young physicians to establish primary care population is aging as many physicians who emigrated practices in rural areas [1, 2]. Among the counties from the former Soviet Union in the 1990’sare reach- where such challenges exist are the United States, ing retirement age [8]. Therefore, it is necessary to at- Australia and Canada [1, 3, 4]. Israel suffers from a tract more medical students to primary care similar problem with shortages of family medicine residencies. To increase recruitment it is important specialists in peripheral areas of the country. The lat- that the medical education and healthcare system ter include the northern and southern regions of the leadership better understand the characteristics of stu- country which encompass the majority of the dents interested in pursuing primary care and how county’s rural districts. These areas chronically suffer they differ from those without such interests. The from physician shortages, greater infant mortality and leadership needs similar information on students in- lowerlifeexpectancy than the rest of thecountry terested in residency positions in the county’s [5]. In an attempt to remedy this maldistribution, the periphery. physicians’ union contract of 2011 included both pay The present study compared the characteristics of increases for practicing in the periphery and one- Israeli 5th-year (out of 6 years) medical students time monetary incentives for moving and committing interested in primary care residencies and residencies to work in the periphery [6, 7]. This programs also in peripheral areas with those without such interests. provided incentives for medical students interested in The dataset used was collected over a 6-year period residencies in specialties suffering workforce short- from a single Israeli medical school and includes over ages. The original program excluded family medicine 500 students. The two hypotheses tested were that residentsfromboththe incentivesfor workin the the student interest in primary care would be greater periphery and the incentives to work in distressed among women medical students and that interest in specialties. However, in 2015 the Israel Ministry of Health residencies in peripheral areas would be greater began to provide financial incentives to family medicine among students who attended high school in the residents willing to train in peripheral areas. northern and southern regions. We also explored The Israeli healthcare system is dependent on whether the one-time monetary grants approved in primary care physicians to provide comprehensive the 2011 physicians’ union contract would encourage out-patient care and to serve along with community spe- students to consider a residency in a peripheral hospital. cialists and internal Health Maintenance Organization The ultimate goal was to provide the medical education regulations and pre-authorization systems as gate- and healthcare leaderships with the attributes that typify keepers for secondary and tertiary care. These students interested in primary care and/or rural practice. primary care physicians, family medicine specialists, Fifth-year students were studied since our previous study pediatricians, internists and general practitioners, are revealed that most had already begun the process of based in health maintenance organization clinics. deciding on a specialty [9]. In order for the healthcare Despite family medicine and pediatrics being popular leadership to influence specialty decisions, it is important specialties among Israeli medical students, there is to be cognizant of the thought patterns of the students still a nationwide shortage of family medicine early in their decision process. Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 3 of 17 Methods included the two points representing positive This study included students from 6 consecutive tendencies; Group 2 included the neutral point; and 5th-year classes of the Hebrew University – Hadassah Group 3 the two points representing negative School of Medicine in Jerusalem (2010–2016). It tendencies. This permitted us to compare students utilized a questionnaire to examine various aspects interested and not interested in a primary care resi- of the medical specialty selection process. The ques- dency, while also examining those who were unsure. tionnaire was based on the results of factor analysis The results from each of the 6 school-years were from a questionnaire used previously [9]. This per- compared to determine whether there were differ- mitted us to reduce repeat Likert scale questions ences between years. thus providing space for new ones that investigated additional issues. Among the new topics examined were the influence of family and colleagues on specialty Rural (periphery) workforce and residency program decisions as well as the interests of Initial data analysis showed that a significant number thestudentsinacademicpursuits. Thequestionnaire of students interested in primary care were inter- included multiple choice questions, free-text queries ested in a residency in the county’s periphery. There- and 5-point Likert scales. In addition to demographic fore, a post-hoc examination was made of the information, the questionnaire elicited information characteristics of students interested in a residency about: (1) Whether the student had already consid- in the country’s periphery. The dataset was divided ered a specialty for their residency, which specialty or into two groups based on the answer to the 5-point specialties they were considering (free-text), when Likert scale question: “Are you interested in a resi- they had first considered a specialty and whether and dency in the country’speriphery?” Group A included when (prior to beginning medical school or when the two points representing positive tendencies while during the first 5 years of medical school) they had Group B included the two points representing nega- changed their mind; (2) The criteria for choosing a tive tendencies. career specialty {20 items, 10 new, 5-point Likert scale}; (3) The criteria for choosing a residency pro- gram {20 items, 9 new, 5-point Likert scale}; and (4) The importance of interest in a specific specialty Incentives when choosing a residency {3 new items, multiple The data set was divided into three groups as per the choice}. (5) Whether the one-time monetary grants responses to the multiple- choice query “As the result authorized in the 2011 physicians’ union contract of the union contract of 2011, residents in peripheral would attract them to a residency in a peripheral hospitals receive a one-time monetary incentive and hospital (1 new item, final 4 classes). higher salaries: (1) These incentives attract me to a After two small (15 students) preliminary studies residency in the periphery (2) I already plan to do a designed to identify problems and test the question- residencyintheperiphery(3) Theincentivesdonot naire’s user-friendliness, the questionnaires were attract me to a residency in the periphery”.The distributed to the 5th year classes of the Hebrew differences between the characteristics of the three University – Hadassah School of Medicine in groups were determined. Jerusalem during the 2010–2011, 2011–2012, 2012– Based on prior research demonstrating significant 2013, 2013–2014, 2014–2015 and 2015–2016 school- gender differences associated with specialty selection years. A parallel article examining medical student an a priori decision was made to separately analyze subgroups also utilized this dataset [10]. and compare the male and female data [11]. Responses to multiple choice questions are pre- sented as frequency distributions. When the Likert Data analysis Scale results were considered continuous variables, Data were entered into Microsoft Excel (Redmond, WA) statistical analyses were performed using all 5 points. spreadsheets and analyses were performed with Systat When presented as categorical variables the Likert 12 (San Jose CA). Scale results were compressed into three categories, (the two points representing negative tendencies and the two points representing positive tendencies were Primary care each combined). The percentages of total responses The dataset was divided into three groups based on for each of the three categories (positive tendency, the answer to the 5-point Likert scale question: “Are middle point and negative tendency) were then you interested in a primary care residency?” Group 1 computed. Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 4 of 17 For continuous data, differences between the groups primary care. Among the latter, none were consider- were analyzed using analysis of variance with Tukey ing family medicine (Table 1). post-hoc tests. Categorical data were analyzed using As can be seen in Tables 1 and 2 (Appendix A), χ or Fisher exact tests, as appropriate. A p value < 0. there was similar interest in a primary care residency 05 was assumed to represent statistical significance. between female (17%) and male (21%) students. Com- Univariate linear regression analysis was used to parisons between men and women students interested examine the association between the answers to two in primary care showed that women rated lifestyle is- queries. Backward multivariate and logistic regression sues, such as family time, more highly than men and analyses were performed with the dependent variable were more interested in pediatrics (Tables 1 and 2, being either interest in a residency in primary care or Appendix A). a peripheral hospital. The independent variables were the demographic parameters and specialty and resident selection criteria. Rural (periphery) workforce Criteria for specialty and residency program Differences between students expressing and not selection were subjected to factor analysis (principal interested in a residency in the country’s periphery are components analysis) using varimax rotation with set found in Table 4 (Appendix B). Results of multivariate eigenvalues of ≥1.0. Thedatawerealsoanalyzedwith and logistic regression analyses are in Table 3. hierarchal cluster analysis. Interactions between the replies to the questions The Institutional Review Board of the Hadassah “Are you interested in a residency in the country’s Medical Organization approved this study. Completion periphery?” and “Are you interested in a primary care of the questionnaire by the student was considered tacit residency?” revealed that 4% of all the students were consent. interested in both a primary care residency and a residency in the periphery (Appendix C). Results Incentives Completed questionnaires were returned by 511 of 740 Responses to the query about monetary incentives (69%) 5th-year medical students. for a residency in peripheral hospitals are in Tables 5 (Appendix D). Thirty percent of the students reported that the incentives interested them, while Primary care another 6% had already decided to do a residency in Ninety-eight (19%) students were interested in the periphery. The relationships between the pursuing a primary care residency, 184 (36%) were responses to this question and those to the query unsure and 229 (45%) were not interested. Demo- “are you interested in a residency in the country’s graphic information is found in Table 1. Interest in periphery?” revealed that 82% of the students who primary care among 5th-year students was stable replied they were not attracted by the incentives over the 6-year study period ranging from 17%–21% indicated that they were not interested in a residency annually. in the periphery while those that reported that the Compared to students not interested in primary incentives interested them showed less aversion (20% care, those interested in primary care were signifi- negative tendency and 54% positive tendency) to a cantly less interested in a specialty with procedures/ residency in the periphery. surgeries and becoming “members of a medical school faculty”, while being more inclined towards a specialty dealing with social problems (Tables 2 and 3). When Discussion choosing a residency program, students attracted to The present study identified several medical student primary care were more interested than their characteristics associated with interest in a primary care colleagues in a residency in the country’s periphery. residency and those interested in a residency in the per- Alternately, 42% of the 48 students who indicated iphery among 5th year students at the Hadassah-Hebrew interest in a residency program in the country’s University Medical School. periphery were also interested in a primary care residency (Table 2). When asked about specialties they were considering, students interested in primary Primary care care expressed significantly more interest in family There were many differences between 5th-year Israeli medicine and pediatrics than those not interested in medical students interested and not interested in a Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 5 of 17 Table 1 Primary care - demographic and other information Primary Undecided No primary Primary care vs Primary care Females care care no primary care vs males Females Males N 98 184 229 41 57 Female 42% 51% 49% Male 58% 50% 51% NS Age (years) 18–20 0% 0% 0.4% 0% 0% 21–23 25% 14% 17% 27% 23% 24–26 19% 31% 29% 34% 9% 27–29 37% 42% 39% 27% 44% 30–32 14% 10% 12% 10% 18% +32 5% 4% 3% NS 2% 7% p < 0.01 Marital status Single 70% 63% 73% 66% 72% Married 30% 36% 26. % 34% 26% Divorced 1% 1% 0.4% NS 0% 2% NS Thought of a specialty when started Yes 85% 79% 82% 85% 84% No 15% 21% 18% NS 15% 16% NS When did you start thinking of a specialty? Pre - med school 25% 29% 26% 27% 23% Year 1 4% 4% 4% 6% 2% Year 2 4% 4% 2% 3% 4% Year 3 4% 3% 5% 0% 6% Year 4 56% 42% 48% 62% 51% Year 5 9% 19% 16% NS 3% 13% NS Have you changed your mind? Yes 61% 59% 63% 59% 62% No 40% 41% 38% NS 41% 38% NS When did you change your mind? Year 1 0% 0% 2% 0% 0% Year 2 0% 3% 1% 0% 0% Year 3 2% 1% 2% 0% 4% Year 4 41% 44% 42% 35% 46% Year 5 57% 52% 54% NS 65% 50% NS Specialties under consideration Family medicine 16% 2% 0% 14% 17% Pediatrics 41% 42% 24% 54% 30% Internal med 26% 30% 32% 26% 26% Ob/Gyn 19% 20% 22% 34% 7% Emergency med 4% 0% 2% 0% 7% Surgical* 20% 31% 31% 9% 30% Other 22% 44% 39% p < 0.01 20% 30% p < 0.01 High school location Israel 97% 97% 96% 95% 98% Other 3% 3% 4% NS 5% 2% NS High school location in israel Jerusalem 32% 25% 23% 26% 36% Central 29% 37% 44% 31% 29% North 26% 28% 23% 33% 21% South 13% 9% 10% 10% 14% Other 0% 1% 1% NS 0% 0% NS Future residency location Israel 98% 98% 99% 97% 98% Other 2% 2% 1% NS 3% 2% NS Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 6 of 17 Table 1 Primary care - demographic and other information (Continued) Primary Undecided No primary Primary care vs Primary care Females care care no primary care vs males Females Males Perferred residency location in Israel Jerusalem 28% 18% 23% 23% 31% Central 22% 32% 34% 13% 29% North 17% 11% 9% 23% 12% South 1% 1% 2% 3% 0% Don’t know 33% 39% 32% p < 0.05 39% 29% p < 0.01 *Surgical specialties primary care residency. Students inclined toward male students. Students inclined toward primary care primary care were more interested in lifestyle: spend- were less interested in academic pursuits, such as ing time with their families, working limited hours being academic faculty members. Reduced interest in and working only during the daytime. This import- academic activities was also observed among ance of lifestyle was more pronounced in female than Japanese medical students with preferences for Table 2 Primary care - selection criteria Primary Undecided No primary Primary care vs Primary care Females vs males care care no primary Females Males N 98 184 229 41 57 98 Criteria for choosing a specialty Time with family (1) 76% 73% 65% p < 0.03 85% 68% p < 0.05 Specialty with team work 57% 54% 45% p < 0.04 56% 58% NS Influence of spouse 43% 43% 31% p < 0.007 49% 39% p < 0.05 Specialty that deals with social issues (3) 42% 35% 22% p < 0.001 51% 35% p < 0.009 Daytime work only (1) 26% 29% 16% p < 0.03 34% 19% p < 0.03 Work only in the community 9% 3% 4% p < 0.001 12% 7% NS Procedures/surgery 43% 41% 57% p < 0.01 34% 49% p < 0.02 High salary 36% 48% 51% p < 0.002 34% 38% NS Opportunity for research (2) 34% 37% 44% p < 0.05 27% 39% NS Academic faculty member 19% 26% 30% p < 0.05 24% 16% NS Criteria for choosing a residency Much supervision by senior physicians 53% 45% 37% p < 0.001 68% 42% p < 0.04 Limited work hours 29% 30% 17% p < 0.001 33% 27% NS Short residency (<4.5. years) 28% 15% 12% p < 0.001 29% 26% NS Much clinic time (2) 23% 16% 5% p < 0.001 20% 25% NS Hospital in the periphery (3) 19% 7% 6% p < 0.001 20% 19% NS Leading department (1) 67% 77% 79% p < 0.03 71% 65% NS Large hospitial 52% 55% 62% p < 0.04 59% 47% NS Family living location 78% 75% 64% NS 88% 70% p < 0.05 Making clinical decisions on your own 66% 50% 55% NS 56% 74% p < 0.05 Pre-determined work hours (2) 47% 48% 35% NS 59% 39% p < 0.05 Influence of family 42% 37% 31% NS 54% 33% p < 0.01 Many on-call shifts 10% 11% 12% NS 5% 14% p < 0.03 Percent of "agree" and "agree much" responses on 5-point Likert Scale Numbers in parenthesis are the results of factor analysis clusters per cluster analysis Bold result indicates the higher value in a statistically significant pair Weissman et al. Israel Journal of Health Policy Research _#####################_ Page 7 of 17 Table 3 Regression analysis Demographics/criteria Multivariable Backward Backward logistic regression regression p Odds ratio 95% confidence limits P coefficient Interest in a primary care residency r = 0.43 Male gender 0.264 0.015 2.251 1.195–4.241 0.012 Criteria for choosing a specialty Opportunity for research −0.096 0.033 0.755 0.578–0.987 0.04 High salary −0.207 0.002 0.580 0.376–0.893 0.013 Influency of spouse 0.122 0.018 Specialty that deals with social issues 0.146 0.004 1.442 1.079–1.927 0.013 Work only in the community 0.278 0.001 Wide range of medical problems 1.512 1.004–2.277 0.048 Criteria for choosing a residency program r = 0.45 Leading department −0.125 0.053 0.581 0.395–0.854 0.006 Influence of family 0.094 0.026 1.414 1.083–1.847 0.011 Short residency (< 4.5 years) 0.159 0.001 1.524 1.122–2.069 0.007 Peripheral hospital 0.188 0.001 Much supervision by senior physicians 0.202 0.001 1.836 1.340–2.515 0.001 Much clinic time 0.207 0.001 1.495 1.110–2.013 0.008 Interest in a residency in a peripheral hospital r = 0.43 Older age 0.157 0.004 1.732 1.144–2.621 0.009 Have considered a specialty −0.234 0.048 High school location (periphery) 0.138 0.002 1.546 1.089–2.193 0.015 Criteria for choosing a specialty Wide range of medical problems 0.144 0.008 Time with family 0.145 0.009 1.686 1.001–2.839 0.049 Work only in the community 0.178 0.002 1.701 1.147–2.524 0.008 Influence of spouse 1.488 1.019–2.173 0.039 Private practice −0.109 0.012 Specialty that deals with social issues 0.123 0.003 Narrow range of medical problems 0.298 0.001 2.156 1.377–3.376 0.001 Criteria for choosing a residency program r = 0.52 Specific location in Israel −0.106 0.031 Leading department −0.280 0.001 0.480 0.091–0.791 0.004 Limited work hours 0.108 0.031 Family living location 0.115 0.046 Many on-call shifts 0.121 0.011 Teaching students 0.144 0.001 1.563 1.061–2.304 0.024 Physical challenge 0.157 0.001 Primary care 0.168 0.002 Much clinic time 0.198 0.003 1.893 1.288–2.783 0.001 Much supervision by senior physicians 0.045 1.010–2.455 0.045 Influence of family 1.430 1.030–1.986 0.022 Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 8 of 17 Table 3 Regression analysis (Continued) Demographics/criteria Multivariable Backward Backward logistic regression regression p Odds ratio 95% confidence limits P coefficient Monetary incentives for residency in the periphery r - 0.58 Opportunity for research −0.126 0.047 0.580 0.360–0.933 0.025 Specialty advancing rapidly −0.143 0.022 0.620 0.393–0.90 0.041 Specific location −0.204 0.001 0.428 0.275–0.667 0.001 Primary care 0.115 0.023 Specialty that deals with social issues 0.126 0.008 1.530 1.044–2.242 0.029 Peripheral hospital 0.258 0.001 2.835 1.782–4.511 0.001 family medicine [12]. Lack of interest in academic entering general internal medicine and pediatric endeavors is problematic since it reduces the number practices [17]. The major reasons cited for the dearth of family medicine faculty members able to serve as of students entering primary care in the United medical student mentors. This lack of mentors might States are relatively low incomes in the face of high decrease the ability to attract students to the student debt burdens, many administrative tasks and specialty. time pressures [16]. Many medical schools have in- It is important to note that the query on the stituted programs to attract more students to pri- questionnaire was about the broader area of primary mary care, with a multi-year exposure to primary care and not specifically about family medicine. care being more successful than adding a single pri- Unlike aprevious studywherewefound afemale- mary care course to a conventional curriculum [18]. predominance among 6th year Israeli medical Other countries face similar problems. In Vietnam students interested in family medicine, in the present less than a third of commune (collective farming study we did not find such predominance [13]. communities) health stations are staffed by a phys- Furthermore, the proportion of women medical ician even though the number of medical school students interested and not interested in primary care graduates almost tripled between 2004 and 2011 was comparable. Similarly, upon multiple regression [19]. The reasons include poor working conditions, analysis, interest in primary care was not associated low income and lack of opportunities for career de- with being female. We thus failed to prove our velopment [19]. In a survey of 9499 South Korean hypothesis that interest in primary care would be medical students only 2.2% expressed interest in greater among women than men medical students. family medicine [20]. This variance with our previous studies is attributable Shortages of primary care physicians are generally to primary care incorporating general internal attributed to low salaries, lack of prestige and medicine, general pediatrics and some aspects of ob- glamor; long hours with frequent on-call responsibil- stetrics/gynecology, in addition to family medicine. ities; and lack of a controllable lifestyle [21, 22]. The We previously found that In Israel, internal medicine situation in Israel differs from other countries in that and obstetrics/gynecology residencies attract many primary care physicians mainly work in health main- male students [13]. When asked which specialties tenance clinics, receive salaries comparable to other they were considering, students interested in primary physicians, have few on-call obligations and have set care listed pediatrics and internal medicine more fre- hours [8]. This was reflected in our previous study quently than family medicine. where Israeli 6th-year students rated family medicine In many countries, attracting medical students to and pediatrics as specialties with controllable life- primary care careers is a daunting task [14]. The styles and positive relationships between controllable reasons for this difficulty differ between countries lifestyle and remuneration [13]. This was also found [15]. In the United States, the proportion of medical in the present study, wherecompared to 5th-year students selecting primary care specialties dropped students not interested in primary care, those inter- from 73% in 1996 to 44% in 2008, although subse- ested in primary care wanted a specialty with time quently there has been some stabilization [16]. More- for family involving only daytime work and practice over, more internal medicine and pediatric residents in the community (i.e. outside the hospital). This are choosing to subspecialize, reducing the numbers interest profile was similarly demonstrated by their Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 9 of 17 Table 4 Residency in a peripheral hospital Table 4 Residency in a peripheral hospital (Continued) Periphery No Periphery Periphery No Periphery periphery vs no periphery vs no Periphery Periphery N 48 382 Work only in the 19% 3% p < 0.001 community Gender Female 45% 48% Narrow range of 10% 2% p < 0.001 Male 55% 52% NS medical problems Age (years) 18–20 0% 0.3% Advancing rapidly 48% 62% p < 0.05 21–23 17% 18% Opportunity for 29% 41% p < 0.03 research 24–26 19% 30% Criteria for choosing a residency program 27–29 42% 39% Family living location 81% 69% p < 0.04 30–32 17% 10% Teaching students 57% 40% p < 0.05 +32 6% 3% NS Pre-determined work 56% 41% p < 0.05 Marital status Single 63% 71% hours Married 38% 29% Influence of family 52% 33% p < 0.02 Divorced 0% 1% NS Much supervision 50% 42% p < 0.03 High school location Israel 100% 97% bysenior physicians Other 0% 3% NS Primary care 42% 15% p < 0.0004 High school location in Jerusalem 17% 27% Limited work hours 42% 21% p < 0.03 Israel Central 31% 42% Much clinic time 33% 8% p < 0.001 North 38% 22% Leading department 58% 79% p < 0.0001 South 15% 8% Large hosptial 47% 60% p < 0.003 Other 0% 1% p < 0.05 Percent of “agree” and “agree much” responses on 5-point Likert Scale Residency location Israel 100% 98% Other 0% 2% NS greater interest in short (in years) residency programs Future residency location Jerusalem 13% 26% in Israel with limited hours and with much time spent in Central 16% 36% clinics. This grouping of interests indicates a desire North 40% 7% for positive life/work balance, something that Israeli South 13% 1% non-hospital primary care practice provides. A recent Don’t know 18% 31% p < 0.01 study of Israeli family medicine residents reported Specialties under Family 0% 2% similar findings. Specifically, more than 85% of resi- consideration medicne dents reported that factors that positively influence Pediatrics 46% 30% their choice included the ability to combine work, family, and free time; direct, meaningful contact with Internal 24% 32% medicine patients; the diversity of patients and medical condi- Ob/Gyn 15% 21% tions; and attractive working conditions [23]. This interest profile is similar to those reported from other Emergency 5% 1% medicine countries among students interested in primary care and family medicine [12, 24]. However, primary care Surgical 32% 30% specialties in isolated Israeli rural village has been reported to Other 32% 35% p < 0.05 lead to unclear boundaries between private life and specialties physician roles leading to problems with life/work Criteria for choosing a specialty balance [25]. This may be among the reasons for the shortage of primary care practitioners in the country’s Time with family 85% 66% p < 0.001 periphery. Controllable lifestyle 75% 65% p < 0.04 Influency of spouse 56% 37% p < 0.01 Specialty that deals 46% 27% p < 0.004 Rural (periphery) workforce with social issues Worldwide, rural areas often suffer physician short- ages. Therefore, in many countries with large rural Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 10 of 17 Table 5 Incentives - residency in periphery 1. Incentive 2. Plan peripheral 3. Incentives don’t 1vs3 1 vs2 2vs 3 interests me residency interest me N 106 20 223 Percent 30% 6% 64% Gender Female 48% 47% 50% Male 52% 53% 50% NS NS NS Age (years) 18–20 0% 0% 0% 21–23 22% 20% 19% 24–26 27% 15% 31% 27–29 36% 50% 35% 30–32 10% 10% 11% +32 5% 5% 3% NS NS p < 0.02 Marital status Single 68% 60% 72% Married 30% 40% 27% Divorced 2% 0% 1% NS p< 0.05 p < 0.02 High school location in Israel Jerusalem 27% 5% 25% Central 36% 32% 40% South 10% 26% 10% Other 1% 0% 1% NS p < 0.01 NS Future residency location in Israel Jerusalem 14% 10% 29% Central 20% 0% 41% North 14% 55% 8% South 0% 20% 1% Don’t know 53% 15% 22% p< 0.03 p < 0.01 p< 0.01 Specialties under consideration Pediatrics 39% 31% 31% Internal medicine 21% 6% 35% Ob/Gyn 29% 19% 15% Emergency medicine 0% 13% 1% Surgical specialties 32% 31% 29% Other specialties 31% 31% 37% p < 0.04 p < 0.01 p < 0.02 Criteria for choosing a specialty Time with family (1) 78% 60% 63% p < 0.004 p < 0.04 NS Specialty that deals with social issues (3) 35% 35% 25% p < 0.02 NS NS Advancing rapidly (2) 51% 45% 69% p < 0.0007 NS p < 0.04 Opportunity for research (2) 29% 5% 47% p < 0.0001 p < 0.04 p < 0.0001 Controllable lifestyle (1) 74% 50% 66% NS NS NS Independent practice 54% 40% 51% NS p < 0.03 p < 0.03 High salary 51% 20% 45% NS p < 0.006 p < 0.01 Procedures/surgery 45% 32% 51% NS NS p < 0.04 Private practice 37% 10% 404% NS p < 0.008 p < 0.009 Criteria for choosing a residency Controllable lifestyle 73% 45% 58% p < 0.04 p < 0.03 NS Primary care 27% 32% 15% p < 0.001 NS p < 0.002 Hospital in the periphery (3) 8% 55% 4% p < 0.001 p < 0.0007 p < 0.001 Intellectual challenge (1) 8% 60% 87% p < 0.004 NS p < 0.007 Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 11 of 17 Table 5 Incentives - residency in periphery (Continued) 1. Incentive 2. Plan peripheral 3. Incentives don’t 1vs3 1 vs2 2vs 3 interests me residency interest me Leading department (1) 69% 45% 85% p < 0.0002 p < 0.004 p < 0.0009 Specific location 51% 68% 70% p < 0.0001 NS NS Large hospitial 50% 26% 68% p < 0.005 p < 0.04 p < 0.0006 Opportunity for research 17% 5% 29% p < 0.02 p < 0.01 p < 0.0005 Much supervision by senior physicians 44% 20% 46% NS NS p < 0.04 Percent of “agree” and “agree much” responses on 5-point Likert Scale Numbers in parenthesis are the results of factor analysis Clusters per cluster analysis Bold result indicares the higher value in a statistically significant pair areas, such as the United States, Canada and the periphery”, 63% had gone to high school in the Australia, emphasis has been placed on encouraging northern or southern areas. Therefore, we confirmed more medical students to become rural primary care the hypothesis that interest in residencies in periph- physicians [26, 27]. To attract students to rural areas, eral areas is greater among students who attended medical schools have programs that expose students high school in peripheral regions. Similar observa- to rural practice and have increased the recruitment tions were made in Kenya, United States, Japan and of students from rural areas [28]. The current study Australia where students of rural origin were more showed that of the more than 500 5th-year Israeli interested in rural practice [2, 11, 28, 29]. These students studied, 8.9% were considering residency in results have potential healthcare policy implications. the country’s periphery. This percentage is greater Firstly, they can contribute to decisions about than that reported in our previous study of 5th year whether to admit more medical school applicants students (4.6%) and might be attributable to the re- residing in the periphery in an attempt to reduce the cent introduction of monetary incentives (one-time shortage of physicians practicing there. Secondly, the grants and salary increases) for physicians choosing to results can also contribute to decisions about train and practice in the periphery. Shortages of rural whether to include rural medicine rotations during physicians frequently includes a lack of primary care the clinical years to provide all students with expos- physicians; a situation also present in Israel. Among ure to such medical practice [30]. students interested in primary care, 19% would The characteristics of students considering a choose a residency in the periphery. Alternately, residencyintheperipheryweresimilar to those among students considering a residency in the periph- interested in a primary care residency. Although this ery, 42% were interested in primary care. This attrac- may be partially attributable to the many students tion to primary care among students interested in interested in a primary care residency, it also likely living in rural areas was also observed among reflects that those interested in residencies in the per- Japanese medical students [29]. However, when we iphery are more interested in life-work balance and examined our overall student sample, only 3.7% of are less interested in a residency in a large hospital the 5th-year students reported interest in both and in a leading department. primary care and peripheral residencies. Regression analysis showed that attending high school in Israel’s south and north was associated with Incentives interest in residency in the same regions. Notably, The last four years of the study provided an oppor- significantly more students interested in residencies tunity to explore the student’s thoughts about the in the periphery reported that the locale of their monetary incentives for rural residency included in family was an important criterion for choosing a the 2011 union contract [7]. Although only 6% were residency program. Furthermore, among students already planning to do a residency in the periphery, who responded to the question concerning the effects 30% indicated that the incentives induced them to of one-time monetary incentives to do a residency in consider a residency there. Fifty-three percent of the the periphery, “Ialreadyplantodoaresidencyin latter students reported that they did not yet know Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 12 of 17 wheretheywishedtodotheir residencyasopposed from such schools [23]. Yet, unlike the foreign to 22% among those not interested in the incentives. graduates who only enter the Israeli healthcare sys- Moreover, there were more differences between the tem as interns, having had exposure to the various two groups. Students interested in the incentives were specialties in foreign healthcare systems during med- more interested in primary care residencies, special- ical school, the Israeli medical students are part of ties dealing with social issues, specialties providing the Israeli healthcare system while they are medical family time and residencies affording controllable life- students providing the Israeli healthcare leadership styles. Alternately, they were less interested in re- the opportunity to directly expose them to Israeli search opportunities, a rapidly advancing specialty primary and rural practices early in their clinical and a residency in a leading department in a large experience. hospital. For medical educators and healthcare leaders A further limitation is that there might be selection these results point to a group with distinct character- criteria that were not included in the questionnaire. istics who might be encouraged to join residency pro- However, both the factor and cluster analyses showed grams in the periphery. The challenge is to better few factors and clusters indicating that a wide-variety characterize this student group, identify them early of topics were queried. during their specialty/residency program decision process and provide positive information and counsel- ing about residency programs and lifestyle in the per- Conclusions iphery. Thirty percent of the residents working in The characteristics of students showing interest in Israel’s periphery reported that the incentives had in- primary care and practice inperipheralareas,that fluenced them greatly, even though initially they had were delineated by this study, should aid department intended to work there [23]. Previous studies have heads and residency program directors in identifying shown that Israeli primary care practitioners in the potential residents. Moreover, the present study re- periphery are more satisfied and had a broader scope vealed that for Israeli medical students the 5th-year is of practice than urban practitioners [29, 31, 32]. an important juncture in their choice of a medical While the aim is to market residency programs in specialty. Eighty percent had already considered vari- the periphery to the students, the results of this ous specialties. Although, about a quarter had begun study show that a third of the students reported that their considerations before beginning medical school, the influence of family was an important part of themajorityhad begunduringtheir 4thand 5th- their residency selection process. Therefore, years. Furthermore, 60% of those who had begun the consideration should be given to including spouses thought process had already changed their minds. in recruitment efforts. Therefore, the 4th and 5th years of medical school appear to be an opportune time to market the various specialties to medical students and might also be the Strengths and limitations time to begin informing them about residency pro- The strength of this study is that the large number of grams. Since the students’ decisions as to specialty students studied allowed us to examine subgroups, and residency program decisions have major influ- such as those interested in primary care. A further ences on the composition and geographic distribution strength was its multi-year design showing that the of the future physician workforce, it is for the health- proportion of students interested in primary care and care leadership to take the initiative and provide the peripheral hospitals remained steady throughout the students with direction, counseling and information study. to help them with their choices. The major limitation is that the study was performed in a single institution that is located in the center of the country and is focused on academic Endnote medicine. Hence the findings are not automatically Our hypothesis is that the findings for the other generalizable to the entire Israeli medical student medical schools will be similar to what we found for population, and parallel studies should be carried out Hebrew University-Hadassah. This is because a) Des- at additional Israeli medical schools. pite its location in the center of the country, the Another limitation is that the study only included Hebrew University- Hadassah Medical School draws Israeli medical students when half the medical in- students from across the country; b) Earlier studies of ternship workforce is comprised of Israeli who grad- family medicine specialty preferences found similar- uated from foreign medical schools and immigrants ities between this medical school and the total for all and 58% of the family medicine residents graduated Israeli medical schools [23]. Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 13 of 17 Appendix A Table 6 Primary care - selection criteria Primary Undecided No primary Primary care vs Primary care Females care care no primary vs males Females Males N 98 184 229 41 Criteria for choosing a specialty Time with family (1) 75.51% 72.68% 65.07% p < 0.03 85.37% 68.42% p < 0.05 Specialty with team work 57.14% 53.80% 44.98% p < 0.04 56.10% 57.89% NS Influence of spouse 42.55% 42.62% 31.14% p < 0.007 48.65% 38.60% p < 0.05 Specialty that deals with social issues (3) 41.84% 34.62% 21.93% p < 0.001 51.22% 35.09% p < 0.009 Daytime work only (1) 25.51% 28.73% 16.23% p < 0.03 34.15% 19.30% p < 0.03 Work only in the community 9.18% 2.73% 3.51% p < 0.001 12.20% 7.02% NS Procedures/surgery 42.86% 40.98% 56.58% p < 0.01 34.15% 49.12% p < 0.02 High salary 36.08% 48.09% 51.09% p < 0.002 34.15% 37.50% NS Opportunity for research (2) 33.67% 37.16% 43.67% p < 0.05 26.83% 38.60% NS Academic faculty member 19.39% 25.68% 30.26% p < 0.05 24.39% 15.79% NS Bedside specialty 93.88% 92.93% 92.07% NS 92.68% 94.74% NS Wide range of medical problems 79.38% 71.04% 68.12% NS 75.61% 82.14% NS Controllable lifestyle (1) 69.39% 73.91% 64.19% NS 78.05% 63.16% NS Advancing rapidly (2) 56.12% 61.41% 58.77% NS 51.22% 59.65% NS Independent practice 51.02% 60.11% 52.40% NS 56.10% 47.37% NS Private practice 39.80% 36.96% 42.48% NS 41.46% 38.60% NS Influence of family 12.37% 9.78% 8.81% NS 15.00% 10.53% NS Specialty that my coleagues choose 2.06% 1.64% 0.00% NS 0.00% 3.57% NS Influence of classmates 2.06% 1.63% 0.44% NS 0.00% 3.57% NS Narrow range of medical problems 2.04% 3.26% 3.49% NS 0.00% 3.51% NS Criteria for choosing a residency Much supervision by senior physicians 53.06% 45.11% 36.68% p < 0.001 68.29% 42.11% p < 0.04 Limited work hours 29.17% 29.89% 16.67% p < 0.001 32.50% 26.79% NS Short residency (< 4.5. Years) 27.55% 15.30% 11.79% p < 0.001 29.27% 26.32% NS Much clinic time (2) 22.45% 16.30% 4.82% p < 0.001 19.51% 24.56% NS Hospital in the periphery (3) 19.39% 6.52% 6.11% p < 0.001 19.51% 19.30% NS Leading department (1) 67.35% 77.17% 79.04% p < 0.03 70.73% 64.91% NS Large hospitial 52.04% 54.64% 61.84% p < 0.04 58.54% 47.37% NS Intellectual challenge (1) 83.67% 82.07% 83.41% NS 87.80% 80.70% NS Family living location 77.55% 74.86% 63.76% NS 87.80% 70.18% p < 0.05 Controllable lifestyle 69.39% 70.49% 60.70% NS 73.17% 66.67% NS Making clinical decisions on your own 66.33% 49.46% 55.02% NS 56.10% 73.68% p < 0.05 Specific location in Israel 65.31% 64.48% 63.88% NS 68.29% 63.16% NS Much “action” 52.04% 33.15% 46.49% NS 51.22% 52.63% NS Pre-determined work hours (2) 46.94% 48.37% 35.37% NS 58.54% 38.60% p < 0.05 Physical challenge 47.96% 36.96% 46.93% NS 41.46% 52.63% NS Teaching students 43.88% 43.48% 43.42% NS 39.02% 47.37% NS Influence of family 41.84% 37.16% 31.00% NS 53.66% 33.33% p < 0.01 Opportunity for research 20.41% 25.00% 27.95% NS 19.51% 21.05% NS Many on-call shifts 10.20% 11.41% 11.79% NS 4.88% 14.04% p < 0.03 Percent of “agree” and “agree much” responses on 5-point Likert Scale Numbers in parenthesis are the results of factor analysis Clusters per cluster analysis Bold results representthe higher value of a statistically significant pair Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 14 of 17 Appendix B Table 7 Residency in a peripheral hospital Periphery No periphery Periphery vs no periphery N 48 382 Criteria for choosing a specialty Time with family 85.42% 66.23% p < 0.001 Controllable lifestyle 75.00% 65.01% p < 0.04 Influency of spouse 56.25% 37.40% p < 0.01 Specialty that deals with social issues 45.83% 27.03% p < 0.004 Work only in the community 18.75% 2.62% p < 0.001 Narrow range of medical problems 10.42% 1.83% p < 0.001 Advancing rapidly 47.92% 62.30% p < 0.05 Opportunity for research 29.17% 40.94% p < 0.03 Bedside specialty 91.67% 93.10% NS Wide rangeof medical problems 62.50% 72.44% NS Independent practice 60.42% 55.24% NS Specialty with teamwork 54.17% 47.52% NS Procedures/surgery 50.00% 47.24% NS High salary 50.00% 47.64% NS Private practice 47.92% 41.05% NS Daytime work only 27.08% 21.78% NS Influence of family 14.89% 10.76% NS Academic faculty member 18.75% 28.61% NS Influence of classmate 4.17% 1.31% NS Specialty that my coleagues choose 2.08% 0.79% NS Criteria for choosing a residency Family living location 81.25% 68.59% p < 0.04 Teaching students 56.25% 40.05% p < 0.05 Pre-determined work hours 56.25% 40.73% p < 0.05 Influence of family 52.08% 32.98% p < 0.02 Much supervision by senior physicians 50.00% 42.15% p < 0.03 Primary care 42.22% 14.72% p < 0.0004 Limited work hours 41.67% 21.26% p < 0.03 Much clinic time 33.33% 8.38% p < 0.001 Leading department 58.33% 78.59% p < 0.0001 Large hosptial 46.81% 60.05% p < 0.003 Intellectual challenge 77.08% 82.77% NS Controllable lifestyle 77.08% 61.56% NS Specific location 75.00% 65.79% NS Making clinical decisions on your own 62.50% 53.26% NS Much “action” 43.75% 40.31% NS Physical challenge 41.67% 41.10% NS Short residency 22.92% 15.18% NS Opportunity for research 20.83% 25.85% NS Many on-call shifts 16.67% 9.14% NS Percent of “agree” and “agree much” responses on 5-point Likert Scale Numbers in parenthesis are the results of factor analysis Clusters per cluster analysis Bold results represent the higher value of a statisitcally significant pair Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 15 of 17 Appendix C Table 8 In “residency in the periphery” and “primary care residency” Residency in the periphery Not intersted Neutral Interested Total Primary Not interested 37.4% 4.7% 2.7% 44.8% Care Neutral 22.7% 11.0% 2.3% 36.0% Residency Interested 10.4% 5.1% 3.7% 19.2% Total 70.5% 20.7% 8.8% Appendix D Table 9 Primary care - selection criteria 1 2 3 1vs3 1vs2 2vs 3 Incentive Plan peripheral Incentives don’t interests me residency interest me N 106 20 223 Criteria for choosing a specialty Time with family (1) 78.30% 60.00% 63.39% p < 0.004 p < 0.04 NS Specialty that deals with social issues (3) 35.24% 35.00% 25.11% p < 0.02 NS NS Advancing rapidly (2) 51.43% 45.00% 68.75% p < 0.0007 NS p < 0.04 Opportunity for research (2) 29.25% 5.00% 46.64% p < 0.0001 p < 0.04 p < 0.0001 Bedside specialty 95.28% 95.00% 92.79% NS NS NS Wide range of medical problems 73.58% 63.16% 73.66% NS NS NS Controllable lifestyle (1) 73.58% 50.00% 66.07% NS NS NS Independent practice practice 53.77% 40.00% 51.28% NS p < 0.03 p < 0.03 High salary 50.48% 20.00% 45.09% NS p < 0.006 p < 0.01 Specialty with team work 48.11% 55.00% 50.89% NS NS NS Procedures/surgery 45.28% 31.58% 50.67% NS NS p < 0.04 Influence of spouse 41.35% 45.00% 34.84% NS NS NS Private practice 36.79% 10.00% 39.64% NS p < 0.008 p < 0.009 Daytime work only (1) 23.30% 21.05% 19.20% NS NS NS Academic faculty member 22.86% 10.53% 31.25% NS NS NS Influence of family 9.43% 10.00% 11.21% NS NS NS Work only in the community 4.72% 10.00% 3.14% NS NS NS Narrow range of medical problems 4.72% 5.00% 2.68% NS NS NS Specialty that my coleagues choose 1.90% 5.00% 0.90% NS NS NS Influence of classmates 0.95% 0.00% 1.34% NS NS NS Criteria for choosing a residency Controllable lifestyle 73.33% 45.00% 58.12% p < 0.04 p < 0.03 NS Primary care 27.18% 31.58% 15.32% p < 0.001 NS p < 0.002 Hospital in the periphery (3) 7.55% 55.00% 3.85% p < 0.001 p < 0.0007 p < 0.001 Intellectual challenge (1) 80.19% 60.00% 87.05% p < 0.004 NS p < 0.007 Leading department (1) 68.87% 45.00% 84.82% p < 0.0002 p < 0.004 p < 0.0009 Specific location 50.94% 68.42% 69.82% p < 0.0001 NS NS Large hospitial 50.00% 26.32% 67.71% p < 0.005 p < 0.04 p < 0.0006 Opportunity for research 16.98% 5.00% 29.02% p < 0.02 p < 0.01 p < 0.0005 Family living location 68.87% 70.00% 69.06% NS NS NS Making clinical decisions on your own 49.06% 50.00% 58.04% NS NS NS Weissman et al. Israel Journal of Health Policy Research (2018) 7:28 Page 16 of 17 Table 9 Primary care - selection criteria (Continued) 1 2 3 1vs3 1vs2 2vs 3 Incentive Plan peripheral Incentives don’t interests me residency interest me Much “action” 45.28% 40.00% 43.75% NS NS NS Much supervision by senior physicians 43.81% 20.00% 46.43% NS NS p < 0.04 Limited work hours 43.40% 30.00% 40.18% NS NS NS Physical challenge 42.45% 30.00% 41.70% NS NS NS Teaching students 38.10% 50.00% 48.21% NS NS NS Influence of family 32.38% 30.00% 34.38% NS NS NSb Pre-determined work hours (2) 25.71% 25.00% 20.72% NS NS NS Short residency 15.09% 10.00% 16.52% NS NS NS Much clinic time (2) 13.33% 20.00% 9.38% NS NS NS Many on-call shifts 12.26% 10.00% 10.71% NS NS NS Percent of “agree” and “agree much” responses on 5-point Likert Scale Numbers in parenthesis are the results of factor analysis Clusters per cluster analysis Bold results represent the higher value of a statistically significant pair Jerusalem, Israel. Department of Family Medicine, Ben Gurion University Acknowledgements Joyce and Irving Goldman School of Medicine, Be’er Sheva, Israel. The authors thank the many students who participated in this study. Received: 15 November 2017 Accepted: 25 April 2018 Funding Israel National Institute for Health Policy Research. Availability of data and materials References The datasets used and/or analyzed during the current study are available 1. Allen SM, Ballweg RA, Cosgrove EM, Engle KA, Robinson LR, Rosenblatt RA, from the corresponding author on reasonable request. Skillman SM, Wenrich MD. Challenges and opportunities in building a sustainable rural primary care workforce in alignment with the Affordable Authors’ contributions Care Act: the WWAMI program as a case study. Acad Med. 2013;88:1862–9. CW – Designed study, collected and analyzed data, wrote and edited 2. Duffrin C, Diaz S, Cashion M, Watson R, Cummings D, Jackson N. Factors manuscript. 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Israel Journal of Health Policy ResearchSpringer Journals

Published: May 29, 2018

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