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| Journal of the New Zealand Medical Association,
16-July-2010, Vol 123 No 1318
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The current New Zealand health workforce faces many
challenges. The WHO Report Can New Zealand
Compete,1 published in May 2008,
highlighted the heavy reliance on overseas-trained doctors to supply our medical
workforce, and the vulnerable position New Zealand holds in the 21st Century
global doctor market. It is claimed New Zealand has the highest proportion of
overseas-trained doctors in the OECD.2
Not only is New Zealand importing overseas-trained doctors,
but it seems to be exporting locally-trained doctors: the same report identified
that loss of doctors in the early postgraduate years was of significant concern,
with 28% of New Zealand-trained doctors leaving the country by
PGY3.1 Indeed, a 2006 study suggested that 66%
would consider leaving within 3 years of graduating.3
Much emphasis has been placed on the factors and conditions
that drive doctors in training offshore. Ongoing industrial action, and
increasing acknowledgement of the extent of the medical workforce crisis has led
many to speculate on the drivers for medical emigration—both from New
Zealand to offshore, particularly Australia, and from contractual employment to
locum work.
Student debt has been identified as having a significant
impact on life choices of doctors in training. In 2001, a series of articles was
published focusing on medical student debt in New
Zealand.4–6 It was estimated that mean
debt at that time was above $60,000 per student, and it was noted that there was
a significant correlation between the predicted size of debt and students’
intentions to practise medicine
overseas.4
A 2002 survey of medical students in Canada was published
around the same time suggesting that increasing levels of debt results in more
medical students taking money into consideration when choosing specialty and
location of practice.7 Another has recently
shown that medical students are able to accurately predict income by specialty
from an early stage of training and have a negative perception of income in
general practice, an area of shortage in New
Zealand.8
The latest figures to estimate the amount of debt are from
the University of Auckland in 2008. It was found that one-third of graduating
medical students owe more than $75,000 to the
Government.9 Moore et al published two papers
in 2006 that showed the total average doctors’ debt at graduation was
$65,206.3,10 Twenty-four percent of students
owed more than $88,875, with a total of 92% having some form of debt.
The same paper showed 42% of students said their debt had
influenced their decision when and whether to have children, and 40% reported
that their debt would influence their career choice. Fifty-five percent of
respondents had considered leaving the country because of the student loan
debt.
As a result of such studies, debt and remuneration are
increasingly being recognised as major contributors to the loss of New Zealand
doctors offshore. Over the past 5 years we have seen an increase in the trainee
intern grant, the introduction of interest-free student loans, and a voluntary
bonding scheme—all of which have acknowledged the importance of debt.
However, there has been little work on what impact internal values, early
medical socialisation, professional attitudes, industrialisation and the
changing nature of the training environment have had on senior medical
students’ perceptions about working and training in New Zealand.
The aim of this study is to define what factors are
important to medical students as they seek to make their decisions about where
they will live, work and train after graduation. The study also aimed to update
figures on student debt, and further identify its influence.
MethodsStudy design—A three-part survey
was developed by the authors firstly to capture current perceptions and
attitudes of senior medical students about living, working and training in New
Zealand, and secondly to identify which factors are the most significant
determinants in deciding to stay in New Zealand or practise overseas in the
short, medium and long term.
The survey comprised sections on students’
perspectives of the workforce, their financial status, and their workforce
intentions. Response modes included Yes/No, option-select, text and numerical
input, and 5-point Likert scales. Respondents were also invited to submit
free-text answers.
The survey was piloted by university academic staff and
modified where necessary. It was conducted in identical hard-copy and online
versions. The online version was developed using Quask FormArtist (v5.1)
software and hosted on the website the New Zealand Medical Students’
Association. Online surveys could only be completed once. Both versions were
confidential and there was no way of identifying which students
participated.
All 5th- and 6th-year students enrolled in medical
schools in New Zealand were invited via email to complete the questionnaire in
October/November 2008. Students on overseas placements at the time were not
included. All students were informed of the online questionnaire via student
email lists. Ethical approval for all participants was obtained from the
University of Otago Human Ethics Committee.
Statistical analysis—Results
from the online survey were converted from Quask to Microsoft Excel 2007
software and merged with the results from the manually-entered hard-copy survey.
The two spreadsheets were collated. Not all respondents answered every question
and missing responses were treated as absent data in all analyses.
SPSS (v16.0.1) software was used for analyses comparing
responses by entry type, gender, ethnicity, relationship status, and year level.
Categorical variables were compared using Chi-squared tests. Continuous
variables were compared with analysis of variance or by Pearson correlation
coefficients as appropriate.
ResultsParticipants—372 of 681 (55%)
eligible medical students responded. The response rate was the same from
5th year as
6th-year students. The mean age of respondents
was 24 years (range of 21–44; standard deviation 3.2) and 58% were female.
Gender, ethnicity, school of medical study, and entry type were representative
of the medical student population. Ten percent of students identified themselves
as international students. Thirty-five percent of students identified themselves
as being in a long-term relationship, and 9% were married. There were no
significant associations with ethnicity or relationship status in the
results.
Intentions—94% of students planned to
work overseas at some point in their career. Nine percent planned to leave
immediately after graduation, and 52% planned to do so at the start of PGY2 or
PGY3 (see Figure 1).
Figure 1. Time of intended move
overseas
 Thirty percent of students planned to leave for fewer than 2
years, 40% for between 2 and 5 years, and 24% planned to leave for greater than
5 years of which 30% planned to leave permanently.
Australia was stated as the most popular destination,
followed by UK/Ireland. There were no significant differences between those who
identified themselves as international students and other respondents.
Thirty-nine percent of students intended to locum. Of these
students, 65% intended to do so for less than 2 years and 32% for 2 to 5 years.
Those students who intended to go overseas were more likely
to locum (142/328 or 43%) than those who did not intend to go overseas (3/24 or
13%; Chi-squared=7.56, p=0.006).
Perceptions—73% percent of
respondents believed that New Zealand is a good place to work. Only 62% (38/61)
of those who entered medical school after a prior degree believed it was a good
place to work compared with 75% (234/311) who entered from the other routes
(Chi-squared=14.744, p=0.022).
Ninety-five percent of respondents believed that New Zealand
is a good place to live, although international students and those who gained
alternative entry were less likely to state this (62/73 or 85%) compared with
school leaver/health science entrants and university graduates (291/299 or 97%;
Chi-squared=21.869, p=0.001).
There was no association between those who believed New
Zealand was a good place to live and when they planned to leave the country.
However, those students who disagreed that New Zealand was a good place to work
were more likely to leave New Zealand for longer: 43% of students who disagreed
that New Zealand is a good place to work intended to work outside New Zealand
for longer than 5 years, compared with 19% of students who agreed that New
Zealand is a good place to work (Chi-squared=11.11, p=0.011).
Sixty-six percent of respondents believed that they would be
valued by their medical colleagues in the workforce. Female students (32/217 or
15%) were more likely to believe they would be undervalued by their medical
colleagues than male students (9/155 or 6%; Chi-squared=11.437, p=0.003).
Sixty-four percent believed they would be valued by the
public, 26% believed they would be valued by hospital management, and 25%
believed they would be valued by the Government. Those who felt undervalued by
the government were more likely to locum (74/158 or 47%) compared with those who
felt valued (26/93 or 28%; Chi-squared=13.112, p=0.011).
Sixty-three percent of students believed the New Zealand
clinical environment to be supportive, with 13% believing that it is
unsupportive. On the other hand, 57% of students believed the Australian
clinical environment to be supportive, with 1.6% believing that it is
unsupportive.
Finance—89% of students said they
were going to graduate with debt. Their average expected debt at graduation was
$75,752. Older students had more debt (r=0.16, p<0.01). International
students had on average more debt (mean $104,000; SD 60,000), followed by
university graduate entrants (mean $86,000; SD 25,000), “Others”
(mean $86000; SD 48,000), and then school leavers/Health science entrants (mean
$68000; SD 30,000; F=11.028, p<0.001).
Thirty-two percent of students always or often worry about
their debt, and 34% sometimes do so. The amount of worry was positively
correlated with the amount of debt (F=5.645, p=0.000) (Table 1).
Table 1. Mean debt levels (in thousands of
dollars) categorized by level of worry about debt
 Thirty-six percent of students responded that their debt
influenced their choice of vocation more than a small amount (i.e. a moderate
amount, a large amount a great amount, or would determine choice), whilst 39%
said it would influence their choice of locality of work within New Zealand; 64%
said debt influenced their probability of doing locum work, and 58% said debt
influenced their choice of locality of work in the world.
Students were asked whether having less debt would change
their decision regarding vocation, location and taking up locum work. Thirteen
percent agreed that having less debt would affect their choice of vocation, and
a further 20% stated it might affect their choice. Eighteen percent agreed that
having less debt would affect their choice of locality in New Zealand, and a
further 24% stated it might affect their choice. Thirty-nine percent agreed that
having less debt would affect their choice of locality in the world, and a
further 25% stated it might affect their choice. Forty-one percent agreed that
having less debt would affect their probability of locuming, and a further 29%
stated that it might affect their choice.
The greater the debt students had, the more likely they were
to say that having less debt would influence their choice of locality of work in
the world (F=7.816, p=0.000), in New Zealand (F=4.148, p=0.017), and their
choice of career (F=7.191, p=0.01) (Table 2).
Those students not intending to work overseas were more
likely to say that less debt would not affect their choice of locality in the
world (16/24 or 67%) compared with those who did intend to work overseas
(116/348 or 34%; Chi-squared= 13.281, p=0.004).
Table 2. Mean debt per student responses as to
whether or not less debt would influence career choice, choice of career
locality in NZ, and choice of career locality in the world (in thousands of
dollars)
 Free text responses—Students were
asked what factors would make them more likely to go overseas. Ninety-four
percent or 351 students provided a response. Fifty-six percent stated financial
motivation, 46% stated reasons of greater experience and/or lifestyle, 45%
stated greater job prospects, training and/or educational opportunities, 21%
stated better working environments, conditions and/or support, and 18% stated
reasons related to family, partners, and/or friends.
They were also asked to provide reasons as to why they may
locum. Forty-two percent or 154 students provided a response. Eighty-four
percent stated financial motivation, 27% stated reasons of lifestyle, family
and/or flexibility, 19% stated wanting to travel as a reason, and 14% stated
wanting to gain greater and/or broader experience.
DiscussionDespite believing that New Zealand is a good place to live,
this study confirms that a high number of our medical graduates plan to leave
the country by PGY 3. Nearly a quarter of graduates plan to leave for longer
than 5 years. Our data suggests that less are intending to leave by PGY 3,
however, in comparison to the 2006 Moore
study.3
Eighty-nine percent of students said that they were going to
graduate with debt, the average of which was $75,752. There was no significant
difference between debt accumulated by male or female students unlike the 2008
Auckland study that suggested that males had bigger
loans.9
Several advocacy groups have suggested that these high
levels of debt are responsible for the large shift overseas. Although often met
with some cynicism, the results of this study make it hard to suggest that it is
not a contributing factor. Fifty-six percent of respondents cited financial
motivations for going overseas, and 84% cited financial motivations for
locuming.
Addressing debt and providing greater financial incentives
in the workforce, therefore, could not only have a positive impact on career
choices and locality of work, but could also reduce the number of doctors who
locum and who thereby currently absorb an alarming proportion of this
country’s medical workforce expenditure.
It is tempting to seek a single causative factor for this
emigration trend but the cause is likely to be multi-factorial. This may
frustrate those designing policy as it is much easier to do so with single
factor objectives, however a more holistic look at the workforce may allow for
some change.
It is important to look at whether or not, for example, our
workforce feels valued. Responses suggest that medical graduates are not
expecting to be greatly valued in the health system. Although nearly two-thirds
of students thought they would be valued by the public and medical colleagues,
there is still a third with a significant driver to look elsewhere to work.
A 2002 review concluded there was significant correlation
between how valued an employee felt and job satisfaction, positive mood,
commitment, performance, and lessened withdrawal
behavior.11 It is therefore crucial that our
doctors feel valued for their satisfaction and the employer’s.
What is more alarming is that only a quarter of students
thought that they would be valued by hospital management or by the Government.
This is not only disappointing but has significant implications as those who
felt undervalued were more likely to indicate they would opt for low-commitment
high-paid locum jobs rather than a RMO position at a district health board. This
has implications for specialist training, and long-term commitment to New
Zealand and the health workforce. Certainly, both the Government and hospital
management groups need to explore ways to improve these perceptions of being
undervalued.
The free text responses were similar to the Moore
study3 and showed that there are reasons for
people leaving the country that cannot be countered at the time; forty-six
percent stated reasons of greater experience and/or lifestyle, and 18% stated
reasons related to family, partners, and/or friends. It is therefore important
that we not only focus on medical graduate retention, but also recruitment of
New Zealand graduates who have already gone overseas. Our graduates will have a
drive to gain wider experience, and this is ultimately beneficial to the New
Zealand public. They should not be punished for gaining this experience but
rather encouraged to return.12
This study begins to provide insight into some of the
factors behind the current workforce crisis. The representativeness of the study
could have been improved with a higher response rate, however the demographics
of respondents were reflective of the general survey population and therefore it
is believed responses can be taken as representative.
There was potential bias in responses hosting the survey on
the NZMSA website, as the Association was at the time of the survey actively in
discussion with the Ministry of Health about medical student debt. Students may
have provided answers that were more likely to help these discussions. Students
were instructed not to complete the paper survey if they had done so online,
however there was potential for people to submit two responses this way.
It would be ideal to construct a follow-up study of these
students during their early postgraduate training years to determine whether
perceptions are translated into actions.
Ultimately it is the young who become the backbone of the
established workforce with time. It is therefore important that they are valued.
Resources, time and money must be invested not only in their undergraduate
education, but their ongoing learning and commitment to the New Zealand
public—“If we wish our future health professionals to work for the
public good, then is it unreasonable for them also to expect that the public
might be good to them?”12
Competing interests: None known.
Author information: William R G Perry, PGY
1 RMO, Canterbury District Health Board, Christchurch—and Immediate Past
President, The New Zealand Medical Students’ Association, Wellington; Tim
J Wilkinson, Associate Dean (medical education), University of Otago,
Christchurch
Acknowledgement: Medical Council of New
Zealand (MCNZ) provided financial support for this study via a Medical Student
Scholarship.
Correspondence: Dr William Perry, C/-
NZMSA, PO Box 156, Wellington, New Zealand; email: ipp@nzmsa.org.nz
References:
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