How to cite this article: Ayuso-Raya MC, Escobar-Rabadán F, López-Torres Hidalgo J, Montoya-Fernández J, Téllez-Lapeira JM, Campa Valera F. Choice of Family Medicine at the exams for Spanish resident doctors in 2011 and 2013. Rev Med Inst Mex Seguro Soc. 2015 Jan-Feb;53(1):44-52.
Received: March 31st 2014
Accepted: December 6th 2014
María Candelaria Ayuso-Raya,a Francisco Escobar-Rabadán,b Jesús López-Torres Hidalgo,b,c Julio Montoya-Fernández,b Juan Manuel Téllez-Lapeira,d Francisco Campa-Valerae
aCentro de Salud de Quintanar del Rey, Cuenca
bCentro de Salud, Zona IV de Albacete
cFacultad de Medicina de Albacete
dCentro de Salud, Zona Vb de Albacete
eServicio Andaluz de Salud, Facultad de Medicina de Sevilla
a,b,dServicio de Salud de Castilla-La Mancha (SESCAM)
Communication with: María Candelaria Ayuso Raya
Background: Family Medicine (FM) is regarded as one of the specialities less interesting to those who choose for resident physicians (MIR) in Spain. Our objective is to know the priority given to the choice of FM in 2011 and 2013 MIR exams, and what factors might be associated with this choice.
Method: We obtained information on the website of the Ministry of Health for the graduates who could choose a speciality (11552 y 9182). The variables analyzed were: number obtained in the opposition, sex, speciality chosen, chosen city, medical school where they studied (for 117 and 155 students of a previous cohort study). We calculated the probability of choice of FM in relation to the order number in the exam and the other variables (Kaplan-Meier).
Results: 1963 and 1772 chose FM, respectively in 2011 and 2013. The median of the order number to choose FM was 7894 (95%CI:7720-8068) and 6561 (95%CI:6442-6680). There were gender differences, as women chose FM with fewer number and a higher proportion (p<0.00001).
Conclusion: Graduates enrolled in the MIR exam have not special preference for FM. Women show a greater interest in this speciality.
Keywords: Medical graduate education; Medical students; Primary health care; Family practice
Traditionally family medicine (FM) is considered as one of the least interesting specialties for students presenting the examination for doctors’ residencies (DR) in Spain. In fact, there is the idea that, except for striking exceptions, it is chosen only by those who have no choice, which coincides with the last numbers to be chosen. The 2012 SESPAS report1 clearly takes on these issues and also emphasizes "the path of decay" that FM has followed since 2004-2005 regarding its preference among competitors, which has brought it to 44th place among DR specialties (ahead of only three that take place in schools and not in health centers), while the number of positions offered is stable, declining slightly. That report concludes that, to avoid structural imbalances, it is necessary to put more emphasis on FM during undergraduate, providing appropriate professors, while post-specialty training of family physicians should be prioritized as well.
FM has an irregular presence in the curriculum of Spanish medical schools. It is given, as in many other countries, what Block et al.2 defined as "a chilly climate for primary care, widespread in academia." Somehow, medical schools discourage students from choosing FM as a career option.3,4 However, the more students know the reality of the health system, the more they appreciate the need for primary care content in undergraduate, the role that FM plays in it, and the importance of aspects that are fundamental for those who end up serving as general practitioners.5
As pointed out by the 2012 SESPAS report,1 the crisis of primary care is not a problem unique to Spain. In the United States the proportion of family physicians has gone from 17.3% in 1997 to 10.5% in 2002 to 9.2% in 2003,6 which has a special significance in rural areas. The recent decline in the number of doctors entering primary care specialties, together with the fact that less than 4% of medical school graduates plan to work in rural areas and small towns, has caused concern for the future.7 Since 1977 the American Academy of Family Physicians has recognized the need for efforts to increase interest among students in FM as a specialty. In this line, the Task Force on Student Interest was created in 1988, whose goals were for all medical schools to have an FM department, to increase the number of graduates who enter FM residency, and to increase the production of qualified clinicians, professors, and researchers in this field.8
In Spain talking about primary care is basically talking about FM, as there is just one other medical specialty in this area: Pediatrics, which caters to children up to 14 years. However, graduates’ declining interest is not only in FM, but also affects other specialties that in other countries also work in primary care. This has been attributed, among other factors, to the lack of recognition of the primary care disciplines as a specialty, which has led to a decrease in the value perceived by students. In part, this disregard is determined by the fact that many hospital specialties have become more competitive, have gained in reputation, and are more prized.9 So many graduates tend to select specialties that are not primary care, based on considerations of prestige and financial income.10
In Spain there is still a long way to go, both in its establishment as an academic discipline and the social value of the specialty. The Facultad de Medicina de Albacete, little more than a decade old, pioneered the inclusion of a course of primary care in the curriculum. One of the issues that we have raised at this time is what impact this academic presence might have in the preferences of graduates choosing a specialty. The result of this concern was the launch of a line of research, of which this work is one part. The objective is to describe the priority given to the choice of FM specialty between competitors in the DR call for applications in 2011 and 2013. Moreover, we want to know what factors might be associated with this choice.
This is a secondary analysis of data. The study subjects were all competitors enrolled in the DR examinations in 2011 and 2013 who chose to apply for these openings (or rejected such an opportunity even though their scores allowed it). The information was obtained from the website of the Ministerio de Sanidad. The selection system consisted of a test at the state level in which the candidates received a total individual score which was summed from their score on a multiple-choice test plus an assessment of their academic merit. The allocation of places was made in the order from highest to lowest individual total score for each applicant.11 The calls for applications are conducted annually and a maximum number of places is set for the different specialties and the centers where they can be practiced. The competitors choose specialty and center by order of number obtained in the competition (the number 1, and therefore the first to choose, is the person with the highest score in the competition). Thus, those who got the best score, and thus have the first numbers to choose from, have a wide range of available possibilities for where to do their specialty residence, while for the final numbers the choice is very limited. The variables studied were: number obtained in competition, sex, chosen specialty, chosen city, medical school where they studied (in the case of graduates who were part of previous cohort studies: 117 students from medical schools in Albacete and Sevilla 2011 and 155 students, mainly from Albacete, but also from other Spanish medical schools in 2013).
Statistical analysis consisted of frequency description, followed by a bivariate analysis using the chi-squared test for contrasting qualitative variables, while for the quantitative variable of order number, which does not follow a normal distribution, nonparametric tests were used (Mann-Whitney and Kruskal-Wallis). The probabilities of choosing FM in relation to order number in the overall competition and depending on other variables, were calculated with the Kaplan-Meier method, which considered order number in the competition as a time variable (the competitor with the highest score chooses first, the second highest score chooses second, and so on, until the final spot is chosen). A logistic regression analysis (backwards stepwise selection) studied which variables best predicted choosing FM. SPSS version 12.0 was used.
Information was revised for 11,552 and 9182 competitors enrolled in the DR examinations in 2011 and 2013, respectively, who chose placements in that call for applications, or gave it up despite having the option to choose. Table I shows the distribution of values of the variables analyzed in the study for those who chose placements: 6924 in 2011 and 6311 in 2013. FM was chosen by 1963 and 1772 in 2011 and 2013, respectively. The median order number in the competition to choose FM was 7894 (95% CI 7720-8068) and 6561 (95% CI 6442-6680) respectively.
|Table I Distribution by sex of values of study variables analyzed for competitors who chose placements in DR calls for applications 2011 and 2013|
|3237 (1583- (5263)|
|Family medicine||1320 (29.8)||621 (25.4)||1941 (22)||1212 (29.0)||513 (25.1)||1725 (47)|
|Pediatrics||343 (7.7)||73 (3.0)†||416 (3)||337 (8.1)||72 (3.5)†||409 (4)|
|Internal medicine||189 (4.3)||103 (4.2)||292 (1)||210 (5.0)||100 (4.9)||310 (0)|
|Gynecology||234 (5.3)||45 (1.8)†||279 (0)||219 (5.2)||37 (1.8)?||256 (4)|
|Other medical specialty||1068 (24.1)||578 (23.6)||1646 (4)||696 (16.7)||331 (16.2)||1027 (14)|
|Other surgical specialty||488 (11.0)||489 (20.0)†||977 (1)||534 (12.8)||459 (22.5)†||993 (12)|
|Other specialty||792 (17.9)||539 (22.0)||1331 (11)||968 (23.2)||528 (25.9)||1496 (14)|
|Albacete||46 (1.0)||27 (1.1)||73 (0)||39 (0.9)||11 (0.5)||50 (1)|
|Other in Castilla- La Mancha||114 (2.6)||91 (3.7)‡||205 (1)||109 (2.6)||40 (2.0)||149 (6)|
|Sevilla||185 (4.2)||81 (3.3)||266 (2)||172 (4.1)||94 (4.6)||266 (2)|
|Other in Andalusia||467 (10.5)||285 (11.6)||752 (0)||495 (11.9)||248 (12.2)||743 (8)|
|Madrid||847 (19.1)||424 (17.3)||1271 (7)||865 (20.7)||409 (20.0)||1274 (13)|
|Barcelona||556 (12.5)||357 (14.6)||913 (4)||525 (12.6)||303 (14.9)||828 (14)|
|Murcia||136 (3.1)||66 (2.7)||202 (1)||140 (3.4)||71 (3.5)||211 (2)|
|Valencia||221 (5.0)||130 (5.3)||351 (0)||192 (4.6)||117 (5.7)§||309 (5)|
|Other||1862 (42.0)||987 (40.3)||2849 (27)||1639 (39.2)||747 (36.6)||2386 (44)|
|Albacete||46 (1.0)||30 (1.2)||76 (0)||57 (1.4)||11 (0.5)||68 (0)|
|Sevilla||28 (0.6)||7 (0.3)||35 (0)|
|Santiago de Compostela||14 (0.3)||2 (0.1)||16 (0)|
|Alicante||11 (0.3)||2 (0.1)||13 (0)|
|Murcia||8 (0.2)||2 (0.1)||10 (0)|
|Granada||10 (0.2)||5 (0.2)||15 (0)|
|Cadiz||5 (0.1)||3 (0.1)||8 (0)|
|Lleida||5 (0.1)||2 (0.1)||7 (0)|
|Valladolid||3 (0.1)||3 (0.1)||6 (0)|
|Oviedo||3 (0.1)||1 (0.05)||4 (0)|
|Barcelona||3 (0.1)||1 (0.05)||4 (0)|
|Madrid||3 (0.1)||1 (0.05)||4 (0)|
|No data||4360 (98.3)||2411 (98.5)||6771 (42)||4054 (97.1)||2007 (98.4)||6061 (95)|
|Total||4434 (64.4)||2448 (35.6)||6882 (42)||4176 (67.2)||2040 (32.8)||6216 (95)|
Frequencies of categorical variables are presented as number of cases and percentage (in parentheses), and the total number of men and women is accompanied by the number of cases in which this data was not available (in parentheses).
Order number is expressed as median and interquartile range (in parentheses).
*p = 0.002, †p < 0.0001, ‡p = 0.005, §p = 0.02
As we can observe in Figure 1, there were differences by gender, as women with lower numbers chose FM (95% CI for medians of 7308-7700 versus 8186-8866 in 2011, and 6348-6612 vs. 6564-7044 in 2013) and in greater proportion (29.8% vs. 25.4%; 29.0% vs. 25.1%).
Figure 1 Cumulative probability of choosing family medicine according to sex
When compared with other competitors, those who had studied in 2011 in Albacete and Sevilla chose FM with lower numbers (95% for medians of 7730-8078, 3152-8790, and 4249-8565, respectively), although in lower proportion (28.6, 10.5, 11.4% respectively). In 2013 the students of the Facultad de Albacete were comparable to the rest because, for those whose faculty of origin was known, there was great dispersion; the differences were not significant (Figure 2).
Figure 2 Cumulative probability of choosing family medicine according to medical school of graduation
As for the city chosen for the residence, Figure 3 shows how in 2011 choosing FM placement in Albacete was more likely than in Sevilla or another city (32.9, 22.8, and 28.5%, respectively) and with lower numbers (median: 5185, 6028 and 7988, respectively). In 2013 the preference for Albacete lost priority, with a median for choosing FM of 7025 versus 5977 for Sevilla and 6335 for other cities.
Figure 3 Cumulative probability of choosing family medicine according to city chosen for residence
Overall, there were gender differences regarding the choice of specialty. As can be seen in Table I, the preference of women for Pediatrics and Gynecology was particularly striking, and to a lesser extent FM (p < 0.0001). In 2011 women had a median order number significantly higher than that of men (p = 0.002). In 2013 these differences were not significant. In terms of geographic preferences, it is noteworthy that in 2013 in Albacete women predominated above what was expected by simple chance (p = 0.02), which was not found in 2011, a year in which a smaller presence of women was noticed in the rest of Castilla-La Mancha (p = 0.005).
The logistic regression analysis showed that the model that best predicted choosing FM in 2011 (Table II) included the variables: number obtained in the competition, sex, and chosen city, as well as the interaction between number and city (including this in the model occasioned a decrease in the level of significance of the city variable); there was no interaction between number and sex. However, in 2013 this interaction did occur, and its inclusion in the model brought with it a loss of statistical significance of the sex variable.
|Table II Variables in logistic regression models that best predict choosing family medicine in 2011 and 2013|
|2011 (Hosmer & Lemeshow Test: 426.14; p < 0.0001)|
|Beta||Standard error||Wald test||p||OR||95% CI|
|Number||0.001||< 0.0001||689.349||< 0.0001||1001||1001-1001|
|Sex (female)||0.321||0.079||16.483||< 0.0001||1378||1,180-1.609|
|City Albacete with respect to:||18.737||0.016|
|Other in CLM||1.609||0.698||5.319||0.021||4.997||1,273-19.613|
|Other in Andalusia||-1,115||0.664||2.823||0.093||0.328||0.089-1.204|
|City interaction* number||36.094||< 0.0001|
|2013 (Hosmer & Lemeshow Test: 129.216; p < 0.0001)|
|Beta||Standard error||Wald test||p||OR||95% CI|
|City Albacete with respect to:||15.707||0.047|
|Other in CLM||1967||1,744||1,272||0.259||7.149||0.234-218.064|
|Other in Andalusia||1614||1.829||0.779||0.378||5.022||0.139-180.978|
|City interaction* number||33.209||< 0.0001|
|Sex interaction number*||12.243||< 0.0001|
We analyzed the choice of other specialties that we would consider somehow related to FM or primary care. FM was chosen with an order number significantly higher than other specialties (p < 0.0001), as we can see in Figure 4.
Figure 4 Score with which different specialties were chosen
As already noted at the beginning of this work, there is a fairly widespread concern about the decline in interest in the specialty of FM. The number of primary care physicians is inadequate to meet the health needs in many countries.12 Since the late nineties of the last century and until today, FM faces several challenges influencing the field of primary care. The tendency to view primary care as a commodity rather than a professional service, or the growing popularity of sub-specialization among medical students have been two key elements in the crisis of FM.13 Moreover, we must not forget that the economic crisis we are currently experiencing is also influencing budget cuts for the development of primary care.
Being interested in the study of possible factors that may influence the choice of the specialty, and being aware of the difficulty of establishing predictions regarding such complex decision-making, we approached the execution of this project. We assume that our approach is limited by the small number of variables analyzed; however, it represents a departure from the basis of our findings. Of particular relevance is the confirmation that choosing FM is done with a score significantly higher than other specialties, as well as women’s greater preference for this specialty. These results are consistent with those presented by González López-Valcárcel et al.;14 it was not in vain that our work in part included identical subjects.
The median order number in the competition to choose FM in 2011 and 2013 was 7894 and 6561, respectively. In the words of Gonzalez and Barber,1 the median order number expresses the "price" of the specialty in the market of medical professionals: the higher, the less demand for the specialty. As these authors point out, it is true that FM is sometimes chosen by candidates who have a very good score, which would be an undoubted indication of vocation.
These authors have also stressed that the DR candidates tend to prefer placement in the care centers where they did clinical practice for their medical degree, which is why we included this variable in our analysis.
We have already discussed the situation in the United States, but graduates’ lack of interest in FM can also be seen in other countries. In Canada, the proportion of medical students who choose FM as first choice of residence was down from 44% in 1992 to 25% in 2003, and there were vacancies in selection tests.15 In the UK this issue has been emerging since the sixties of the last century, due to a lack of applicants even though there are places available: only 13% of female and 7% of male graduates expressed interest in a career in general medicine.16 Similarly, only a minority of Australian graduates show interest in careers in general medicine: about a quarter chose this option in 2002, so training placements went unfilled.17
It has been suggested that students who have FM as compulsory subjects in the curriculum would have a greater interest in this field, although our results do not confirm this hypothesis.
In a study by Lynch et al.,18 which contrasts views toward primary care and career preferences of students in first and fourth years, the authors found statistically significant differences between groups. The first year saw the practice of primary care more intellectually stimulating, requiring a large knowledge base for its practice; according to these students, it allowed greater control of working hours and enjoyed great social prestige. By contrast, fourth-year students disagreed with the statement that primary care was well compensated financially and in working hours and that it had great social prestige. Therefore, the positive perceptions of students of primary care practice may change as, during the years of medical school, they develop realistic perceptions about the professional demands and practice of primary care. Zinn et al.,19 came to similar conclusions, showing that positive attitudes towards FM can become unfavorable throughout the years of school. But the opposite can also be the case, as McKnee et al.20 demonstrated when assessing the impact of a program designed in 2001 to give medical students information about the challenge and gratification of opting for a career in FM. In 2006, they analyzed the results and concluded that students interested in it reinforced their decision when choosing a specialty. When the primary care clinical experiences have been positive over the years of medical school, attitudes are favorable and there are changes in preferences of specialty in favor of FM.
The great disparity in results requires new evidence in this regard. They are probably other effect-modifying variables involved relating to the fact of having studied specific subjects of FM or primary care.
The sex of the competitors is related to certain preferences for specialty choice. In our study, women show a more favorable predisposition to FM than men, although their preference for Pediatrics and Gynecology is much more striking, with similar results in 2011 and 2013. Several studies15,21-23 corroborate this more favorable attitude of women towards FM. According to Block et al.,24 the more favorable attitudes of women are due to a greater appreciation of the relationship with patients and colleagues, and less on income and prestige.
We emphasize that FM is not a preferred option for graduates presenting the DR exam. However, some favorable circumstances for choosing FM can be emphasized, such as the greater interest in this specialty shown by women.
Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.