This nationwide study had the participation of the majority of the medical schools in Spain. Amongst the study limitations is the different reply rate of the participating schools, probably related to differences in student attendance to the activity at which the questionnaire was administered. Nevertheless, since there were not differences by campus, the school of medicine is not a relevant confounder. The lower response rate from third and fifth-year students to a survey on campus could be related to lower participation rates in campus activities in general, as well as higher rates of participation in rotations and exchange programs. Of the 27 medical schools in Spain at the time of the start of the study five did not resply to our invitation to participate. Their characteristics are not different from the rest that did, therefore, we do not consider that this has introduced any relevant bias in the results of the study.
Students acknowledged the social importance of FM as a specialization and of the PC environment, but did not consider them to be attractive in terms of scientific-technical interest, workplace conditions, and research potential, as has been reported in other studies [14–16]. More than 75% of those surveyed think that working as a family physician would provide lower economic rewards than other areas of medicine. However, this trend was not observed in ther remaining items in this section of the survey.
The opinions of hospitalists and of FM specialists, together with the students’ own experiences, are the most important elements that determine this negative perception. This perception increases as students move through their curriculum, which might indicate that students progressively lean toward other fields of specialization and practice. The opinions of family doctors themselves are the factor that has the most influence on this trend, which might reflect their own disenchantment or unhappiness with their working conditions and professional opportunities .
The great majority of students (88%) agreed with the need for mandatory instruction in FM to learn about this part of the health care system, within which they will very probably practice their profession. Nevertheless, less than half thought it should be taught because of its specific scientific content.
More than 60% of those surveyed thought that a combination of integrated teaching and specific courses is the best approach to learning about FM. A majority thought that this instruction should begin in the third or fourth year, although more than 20% indicated that it should begin earlier. This view supports the curriculum design suggested by some authors [18, 19] who have advocated for an early start to teaching the basic elements of FM and PC.
The students considered the essential contributions of FM training to the medical degree program to be communication skills, knowledge about disease prevention and health promotion, and attention to the most common clinical problems, followed by the biopsychosocial focus on family and community, nuclear characteristics of a comprehensive health care reinforcing the need to include them in the undergraduate curricula.
The expectations and interest level that the students demonstrated with respect to their future professional work as family physicians fall into an intermediate zone in comparison with other specialties, although the scale does not coincide with the preferences selected in the national residency program exams . This suggests that other factors appear to have some influence between the end of the degree and sitting for this national exam that are difficult to identify and evaluate. In our study, in contrast with others [21, 22], student interest in FM is only slightly higher among women than men (46.9% vs. 40.4%).
In agreement with other studies [23, 24], anticipated working conditions have a decisive influence on the choice of a specialization, closely followed by the nature of the clinical practice itself (close doctor-patient relationships, a wide spectrum of medical conditions to treat) . The income level does not appear to be considered a determining factor, in contrast to what studies have reported in countries where many students have to repay their loans that cover university costs [26, 27].
Only 25% of the students who begin medical school have or think they have made a decision about the specialization they want to pursue. The most influential factors we identified that change this preference are related to the practical and theoretical content of the courses taken and the opinions and information that professors share with them. A majority (55%) of the respondents who were in their third or fifth year of study indicated that their level of interest in FM had not varied during their degree program, but 37% indicated that it had increased and 8% said it declined. In any case, if we add to these findings that only a quarter of beginning medical school students report knowing which specialization they want to practice, there is plenty of room to positively (or negatively) influence student preferences over the course of their academic program. Data from this study regarding the low status that MF and PC have from a scientific and technical view, amongst medical students, also could partially explain the low popularity it has for new graduates as a specialty choice. Despite the implementation of the Bologna process in Europe and the persistence of differences in objectives and training content in medical schools across countries, we believe that the results of this study may be of interest also from an international perspective. Administering the survey again after 2 years will enable us to assess possible changes in the overall expectations and perceptions of the student cohort. The context of these changes could be influenced by curricular modifications introduced in light of the Bologna Process or by other changes derived from a wider use of theoretical and practical FM instruction in Spain in recent years. In this regard it should be noted that in the Spanish medical school training has been mostly theoretical for many years. Only in recent times, possibly due to the influence of the Bologna process, is when there is more prominence to the practical content of learning and supervision of students by tutors. These changes should have a positive impact on enhancing MF and PC in the curriculum of Medical Schools and thus, gradually modify the results obtained in our study.
A goal of our research group is to continue this project, deepening the analysis of the perceptions and expectations of the academic world (both faculty and students) with respect to FM and PC. Our objective is to inform political and academic authorities and help them to achieve a more efficient and balanced health care system, in which FM and PC could be attractive arenas for preparation and practice for future generations of professionals.