Experience of medical students in their education is critical in their decision for specialization. It is hard to answer why medical students prefer some specialization programs to others more frequently [1,2]. There are several factors that play roles on career choices [2]. Investigations show that clerkships have an important effect on graduating medical students’ specialty choices [3-7].

Healthcare system in Turkey, nowadays, is in need of a significant modification. As the importance of family medicine is appreciated, a great need for family medicine specialists exists since the success of a health system in a country, is dependent on a solid primary health care. In our country, family medicine specialists have been trained in 3-year residency programs of 21 family medicine departments or clinics in 41 medical schools and some teaching state hospitals since 1984.

To increase the number of family physicians, we require a planned increase in the number of students who would show interest in family medicine [8]. In our school, the most important step of appreciation of family medicine specialization by medical students is a four-week family medicine field practice in the final year of medicine. Field practice is crucial in choosing family medicine specialization [9]. We expect students to foster their experience and knowledge on preventive health services, patient management, consultation, organization, disease diagnosis-treatment-survey protocols and patient-physician interaction in primary care during the field practice. Family medicine clinical training period is a good opportunity for medical students to realize the importance of family medicine representing primary care [10].

Many studies reveal that family medicine training could be helpful to encourage students to choose careers representing general medicine such as family medicine or primary care [3,5,8,10,11]. In this study, we aimed to investigate if a career in family medicine is preferred by final year medical students, reasons for the preference, and if family medicine clerkship may influence the preference of a career in family medicine.

We asked the whole (n: 93) final year medical students who attended a 4-week family medicine clinical clerkship between the months of January and June 2004 to fill the pre- and post-clerkship questionnaires and our study consisted of 90 students who answered both questionnaires. In the prior questionnaire, we aimed to receive answers to the following topics: Demographic characteristics, time spent in medical school education thus far, presence of a health problem in their families, first three choices for residency education, attitude to family medicine residency and its reasons, rank of family medicine in their residency education preferences and would they have chosen family medicine residency had it been on a volunteer basis or had its residency entry been an easier process. At the end of clerkship, we asked the same questions on the prior questionnaire and also the effects of this clerkship on the choice for residency education preferences and its reasons.

Statistics
For statistical comparison, we performed the McNemar-Bowker Test and Wilcoxon Signed Ranks Test according to data in dependent groups. In independent groups we utilized Mann-Whitney U test and compared categorical data by Chi-square and Fisher’s Exact tests. Statistical significance was considered to be p< 0.05. Statistical analysis was performed by SPSS 11.0 and Epi-Info 2000 software.

The mean age of students included in the study was 23.9 ± 1.5 years. 54.4% (n:49) of the study group was male and 45.6% (n:41) was female. Mean time in medical school was 6.2 ± 0.8 years. The ratio of students with health problems in family was %23.3. As Table 1 shows, the ranking of family medicine residency, which was 4.19 ± 0.10 before clerkship increased to 3.88 ± 0.10 after clerkship. There was a significant difference in the preference list between the first and the last test (before and after clerkship (p< 0.05).

There was no significant difference in attitude to family medicine as a medical career between before and after clerkship (p> 0.05). We found no statistical significant difference between indecisive students before clerkship and after clerkship. When indecision was scrutinized in itself, students who were indecisive before clerkship gave a “yes” answer in 36% after the clerkship, a “no” answer in 24%, and 40% remained “uncertain”. There was a significant difference when we analyzed “yes” and “no” responders with respect to “indecisive” students before clerkship, however.

“Yes” ratio increased to 37.5% in “indecisive” students before clerkship, while a 13.6% shift from “no” responders to “indecisive” group was observed. We considered this difference to be important (p< 0.05).

As we asked students to list their first three preferred residency programs before and after clerkship, they didn’t list family medicine. However, ranking of family medicine as a career was not different before and after clerkship, while the number of family medicine preferring students doubled (n:6-n:12). Most of the students who chose family medicine as a career before clerkship were female (66%). After clerkship, the percentage of females decreased (58%). Although female students preferred family medicine more frequently, we determined that male students change their choice of career relatively more frequently.

Attitude to family medicine specialization between answers on pre- and post-clerkship questionnaires was not considerable when compared by McNemar-Bowker test (p> 0.05). Table 2 summarizes the reasons why final year medical students choose family medicine as a career or not.

We asked the students whether they would choose family medicine residency had it been on a volunteer basis or had its entry been easier. As Table 3 indicates, volunteer ratio significantly increased after family medicine clerkship (p< 0.05).

The ratio of change in attitudes of students on the choice of a family medicine career after clerkship was remarkable. Table 4 exposes the reasons for the preference change.

As we investigated factors affecting the changing of minds, we found statistical significance in clerkship enjoyment especially by students with health problems in their family, influence by teaching staff’s attitude, interest and compassion (p< 0.05). On the other hand, age, sex and time in medical education had no effect on the students’ attitude.

In Turkey, family medicine specialization is a hot topic because of the problems in the health system. However, family medicine as a medical career is not a well-known concept by medical students. Studies propose that clerkship in a medical branch in the final year of medical education plays an important role in choosing this branch as a medical career [3-6, 9-17]. In particular, final year field practice is an important factor to encourage students to choose family medicine as a career [9]. Uludag University Medical Faculty enables students in their final year to get familiar with the family medicine program during a 4-week clerkship. This period is a perfect opportunity to present family medicine and encourage students to a family medicine career. To make an assessment, it is important to define the students’ characteristics and their attitude to family medicine specialization and categorize the data in order to plan our studies. Describing the factors influencing students’ career choices towards primary care in our school as already done in several studies, will show us how to encourage our students to contemplate a career in family medicine [8,11,12]. Such an approach can help training of compassionate and well-read primary care physicians in our country. Demographic characteristics are important in family medicine choice as a career [16]. As students preferring family medicine are scrutinized, despite the fact that more female students (66%) preferred family medicine initially, this ratio decreased to 58% after clerkship. However, taking into consideration the doubling of student numbers preferring family medicine, more male students showed preference after clerkship compared to previously. This result is parallel to results of Marrison et al’s study [1].

We gathered that older age and time in medical school does not affect the attitudes of graduating students. It may depend on the fact that the mean age and time in medical school was not high in our study group.

We found more enjoyment of clerkship and greater influence by teaching staff’s attitude, interest and compassion in students with health problems in their family (23%); this is similar to Bland et al’s study [10]. Highlighted section: Should this be decreased from 4.19 to 3.88 OR increased from 3.88 to 4.19
Although there was no significant difference in attitude to family medicine preference before and after clerkship, family medicine preference ranking increased from 4.19 to 3.88 after clerkship. Moreover, a shift to “yes” in 37.5% of “indecisive” and a shift to “indecisive” in 13.6% of “no” may imply a positive effect of family medicine clinical clerkship (p< 0.05). Family medicine had never been in the first three choices in residency program choices before and after clerkship. It may indicate that unfortunately, family medicine is not a priority in our students’ career choices.

Students described their reasons of preference for family medicine specialization as a better working environment, more comfortable facilities, more suitable branch for themselves, interest in clinical sciences, a new and different residency program, diversity in practice, personal patient interaction and lower exam grade for entry. We could make some adjustments on these factors to make family medicine more favorable. Students described their reasons of non-preference for a family medicine career, as interest in surgical sciences, poor financial satisfaction, low social prestige, no promise for a future and unfamiliarity with family medicine. We should keep in mind that if these suspicions could be overcome, choice of a family medicine career can be increased.

The shift to “yes” in 37.5% of the “indecisive” group and the shift to “indecisive” in 13.6% of “no” responders after clerkship, are considerable and may imply that primarily the “indecisive” group, and secondarily the “no” group, are influenced to move to one group above by family medicine field practice.

An easier entry process is an important factor affecting career choices of final year medical students. In our study, decreasing the eligibility requirements for family medicine residency program or a volunteer-based residency program had an important effect on increasing the number of individuals preferring a family medicine career.

In residency application process adjustments, these factors may need to be considered to increase the number of individuals preferring a family medicine career. Although the number of students preferring family medicine career doubled after the clerkship, family medicine was still not in the first three in the preference list and this may be due to its preference rate being already very low.

As we investigated the frequency of factors positively influencing entry into the family medicine residency program, leading ones were: enjoyment of the working environment, absorption of medical life style, influenced by behavior, interest and compassion of the teaching staff, and this result was similar to other studies [1-3,6,8]. Improvement of physical working environment conditions in which model education on family medicine is given, better representation of working environment and encouragement of competency and motivation of teaching staff, may lead more final year medical students to prefer a family medicine career.
To increase the number of students preferring family medicine specialization, family medicine clerkship in graduate medical education is important. We should take measures for more field practices, better working conditions and higher motivation of family medicine teaching staff to encourage students to choose a family medicine career.

The authors are grateful to final year medical students of Uludag University School of Medicine for research assistance.