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Almost all students who enter medical school go on to practise medicine. Their education and training is expensive both to the taxpayer and to individual students, requiring input from multiple stakeholders including communities, universities, hospitals, general practices, the Medical Council of New Zealand and postgraduate colleges. These stakeholders reasonably expect a medical workforce to address health needs. For decades, New Zealand has been heavily reliant on International Medical Graduates (IMGs) to fill shortages especially in general practice and psychiatry, or in rural areas.1–3 As a result, over 40% of New Zealand’s current medical workforce received their medical degree overseas. In the 2016 New Zealand workforce survey, general practitioners comprised around 33% of the workforce and psychiatrists, 6.5%.3 To meet future primary care demands created by an ageing population with more chronic or complex disease, along with a preference for reduced hours of work by doctors, it is estimated that the proportion of general practitioners needs to be higher.1 In response to current and anticipated workforce shortages and to reduce reliance on IMGs, the Government has recently increased New Zealand’s medical student numbers.4 Medical schools have a key role in identifying students with favourable attributes and providing them with formative undergraduate experiences as important first steps in workforce development.5 The resulting graduate cohorts must be disposed towards the full range of vocational scopes.2 However, evidence for what influences career choice at the undergraduate stage is relatively limited.

It is well-established that students from rural backgrounds are more than twice as likely as other students to enter rural practice.6 This was the rationale for the establishment of dedicated rural admission pathways at the Universities of Auckland and Otago in 2003. Furthermore, rural placements during medical programmes increase the likelihood of practising in rural locations in the longer term, over and above background.7–9 Again, both schools provide these experiences for all students. Moreover, there are long-standing equity pathways for admission of students who are Māori or with Pacific ancestry. Proportions of these students in recent medical classes now approximate those in the general population. International evidence suggests these students may be more likely to choose to work in underserved areas.10 Women are more likely than men to work in careers with more ‘predictable’ work patterns such as general practice, or in work environments which are perceived as more flexible or family-friendly.11–15

The context and mission of the medical school itself may affect how curriculum resources are allocated, as well as what types of students might apply or be selected. A common assumption is that spending more time in a specific medical school attachment may result in greater interest in a particular specialty. Yet, are people who have experiences in a particular specialty more interested in that specialty because of that experience (causation), or because they were already interested and that’s why they elected to get more experience in it (association)? Might there be serendipity such as being exposed to role models at crucial times? The quality of that experience or role models may be influential, but this might be positive or negative.16,17 Furthermore, media portrayal and the attitudes of family and friends may influence early career decisions.18 How a medical school articulates with postgraduate training may be important in maintaining pathways to specific careers.19

Collecting prospective data from medical students and early postgraduate doctors enables the exploration of how individual student background or attributes might interact with curriculum or early postgraduate training to affect eventual career choice and location. This information may prove useful for regarding the required future medical workforce both in terms of numbers and in aptitude for the range of careers needed.

Existing studies elsewhere

Workforce surveys provide cross-sectional information that describe the demography and distribution of the medical workforce at one time point. When conducted iteratively, trends or areas of current or future shortages may be signalled. These data might be useful in arguing for more training places, but are of limited value in clarifying factors influencing medical workforce development. For example, a study in the UK showed the proportion of graduates indicating an interest in general practice ranged from 11% at Oxford to 33% at Birmingham2 but the factors driving this were not clear.

Prospective longitudinal tracking helps an understanding of how the medical workforce develops and factors affecting career choices, particularly if the experiences and types of training gained over time are captured. For example, since 1972, careers of graduates from a rural medical school in Pennsylvania have been tracked.21 Over 45% of medical students who had all three characteristics of a rural background, intention to practice rurally, and intention to practice in family medicine eventually worked in a rural area.22 Furthermore, 70% of those who entered rural practice soon after medical school were still there two or three decades later.23

Longitudinal studies in the UK have clarified the predictive ability of a range of selection tools and career intentions through medical training.24–27 Intentions at one year post-graduation (PGY1) matched eventual career for just over half of doctors, while over 80% of intentions at PGY5 were realised.25 Closer matches were seen in some specialties, such as surgery, or when doctors were more definite about their intentions early on. General practice was the destination of about half of those who had initially embarked on a hospital specialty but who subsequently changed their minds.27

The Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD)

In the early 2000s, the Deans of medical schools in Australia and New Zealand embarked on an ambitious project to explore how individual student background or attributes might interact with curriculum or early postgraduate training to impact on eventual career choice and location. In Australia, a driver was to justify Commonwealth investment in rural clinical schools in terms of rural workforce enhancement. The Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) emerged as the world’s first bi-national medical workforce study aiming to track students from all Australian and New Zealand medical schools from selection, through their medical school programme, into postgraduate training, and thence practice.28,29 The MSOD project secretariat was housed in Sydney, with funding from the Australian government and the Medical Deans.

The original MSOD design invited students to participate in a Commencing Medical Students Questionnaire (CMSQ) at entry, an exit questionnaire (EQ) at graduation, followed by further surveys at PGY 1, 3, 5 and 8. In order to distil curriculum effect from student factors, it was deemed important to understand levels of interest in various disciplines at entry into medical school. This was to be supplemented by medical school data on aspects of the curriculum experienced by each participant. There was thought to be sufficient diversity among the 23 Australasian medical programmes to provide insights into the effect of different curriculum factors and environments as predictors of career paths.

The MSOD project began enrolling participants in Australia in 2005, with the University of Otago following from 2007 and the University of Auckland from 2012. For Auckland medical students, MSOD superseded a career tracking project involving all health professional students underway since 2006. Since 2012, the NZ MSOD Steering Group has coordinated the efforts of the two New Zealand medical schools, supported by funding from Health Workforce New Zealand (HWNZ) plus in-kind support from both universities. The project is covered by ethics approvals from the respective medical schools, with datasets housed securely but accessible to researchers following established protocols.

In 2014, the MSOD project in Australia changed considerably in scope for reasons including a change of funder. There is now a single survey of final year students with the dataset being stored and managed by the Australian Institute of Health and Welfare on behalf of Medical Deans. It is intended that data will be linked to information in the annual medical workforce survey conducted by the national registration body. For now, New Zealand continues as a separate but linked arm of the MSOD project, collecting comprehensive data according to the original project method.

The MSOD project has been embraced by medical students, schools and other stakeholders in the medical workforce on both sides of the Tasman. To date, the Australian dataset contains information on over 32,000 participants,30 with the New Zealand dataset, over 4,000. Response rates in New Zealand are over 85% at entry and over 75% at exit, giving considerable power to answer workforce questions.

Selected early findings from MSOD

The NZ MSOD Steering Group collates data and regularly produces reports at a national level which are available through the MSOD (NZ) website (https://www.otago.ac.nz/medical-school/undergraduate/medicine/msod/).

The demography of recent New Zealand medical students is typified by the students who completed a CMSQ in 2017 (response rate 96%). Of these, 59% were female and 63% were under 20 years; the majority (93%) were New Zealand citizens or permanent residents, with 64% of all students born in New Zealand. Over a quarter of students (26%) considered they were from a rural background. Of the total, 57% self-identified as New Zealand European, 17% as Māori and 7% as Pacifica. Among those who attended secondary school in New Zealand, 43% went to a school in the Auckland region. Some of the MSOD reports have accumulated data over a number of years. Table 1 shows the career intentions of respondents who answered entry, exit and PGY1 questionnaires in the years shown. The top 10 specialties at each time point are in bold. It can be seen that some specialties hold increased interest over time (such as general practice, adult medicine, anaesthesia), and some less so (such as surgery, paediatrics).

Table 1: Career specialty intentions at three time points: entry to a New Zealand medical programme, exit and after PGY1.

The top 10 specialties at each timepoint are in bold.

Based on the same three cohorts, there are changes in the distribution of preferred location of practice over time (Table 2) with fewer preferring practice in a major city and more in a regional centre (p<0.00001).

Table 2: Intended location of practice at three time points: entry to a New Zealand medical programme, exit and after PGY1.

On completing their medical programme, students are asked to rate factors influencing their choice of specialty on a scale of 1, not at all, to 5, a great deal (see Table 3). We have not shown the individual data from year to year as it is remarkably consistent. As seen in the table, students report the most important factors influencing their career decisions relate to the nature of the work, including role models and intellectual content, and experiences during medical school. Moderately important are factors around work flexibility, appraisal of own circumstances and career prospects. Financial influences and prestige, along with length of training are perceived as relatively unimportant.

Table 3: Factors influencing choice of specialty at time of graduation for cohorts for 2013 to 2017 on a scale of 1, not at all, to 5, a great deal.

Comparisons between Australian and New Zealand medical students

As there are published summaries of exit student data in the two countries,it is possible to compare student career intentions. Despite differences in the education and health systems, there are striking similarities in the career intentions of students. Compared with forecast need, there is under-interest in general practice and in psychiatry, and over-interest in surgery. It is encouraging to see interest in rural and remote medicine among New Zealand students. However, it must be noted that fewer than half of graduates are certain of their specialty at this stage.

Table 4: Career intentions of graduating New Zealand and Australian medical students in 2017.

Longitudinally-linked rural data

Now that data have been collected at various time points for over a decade, it is possible to link individual student data longitudinally. This allows greater insight into whether intentions change, when they change, and factors associated with the change. Given the concern about the rural workforce, these were the first longitudinal research projects undertaken by NZ MSOD Steering Group. ‘Rural’ was defined as an area of 100,000 or fewer; ie, ‘regional-rural’.31,32 The studies found that about one fifth of New Zealand medical students come from a rural background, with most being admitted to medical school via a dedicated rural entry pathway. A third of all students intend to work in a rural setting. Half of students changing from a rural to urban career intention are rural students with these more than offset by urban students who switch to a rural intention. Rural background and rural intention at entry to medical school are each significantly associated with a rural intention at exit. One fifth of students have a persistent rural career intention at both entry and exit, with these students more likely to be female (68%), from a rural background (70%), New Zealand European (76%) or involved in a rural club for at least one year (45%).

Where to from here?

The majority of New Zealand students are still undecided on career intentions at the time of graduation, and for these doctors, it will be particularly important to track areas of interest in the early postgraduate years. These are years in which workplace environments, completion for training places and changes in personal circumstances such as parenting, may become more influential.

The NZ MSOD Steering Group has been collecting PGY1, PGY3 and PGY5 responses for several years. In 2019, the first PGY8 responses will be collected, by which stage most graduates will have differentiated into their chosen specialties. Hopefully the results will point to demographic, curricular, workplace or socio-political factors amenable to change, thus better aligning student and graduate intentions with health workforce needs. It will also allow exploration of associations with experiences in the early postgraduate years, such as the new community-based attachments for house officers.

The MSOD Steering Group’s priorities are to clarify which, if any, curriculum or training experiences influence a student towards an area of need such as general or rural practice. The group recognises the need for further work using definitions of ‘rural’ that relate to smaller or more isolated areas. On the whole, rural placements during medical school are less plentiful, and may cost more than those in large urban hospitals. Resource-constrained medical schools and healthcare providers33 are faced with questions such as: when and for how long should the placement occur? Should they be repeated? Which students are the ‘best bet’ in workforce terms to undertake extended general practice or rural placements? Another priority workforce to study is psychiatry. We also don’t know how careers of New Zealand students entering via equity or rural origin pathways develop and may best be supported. Does the medical school experience or the early postgraduate experience have more influence? The latter would guide workforce strategies, as it would inform whether any mismatch between student intentions and future workforce are due to student factors or the work/training environment following graduation.

To this end, the NZ MSOD Steering Group recently expanded to include staff from the Health Workforce Directorate in the Ministry of Health. The group is working to link career intention data with actual workforce outcomes from the annual practicing certificate data and subsequently the annual survey of the New Zealand medical workforce. This will allow greater confidence in determining the most important career predictors.

Conclusions

Longitudinal tracking projects such as MSOD take many years to realise their full potential.22 They rely on the goodwill and trust of students and doctors who complete surveys, as well as the support of multiple stakeholders. Important considerations are consistency of vision, method, relevant analyses and reporting. Ongoing resourcing is necessary. The MSOD project has been underway for over a decade and now has large datasets giving significant power to provide evidence to various stakeholders. Some of the key findings to date are:

  • Most New Zealand graduates wish to work in New Zealand.
  • Rural background is very important in rural career intention, justifying the rural preferential entry pathways to New Zealand medical schools.
  • Over time, fewer New Zealand students have an urban career intention, while rural and remote medicine is emerging as a career path.
  • Student perception places the major influence on career intention as ‘atmosphere/work culture typical of the discipline’. The importance of a range of positive undergraduate and early postgraduate experiences cannot be overstated, especially since most students are undecided at graduation. Specialties finding it difficult to attract sufficient numbers of trainees need to address factors that affect student choices.

Both medical schools remain strongly committed to the MSOD project, and intend to continue working with students, the Health Workforce Directorate and other stakeholders to ensure that the initial potential is realised. The NZ MSOD Steering Group welcomes feedback as well as collaboration with interested parties. Contact may be made with the Group through msod.project@otago.ac.nz.

Summary

Abstract

For over a decade, the Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) has collected data from medical students in Australia and New Zealand. This project aims to explore how individual student background or attributes might interact with curriculum or early postgraduate training to affect eventual career choice and location. In New Zealand, over 4,000 students have voluntarily provided information at various time points, and the project is at a stage where some firm conclusions are starting to be drawn. This paper presents the background to the project along with some early results and future directions.

Aim

Method

Results

Conclusion

Author Information

- Phillippa Poole, Head, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland; Tim J Wilkinson, Programme Director, University of Otago, Dunedin;- Warwick Bagg, Professor of Medicine, Faculty of Medical and Heal

Acknowledgements

'- The authors gratefully acknowledge the medical students/graduates who have completed questionnaires and agreed to the anonymised use of their responses. The New Zealand Medical Schools Outcomes Database and Longitudinal Tracking (MSOD) Project is fund

Correspondence

Professor Phillippa Poole, Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142.

Correspondence Email

p.poole@auckland.ac.nz

Competing Interests

Dr Poole and Ms Verstappen report grants from Health Workforce New Zealand during the conduct of the study.

  1. Medical Training Board. The future of the medical workforce: first annual report Nov 2007–Dec 2008. Wellington: Ministry of Health; 2009.
  2. Cox M, Hope S, Davies P. Ageing New Zealand and health and disability services demand projections and workforce implications 2001–2021: discussion document. Wellington: NZIER; 2004.
  3. Medical Council of New Zealand. The New Zealand Medical Workforce in 2016. Wellington: Medical Council of New Zealand; 2018.
  4. The Government’s health agenda. Ryall T, 2009. (Accessed 20 May 2010, at http://www.beehive.govt.nz/speech/tony+ryall+speech+-+government039s+health+agenda)
  5. Boelen C, Woollard B. Social accountability and accreditation: a new frontier for educational institutions. Med Educ 2009; 43:887–94.
  6. Hseuh W, Wilkinson T, Bills J. What evidence-based undergraduate interventions promote rural health? N Z Med J 2004; 117:U1117.
  7. Farry P, Williamson M. Aligning medical education with the healthcare needs of the population. N Z Med J 2004; 117:1114.
  8. Poole P, Bagg W, O’Connor B, et al. The Northland Regional-Rural program (Pūkawakawa): broadening medical undergraduate learning in New Zealand. Rural Remote Health 2010; 10:1254. Epub 2010 Mar 1
  9. Playford D, Ngo H, Gupta S, Puddey IB. Opting for rural practice: the influence of medical student origin, intention and immersion experience. Med JAust 2017; 207:154–8.
  10. Lakhan S. Diversification of U.S. medical schools via affirmative action implementation. BMC Med Educ 2003; 3:1–6.
  11. Allen I. Women doctors and their careers: what now? BMJ 2005; 331:569–72.
  12. Lawrence J, Poole P. Career and life experiences of New Zealand women medical graduates. NZ Med J 2001; 114:537–40.
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  19. Rourke J, Asghari S, Hurley O, Ravalia M, Jong M, Graham W, et al. Does rural generalist focused medical school and family medicine training make a difference? Memorial University of Newfoundland outcomes. Rural Remote Health. 2018 Mar; 18(1):4426.
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Almost all students who enter medical school go on to practise medicine. Their education and training is expensive both to the taxpayer and to individual students, requiring input from multiple stakeholders including communities, universities, hospitals, general practices, the Medical Council of New Zealand and postgraduate colleges. These stakeholders reasonably expect a medical workforce to address health needs. For decades, New Zealand has been heavily reliant on International Medical Graduates (IMGs) to fill shortages especially in general practice and psychiatry, or in rural areas.1–3 As a result, over 40% of New Zealand’s current medical workforce received their medical degree overseas. In the 2016 New Zealand workforce survey, general practitioners comprised around 33% of the workforce and psychiatrists, 6.5%.3 To meet future primary care demands created by an ageing population with more chronic or complex disease, along with a preference for reduced hours of work by doctors, it is estimated that the proportion of general practitioners needs to be higher.1 In response to current and anticipated workforce shortages and to reduce reliance on IMGs, the Government has recently increased New Zealand’s medical student numbers.4 Medical schools have a key role in identifying students with favourable attributes and providing them with formative undergraduate experiences as important first steps in workforce development.5 The resulting graduate cohorts must be disposed towards the full range of vocational scopes.2 However, evidence for what influences career choice at the undergraduate stage is relatively limited.

It is well-established that students from rural backgrounds are more than twice as likely as other students to enter rural practice.6 This was the rationale for the establishment of dedicated rural admission pathways at the Universities of Auckland and Otago in 2003. Furthermore, rural placements during medical programmes increase the likelihood of practising in rural locations in the longer term, over and above background.7–9 Again, both schools provide these experiences for all students. Moreover, there are long-standing equity pathways for admission of students who are Māori or with Pacific ancestry. Proportions of these students in recent medical classes now approximate those in the general population. International evidence suggests these students may be more likely to choose to work in underserved areas.10 Women are more likely than men to work in careers with more ‘predictable’ work patterns such as general practice, or in work environments which are perceived as more flexible or family-friendly.11–15

The context and mission of the medical school itself may affect how curriculum resources are allocated, as well as what types of students might apply or be selected. A common assumption is that spending more time in a specific medical school attachment may result in greater interest in a particular specialty. Yet, are people who have experiences in a particular specialty more interested in that specialty because of that experience (causation), or because they were already interested and that’s why they elected to get more experience in it (association)? Might there be serendipity such as being exposed to role models at crucial times? The quality of that experience or role models may be influential, but this might be positive or negative.16,17 Furthermore, media portrayal and the attitudes of family and friends may influence early career decisions.18 How a medical school articulates with postgraduate training may be important in maintaining pathways to specific careers.19

Collecting prospective data from medical students and early postgraduate doctors enables the exploration of how individual student background or attributes might interact with curriculum or early postgraduate training to affect eventual career choice and location. This information may prove useful for regarding the required future medical workforce both in terms of numbers and in aptitude for the range of careers needed.

Existing studies elsewhere

Workforce surveys provide cross-sectional information that describe the demography and distribution of the medical workforce at one time point. When conducted iteratively, trends or areas of current or future shortages may be signalled. These data might be useful in arguing for more training places, but are of limited value in clarifying factors influencing medical workforce development. For example, a study in the UK showed the proportion of graduates indicating an interest in general practice ranged from 11% at Oxford to 33% at Birmingham2 but the factors driving this were not clear.

Prospective longitudinal tracking helps an understanding of how the medical workforce develops and factors affecting career choices, particularly if the experiences and types of training gained over time are captured. For example, since 1972, careers of graduates from a rural medical school in Pennsylvania have been tracked.21 Over 45% of medical students who had all three characteristics of a rural background, intention to practice rurally, and intention to practice in family medicine eventually worked in a rural area.22 Furthermore, 70% of those who entered rural practice soon after medical school were still there two or three decades later.23

Longitudinal studies in the UK have clarified the predictive ability of a range of selection tools and career intentions through medical training.24–27 Intentions at one year post-graduation (PGY1) matched eventual career for just over half of doctors, while over 80% of intentions at PGY5 were realised.25 Closer matches were seen in some specialties, such as surgery, or when doctors were more definite about their intentions early on. General practice was the destination of about half of those who had initially embarked on a hospital specialty but who subsequently changed their minds.27

The Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD)

In the early 2000s, the Deans of medical schools in Australia and New Zealand embarked on an ambitious project to explore how individual student background or attributes might interact with curriculum or early postgraduate training to impact on eventual career choice and location. In Australia, a driver was to justify Commonwealth investment in rural clinical schools in terms of rural workforce enhancement. The Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) emerged as the world’s first bi-national medical workforce study aiming to track students from all Australian and New Zealand medical schools from selection, through their medical school programme, into postgraduate training, and thence practice.28,29 The MSOD project secretariat was housed in Sydney, with funding from the Australian government and the Medical Deans.

The original MSOD design invited students to participate in a Commencing Medical Students Questionnaire (CMSQ) at entry, an exit questionnaire (EQ) at graduation, followed by further surveys at PGY 1, 3, 5 and 8. In order to distil curriculum effect from student factors, it was deemed important to understand levels of interest in various disciplines at entry into medical school. This was to be supplemented by medical school data on aspects of the curriculum experienced by each participant. There was thought to be sufficient diversity among the 23 Australasian medical programmes to provide insights into the effect of different curriculum factors and environments as predictors of career paths.

The MSOD project began enrolling participants in Australia in 2005, with the University of Otago following from 2007 and the University of Auckland from 2012. For Auckland medical students, MSOD superseded a career tracking project involving all health professional students underway since 2006. Since 2012, the NZ MSOD Steering Group has coordinated the efforts of the two New Zealand medical schools, supported by funding from Health Workforce New Zealand (HWNZ) plus in-kind support from both universities. The project is covered by ethics approvals from the respective medical schools, with datasets housed securely but accessible to researchers following established protocols.

In 2014, the MSOD project in Australia changed considerably in scope for reasons including a change of funder. There is now a single survey of final year students with the dataset being stored and managed by the Australian Institute of Health and Welfare on behalf of Medical Deans. It is intended that data will be linked to information in the annual medical workforce survey conducted by the national registration body. For now, New Zealand continues as a separate but linked arm of the MSOD project, collecting comprehensive data according to the original project method.

The MSOD project has been embraced by medical students, schools and other stakeholders in the medical workforce on both sides of the Tasman. To date, the Australian dataset contains information on over 32,000 participants,30 with the New Zealand dataset, over 4,000. Response rates in New Zealand are over 85% at entry and over 75% at exit, giving considerable power to answer workforce questions.

Selected early findings from MSOD

The NZ MSOD Steering Group collates data and regularly produces reports at a national level which are available through the MSOD (NZ) website (https://www.otago.ac.nz/medical-school/undergraduate/medicine/msod/).

The demography of recent New Zealand medical students is typified by the students who completed a CMSQ in 2017 (response rate 96%). Of these, 59% were female and 63% were under 20 years; the majority (93%) were New Zealand citizens or permanent residents, with 64% of all students born in New Zealand. Over a quarter of students (26%) considered they were from a rural background. Of the total, 57% self-identified as New Zealand European, 17% as Māori and 7% as Pacifica. Among those who attended secondary school in New Zealand, 43% went to a school in the Auckland region. Some of the MSOD reports have accumulated data over a number of years. Table 1 shows the career intentions of respondents who answered entry, exit and PGY1 questionnaires in the years shown. The top 10 specialties at each time point are in bold. It can be seen that some specialties hold increased interest over time (such as general practice, adult medicine, anaesthesia), and some less so (such as surgery, paediatrics).

Table 1: Career specialty intentions at three time points: entry to a New Zealand medical programme, exit and after PGY1.

The top 10 specialties at each timepoint are in bold.

Based on the same three cohorts, there are changes in the distribution of preferred location of practice over time (Table 2) with fewer preferring practice in a major city and more in a regional centre (p<0.00001).

Table 2: Intended location of practice at three time points: entry to a New Zealand medical programme, exit and after PGY1.

On completing their medical programme, students are asked to rate factors influencing their choice of specialty on a scale of 1, not at all, to 5, a great deal (see Table 3). We have not shown the individual data from year to year as it is remarkably consistent. As seen in the table, students report the most important factors influencing their career decisions relate to the nature of the work, including role models and intellectual content, and experiences during medical school. Moderately important are factors around work flexibility, appraisal of own circumstances and career prospects. Financial influences and prestige, along with length of training are perceived as relatively unimportant.

Table 3: Factors influencing choice of specialty at time of graduation for cohorts for 2013 to 2017 on a scale of 1, not at all, to 5, a great deal.

Comparisons between Australian and New Zealand medical students

As there are published summaries of exit student data in the two countries,it is possible to compare student career intentions. Despite differences in the education and health systems, there are striking similarities in the career intentions of students. Compared with forecast need, there is under-interest in general practice and in psychiatry, and over-interest in surgery. It is encouraging to see interest in rural and remote medicine among New Zealand students. However, it must be noted that fewer than half of graduates are certain of their specialty at this stage.

Table 4: Career intentions of graduating New Zealand and Australian medical students in 2017.

Longitudinally-linked rural data

Now that data have been collected at various time points for over a decade, it is possible to link individual student data longitudinally. This allows greater insight into whether intentions change, when they change, and factors associated with the change. Given the concern about the rural workforce, these were the first longitudinal research projects undertaken by NZ MSOD Steering Group. ‘Rural’ was defined as an area of 100,000 or fewer; ie, ‘regional-rural’.31,32 The studies found that about one fifth of New Zealand medical students come from a rural background, with most being admitted to medical school via a dedicated rural entry pathway. A third of all students intend to work in a rural setting. Half of students changing from a rural to urban career intention are rural students with these more than offset by urban students who switch to a rural intention. Rural background and rural intention at entry to medical school are each significantly associated with a rural intention at exit. One fifth of students have a persistent rural career intention at both entry and exit, with these students more likely to be female (68%), from a rural background (70%), New Zealand European (76%) or involved in a rural club for at least one year (45%).

Where to from here?

The majority of New Zealand students are still undecided on career intentions at the time of graduation, and for these doctors, it will be particularly important to track areas of interest in the early postgraduate years. These are years in which workplace environments, completion for training places and changes in personal circumstances such as parenting, may become more influential.

The NZ MSOD Steering Group has been collecting PGY1, PGY3 and PGY5 responses for several years. In 2019, the first PGY8 responses will be collected, by which stage most graduates will have differentiated into their chosen specialties. Hopefully the results will point to demographic, curricular, workplace or socio-political factors amenable to change, thus better aligning student and graduate intentions with health workforce needs. It will also allow exploration of associations with experiences in the early postgraduate years, such as the new community-based attachments for house officers.

The MSOD Steering Group’s priorities are to clarify which, if any, curriculum or training experiences influence a student towards an area of need such as general or rural practice. The group recognises the need for further work using definitions of ‘rural’ that relate to smaller or more isolated areas. On the whole, rural placements during medical school are less plentiful, and may cost more than those in large urban hospitals. Resource-constrained medical schools and healthcare providers33 are faced with questions such as: when and for how long should the placement occur? Should they be repeated? Which students are the ‘best bet’ in workforce terms to undertake extended general practice or rural placements? Another priority workforce to study is psychiatry. We also don’t know how careers of New Zealand students entering via equity or rural origin pathways develop and may best be supported. Does the medical school experience or the early postgraduate experience have more influence? The latter would guide workforce strategies, as it would inform whether any mismatch between student intentions and future workforce are due to student factors or the work/training environment following graduation.

To this end, the NZ MSOD Steering Group recently expanded to include staff from the Health Workforce Directorate in the Ministry of Health. The group is working to link career intention data with actual workforce outcomes from the annual practicing certificate data and subsequently the annual survey of the New Zealand medical workforce. This will allow greater confidence in determining the most important career predictors.

Conclusions

Longitudinal tracking projects such as MSOD take many years to realise their full potential.22 They rely on the goodwill and trust of students and doctors who complete surveys, as well as the support of multiple stakeholders. Important considerations are consistency of vision, method, relevant analyses and reporting. Ongoing resourcing is necessary. The MSOD project has been underway for over a decade and now has large datasets giving significant power to provide evidence to various stakeholders. Some of the key findings to date are:

  • Most New Zealand graduates wish to work in New Zealand.
  • Rural background is very important in rural career intention, justifying the rural preferential entry pathways to New Zealand medical schools.
  • Over time, fewer New Zealand students have an urban career intention, while rural and remote medicine is emerging as a career path.
  • Student perception places the major influence on career intention as ‘atmosphere/work culture typical of the discipline’. The importance of a range of positive undergraduate and early postgraduate experiences cannot be overstated, especially since most students are undecided at graduation. Specialties finding it difficult to attract sufficient numbers of trainees need to address factors that affect student choices.

Both medical schools remain strongly committed to the MSOD project, and intend to continue working with students, the Health Workforce Directorate and other stakeholders to ensure that the initial potential is realised. The NZ MSOD Steering Group welcomes feedback as well as collaboration with interested parties. Contact may be made with the Group through msod.project@otago.ac.nz.

Summary

Abstract

For over a decade, the Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) has collected data from medical students in Australia and New Zealand. This project aims to explore how individual student background or attributes might interact with curriculum or early postgraduate training to affect eventual career choice and location. In New Zealand, over 4,000 students have voluntarily provided information at various time points, and the project is at a stage where some firm conclusions are starting to be drawn. This paper presents the background to the project along with some early results and future directions.

Aim

Method

Results

Conclusion

Author Information

- Phillippa Poole, Head, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland; Tim J Wilkinson, Programme Director, University of Otago, Dunedin;- Warwick Bagg, Professor of Medicine, Faculty of Medical and Heal

Acknowledgements

'- The authors gratefully acknowledge the medical students/graduates who have completed questionnaires and agreed to the anonymised use of their responses. The New Zealand Medical Schools Outcomes Database and Longitudinal Tracking (MSOD) Project is fund

Correspondence

Professor Phillippa Poole, Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142.

Correspondence Email

p.poole@auckland.ac.nz

Competing Interests

Dr Poole and Ms Verstappen report grants from Health Workforce New Zealand during the conduct of the study.

  1. Medical Training Board. The future of the medical workforce: first annual report Nov 2007–Dec 2008. Wellington: Ministry of Health; 2009.
  2. Cox M, Hope S, Davies P. Ageing New Zealand and health and disability services demand projections and workforce implications 2001–2021: discussion document. Wellington: NZIER; 2004.
  3. Medical Council of New Zealand. The New Zealand Medical Workforce in 2016. Wellington: Medical Council of New Zealand; 2018.
  4. The Government’s health agenda. Ryall T, 2009. (Accessed 20 May 2010, at http://www.beehive.govt.nz/speech/tony+ryall+speech+-+government039s+health+agenda)
  5. Boelen C, Woollard B. Social accountability and accreditation: a new frontier for educational institutions. Med Educ 2009; 43:887–94.
  6. Hseuh W, Wilkinson T, Bills J. What evidence-based undergraduate interventions promote rural health? N Z Med J 2004; 117:U1117.
  7. Farry P, Williamson M. Aligning medical education with the healthcare needs of the population. N Z Med J 2004; 117:1114.
  8. Poole P, Bagg W, O’Connor B, et al. The Northland Regional-Rural program (Pūkawakawa): broadening medical undergraduate learning in New Zealand. Rural Remote Health 2010; 10:1254. Epub 2010 Mar 1
  9. Playford D, Ngo H, Gupta S, Puddey IB. Opting for rural practice: the influence of medical student origin, intention and immersion experience. Med JAust 2017; 207:154–8.
  10. Lakhan S. Diversification of U.S. medical schools via affirmative action implementation. BMC Med Educ 2003; 3:1–6.
  11. Allen I. Women doctors and their careers: what now? BMJ 2005; 331:569–72.
  12. Lawrence J, Poole P. Career and life experiences of New Zealand women medical graduates. NZ Med J 2001; 114:537–40.
  13. Kilminster S, Downes J, Gough B, Murdoch-Eaton D, Roberts T. Women in medicine - is there a problem? A literature review of the changing gender composition, structures and occupational cultures in medicine. Med Educ 2007; 41:39–49.
  14. Angell M. Women in medicine:beyond prejudice. N Engl J Med 1981; 304:1161–3.
  15. Baroness Deech. Women in medicine: making a difference. London: Department of Health; Oct 2009.
  16. Parker J, Hudson B, Wilkinson TJ. Influences on final year medical students’ attitudes to general practice as a career. J Prim Health Care 2014; 6:56–63.
  17. Lambert TW, Smith F, Goldacre MJ. Trends in attractiveness of general practice as a career: surveys of views of UK-trained doctors. Br J Gen Pract 2017; 67:e238–e24.
  18. Parker J, Hudson B, Wilkinson TJ. Influences on final year medical students’ attitudes to general practice as a career. J Prim Health Care 2014; 6:56–63.
  19. Rourke J, Asghari S, Hurley O, Ravalia M, Jong M, Graham W, et al. Does rural generalist focused medical school and family medicine training make a difference? Memorial University of Newfoundland outcomes. Rural Remote Health. 2018 Mar; 18(1):4426.
  20. Goldacre M, Turner G, Lambert T. Variation by medical school in career choices of UK graduates of 1999 and 2000. Med Educ 2004; 38:249–58.
  21. Rabinowitz H. Recruitment, retention, and follow-up of graduates of a program to increase the number of family physicians in rural and underserved areas. N Engl J Med 1993; 328:934–9.
  22. Rabinowitz H, Diamond J, Markham F, Santana A. The relationship between entering medical students’ backgrounds and career plans and their rural practice outcomes three decades later. Acad Med 2012; 87:493–7.
  23. Rabinowitz H, Diamond J, Markham F, Santana A. Retention of rural family physicians after 20–25 years: outcomes of a comprehensive medical school rural program. J Am Board Fam Med 2013; 26:24–7.
  24. McManus I, Smithers E, Partridge P, Keeling A, Fleming P. A levels and intelligence as predictors of medical careers in UK doctors: a 20 year prospective study. BMJ 2003; 327:139–42.
  25. Goldacre M, Laxton L, Lambert T. Medical graduates’ early career choices of specialty and their eventual specialty destinations: UK prospective cohort studies. BMJ 2010; 341:c3199.
  26. Lambert T, Goldacre M, Davidson J, Parkhouse J. Graduate status and age at entry to medical school as predictors of doctors’ choice of long-term career. Med Educ 2001; 35:450–4.
  27. Lambert T, Goldacre M. Trends in doctors’ early career choices for general practice in the UK: longitudinal questionnaire surveys. Br J Gen Pract 2011; 61:e397–e403.
  28. Medical Deans Australia and New Zealand. Overview of Medical Deans Australia & New Zealand Medical Schools Outcomes Database (MSOD) & longitudinal tracking project. Sydney: Medical Deans Australia and New Zealand; 2008.
  29. Kaur B, Roberton D, Glasgow N. Evidence-based medical workforce planning and education: the MSOD project. Med J Aust 2013; 198:518–9.
  30. Medical Deans Australia and New Zealand. Medical Schools Outcomes Database. National Data Report 2013-2017. Sydney: Medical Deans Australia and New Zealand 2018. Available from http://www.medicaldeans.org.au/projects-activities/msodproject/
  31. Poole P, Stoner T, Verstappen A, Bagg W. Medical students: where have they come from; where are they going? NZ Med J 2016; 129:1435.
  32. Kent M, Verstappen A, Wilkinson TJ, Poole P. Keeping them interested – a national study of factors that change medical student interest in working rurally Rural Remote Health 2018; 18(4):4872.
  33. Hays R. The utilisation of the health care system for authentic early experience placements. Rural Remote Health 2013; 13:2328.

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Almost all students who enter medical school go on to practise medicine. Their education and training is expensive both to the taxpayer and to individual students, requiring input from multiple stakeholders including communities, universities, hospitals, general practices, the Medical Council of New Zealand and postgraduate colleges. These stakeholders reasonably expect a medical workforce to address health needs. For decades, New Zealand has been heavily reliant on International Medical Graduates (IMGs) to fill shortages especially in general practice and psychiatry, or in rural areas.1–3 As a result, over 40% of New Zealand’s current medical workforce received their medical degree overseas. In the 2016 New Zealand workforce survey, general practitioners comprised around 33% of the workforce and psychiatrists, 6.5%.3 To meet future primary care demands created by an ageing population with more chronic or complex disease, along with a preference for reduced hours of work by doctors, it is estimated that the proportion of general practitioners needs to be higher.1 In response to current and anticipated workforce shortages and to reduce reliance on IMGs, the Government has recently increased New Zealand’s medical student numbers.4 Medical schools have a key role in identifying students with favourable attributes and providing them with formative undergraduate experiences as important first steps in workforce development.5 The resulting graduate cohorts must be disposed towards the full range of vocational scopes.2 However, evidence for what influences career choice at the undergraduate stage is relatively limited.

It is well-established that students from rural backgrounds are more than twice as likely as other students to enter rural practice.6 This was the rationale for the establishment of dedicated rural admission pathways at the Universities of Auckland and Otago in 2003. Furthermore, rural placements during medical programmes increase the likelihood of practising in rural locations in the longer term, over and above background.7–9 Again, both schools provide these experiences for all students. Moreover, there are long-standing equity pathways for admission of students who are Māori or with Pacific ancestry. Proportions of these students in recent medical classes now approximate those in the general population. International evidence suggests these students may be more likely to choose to work in underserved areas.10 Women are more likely than men to work in careers with more ‘predictable’ work patterns such as general practice, or in work environments which are perceived as more flexible or family-friendly.11–15

The context and mission of the medical school itself may affect how curriculum resources are allocated, as well as what types of students might apply or be selected. A common assumption is that spending more time in a specific medical school attachment may result in greater interest in a particular specialty. Yet, are people who have experiences in a particular specialty more interested in that specialty because of that experience (causation), or because they were already interested and that’s why they elected to get more experience in it (association)? Might there be serendipity such as being exposed to role models at crucial times? The quality of that experience or role models may be influential, but this might be positive or negative.16,17 Furthermore, media portrayal and the attitudes of family and friends may influence early career decisions.18 How a medical school articulates with postgraduate training may be important in maintaining pathways to specific careers.19

Collecting prospective data from medical students and early postgraduate doctors enables the exploration of how individual student background or attributes might interact with curriculum or early postgraduate training to affect eventual career choice and location. This information may prove useful for regarding the required future medical workforce both in terms of numbers and in aptitude for the range of careers needed.

Existing studies elsewhere

Workforce surveys provide cross-sectional information that describe the demography and distribution of the medical workforce at one time point. When conducted iteratively, trends or areas of current or future shortages may be signalled. These data might be useful in arguing for more training places, but are of limited value in clarifying factors influencing medical workforce development. For example, a study in the UK showed the proportion of graduates indicating an interest in general practice ranged from 11% at Oxford to 33% at Birmingham2 but the factors driving this were not clear.

Prospective longitudinal tracking helps an understanding of how the medical workforce develops and factors affecting career choices, particularly if the experiences and types of training gained over time are captured. For example, since 1972, careers of graduates from a rural medical school in Pennsylvania have been tracked.21 Over 45% of medical students who had all three characteristics of a rural background, intention to practice rurally, and intention to practice in family medicine eventually worked in a rural area.22 Furthermore, 70% of those who entered rural practice soon after medical school were still there two or three decades later.23

Longitudinal studies in the UK have clarified the predictive ability of a range of selection tools and career intentions through medical training.24–27 Intentions at one year post-graduation (PGY1) matched eventual career for just over half of doctors, while over 80% of intentions at PGY5 were realised.25 Closer matches were seen in some specialties, such as surgery, or when doctors were more definite about their intentions early on. General practice was the destination of about half of those who had initially embarked on a hospital specialty but who subsequently changed their minds.27

The Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD)

In the early 2000s, the Deans of medical schools in Australia and New Zealand embarked on an ambitious project to explore how individual student background or attributes might interact with curriculum or early postgraduate training to impact on eventual career choice and location. In Australia, a driver was to justify Commonwealth investment in rural clinical schools in terms of rural workforce enhancement. The Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) emerged as the world’s first bi-national medical workforce study aiming to track students from all Australian and New Zealand medical schools from selection, through their medical school programme, into postgraduate training, and thence practice.28,29 The MSOD project secretariat was housed in Sydney, with funding from the Australian government and the Medical Deans.

The original MSOD design invited students to participate in a Commencing Medical Students Questionnaire (CMSQ) at entry, an exit questionnaire (EQ) at graduation, followed by further surveys at PGY 1, 3, 5 and 8. In order to distil curriculum effect from student factors, it was deemed important to understand levels of interest in various disciplines at entry into medical school. This was to be supplemented by medical school data on aspects of the curriculum experienced by each participant. There was thought to be sufficient diversity among the 23 Australasian medical programmes to provide insights into the effect of different curriculum factors and environments as predictors of career paths.

The MSOD project began enrolling participants in Australia in 2005, with the University of Otago following from 2007 and the University of Auckland from 2012. For Auckland medical students, MSOD superseded a career tracking project involving all health professional students underway since 2006. Since 2012, the NZ MSOD Steering Group has coordinated the efforts of the two New Zealand medical schools, supported by funding from Health Workforce New Zealand (HWNZ) plus in-kind support from both universities. The project is covered by ethics approvals from the respective medical schools, with datasets housed securely but accessible to researchers following established protocols.

In 2014, the MSOD project in Australia changed considerably in scope for reasons including a change of funder. There is now a single survey of final year students with the dataset being stored and managed by the Australian Institute of Health and Welfare on behalf of Medical Deans. It is intended that data will be linked to information in the annual medical workforce survey conducted by the national registration body. For now, New Zealand continues as a separate but linked arm of the MSOD project, collecting comprehensive data according to the original project method.

The MSOD project has been embraced by medical students, schools and other stakeholders in the medical workforce on both sides of the Tasman. To date, the Australian dataset contains information on over 32,000 participants,30 with the New Zealand dataset, over 4,000. Response rates in New Zealand are over 85% at entry and over 75% at exit, giving considerable power to answer workforce questions.

Selected early findings from MSOD

The NZ MSOD Steering Group collates data and regularly produces reports at a national level which are available through the MSOD (NZ) website (https://www.otago.ac.nz/medical-school/undergraduate/medicine/msod/).

The demography of recent New Zealand medical students is typified by the students who completed a CMSQ in 2017 (response rate 96%). Of these, 59% were female and 63% were under 20 years; the majority (93%) were New Zealand citizens or permanent residents, with 64% of all students born in New Zealand. Over a quarter of students (26%) considered they were from a rural background. Of the total, 57% self-identified as New Zealand European, 17% as Māori and 7% as Pacifica. Among those who attended secondary school in New Zealand, 43% went to a school in the Auckland region. Some of the MSOD reports have accumulated data over a number of years. Table 1 shows the career intentions of respondents who answered entry, exit and PGY1 questionnaires in the years shown. The top 10 specialties at each time point are in bold. It can be seen that some specialties hold increased interest over time (such as general practice, adult medicine, anaesthesia), and some less so (such as surgery, paediatrics).

Table 1: Career specialty intentions at three time points: entry to a New Zealand medical programme, exit and after PGY1.

The top 10 specialties at each timepoint are in bold.

Based on the same three cohorts, there are changes in the distribution of preferred location of practice over time (Table 2) with fewer preferring practice in a major city and more in a regional centre (p<0.00001).

Table 2: Intended location of practice at three time points: entry to a New Zealand medical programme, exit and after PGY1.

On completing their medical programme, students are asked to rate factors influencing their choice of specialty on a scale of 1, not at all, to 5, a great deal (see Table 3). We have not shown the individual data from year to year as it is remarkably consistent. As seen in the table, students report the most important factors influencing their career decisions relate to the nature of the work, including role models and intellectual content, and experiences during medical school. Moderately important are factors around work flexibility, appraisal of own circumstances and career prospects. Financial influences and prestige, along with length of training are perceived as relatively unimportant.

Table 3: Factors influencing choice of specialty at time of graduation for cohorts for 2013 to 2017 on a scale of 1, not at all, to 5, a great deal.

Comparisons between Australian and New Zealand medical students

As there are published summaries of exit student data in the two countries,it is possible to compare student career intentions. Despite differences in the education and health systems, there are striking similarities in the career intentions of students. Compared with forecast need, there is under-interest in general practice and in psychiatry, and over-interest in surgery. It is encouraging to see interest in rural and remote medicine among New Zealand students. However, it must be noted that fewer than half of graduates are certain of their specialty at this stage.

Table 4: Career intentions of graduating New Zealand and Australian medical students in 2017.

Longitudinally-linked rural data

Now that data have been collected at various time points for over a decade, it is possible to link individual student data longitudinally. This allows greater insight into whether intentions change, when they change, and factors associated with the change. Given the concern about the rural workforce, these were the first longitudinal research projects undertaken by NZ MSOD Steering Group. ‘Rural’ was defined as an area of 100,000 or fewer; ie, ‘regional-rural’.31,32 The studies found that about one fifth of New Zealand medical students come from a rural background, with most being admitted to medical school via a dedicated rural entry pathway. A third of all students intend to work in a rural setting. Half of students changing from a rural to urban career intention are rural students with these more than offset by urban students who switch to a rural intention. Rural background and rural intention at entry to medical school are each significantly associated with a rural intention at exit. One fifth of students have a persistent rural career intention at both entry and exit, with these students more likely to be female (68%), from a rural background (70%), New Zealand European (76%) or involved in a rural club for at least one year (45%).

Where to from here?

The majority of New Zealand students are still undecided on career intentions at the time of graduation, and for these doctors, it will be particularly important to track areas of interest in the early postgraduate years. These are years in which workplace environments, completion for training places and changes in personal circumstances such as parenting, may become more influential.

The NZ MSOD Steering Group has been collecting PGY1, PGY3 and PGY5 responses for several years. In 2019, the first PGY8 responses will be collected, by which stage most graduates will have differentiated into their chosen specialties. Hopefully the results will point to demographic, curricular, workplace or socio-political factors amenable to change, thus better aligning student and graduate intentions with health workforce needs. It will also allow exploration of associations with experiences in the early postgraduate years, such as the new community-based attachments for house officers.

The MSOD Steering Group’s priorities are to clarify which, if any, curriculum or training experiences influence a student towards an area of need such as general or rural practice. The group recognises the need for further work using definitions of ‘rural’ that relate to smaller or more isolated areas. On the whole, rural placements during medical school are less plentiful, and may cost more than those in large urban hospitals. Resource-constrained medical schools and healthcare providers33 are faced with questions such as: when and for how long should the placement occur? Should they be repeated? Which students are the ‘best bet’ in workforce terms to undertake extended general practice or rural placements? Another priority workforce to study is psychiatry. We also don’t know how careers of New Zealand students entering via equity or rural origin pathways develop and may best be supported. Does the medical school experience or the early postgraduate experience have more influence? The latter would guide workforce strategies, as it would inform whether any mismatch between student intentions and future workforce are due to student factors or the work/training environment following graduation.

To this end, the NZ MSOD Steering Group recently expanded to include staff from the Health Workforce Directorate in the Ministry of Health. The group is working to link career intention data with actual workforce outcomes from the annual practicing certificate data and subsequently the annual survey of the New Zealand medical workforce. This will allow greater confidence in determining the most important career predictors.

Conclusions

Longitudinal tracking projects such as MSOD take many years to realise their full potential.22 They rely on the goodwill and trust of students and doctors who complete surveys, as well as the support of multiple stakeholders. Important considerations are consistency of vision, method, relevant analyses and reporting. Ongoing resourcing is necessary. The MSOD project has been underway for over a decade and now has large datasets giving significant power to provide evidence to various stakeholders. Some of the key findings to date are:

  • Most New Zealand graduates wish to work in New Zealand.
  • Rural background is very important in rural career intention, justifying the rural preferential entry pathways to New Zealand medical schools.
  • Over time, fewer New Zealand students have an urban career intention, while rural and remote medicine is emerging as a career path.
  • Student perception places the major influence on career intention as ‘atmosphere/work culture typical of the discipline’. The importance of a range of positive undergraduate and early postgraduate experiences cannot be overstated, especially since most students are undecided at graduation. Specialties finding it difficult to attract sufficient numbers of trainees need to address factors that affect student choices.

Both medical schools remain strongly committed to the MSOD project, and intend to continue working with students, the Health Workforce Directorate and other stakeholders to ensure that the initial potential is realised. The NZ MSOD Steering Group welcomes feedback as well as collaboration with interested parties. Contact may be made with the Group through msod.project@otago.ac.nz.

Summary

Abstract

For over a decade, the Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) has collected data from medical students in Australia and New Zealand. This project aims to explore how individual student background or attributes might interact with curriculum or early postgraduate training to affect eventual career choice and location. In New Zealand, over 4,000 students have voluntarily provided information at various time points, and the project is at a stage where some firm conclusions are starting to be drawn. This paper presents the background to the project along with some early results and future directions.

Aim

Method

Results

Conclusion

Author Information

- Phillippa Poole, Head, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland; Tim J Wilkinson, Programme Director, University of Otago, Dunedin;- Warwick Bagg, Professor of Medicine, Faculty of Medical and Heal

Acknowledgements

'- The authors gratefully acknowledge the medical students/graduates who have completed questionnaires and agreed to the anonymised use of their responses. The New Zealand Medical Schools Outcomes Database and Longitudinal Tracking (MSOD) Project is fund

Correspondence

Professor Phillippa Poole, Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland 1142.

Correspondence Email

p.poole@auckland.ac.nz

Competing Interests

Dr Poole and Ms Verstappen report grants from Health Workforce New Zealand during the conduct of the study.

  1. Medical Training Board. The future of the medical workforce: first annual report Nov 2007–Dec 2008. Wellington: Ministry of Health; 2009.
  2. Cox M, Hope S, Davies P. Ageing New Zealand and health and disability services demand projections and workforce implications 2001–2021: discussion document. Wellington: NZIER; 2004.
  3. Medical Council of New Zealand. The New Zealand Medical Workforce in 2016. Wellington: Medical Council of New Zealand; 2018.
  4. The Government’s health agenda. Ryall T, 2009. (Accessed 20 May 2010, at http://www.beehive.govt.nz/speech/tony+ryall+speech+-+government039s+health+agenda)
  5. Boelen C, Woollard B. Social accountability and accreditation: a new frontier for educational institutions. Med Educ 2009; 43:887–94.
  6. Hseuh W, Wilkinson T, Bills J. What evidence-based undergraduate interventions promote rural health? N Z Med J 2004; 117:U1117.
  7. Farry P, Williamson M. Aligning medical education with the healthcare needs of the population. N Z Med J 2004; 117:1114.
  8. Poole P, Bagg W, O’Connor B, et al. The Northland Regional-Rural program (Pūkawakawa): broadening medical undergraduate learning in New Zealand. Rural Remote Health 2010; 10:1254. Epub 2010 Mar 1
  9. Playford D, Ngo H, Gupta S, Puddey IB. Opting for rural practice: the influence of medical student origin, intention and immersion experience. Med JAust 2017; 207:154–8.
  10. Lakhan S. Diversification of U.S. medical schools via affirmative action implementation. BMC Med Educ 2003; 3:1–6.
  11. Allen I. Women doctors and their careers: what now? BMJ 2005; 331:569–72.
  12. Lawrence J, Poole P. Career and life experiences of New Zealand women medical graduates. NZ Med J 2001; 114:537–40.
  13. Kilminster S, Downes J, Gough B, Murdoch-Eaton D, Roberts T. Women in medicine - is there a problem? A literature review of the changing gender composition, structures and occupational cultures in medicine. Med Educ 2007; 41:39–49.
  14. Angell M. Women in medicine:beyond prejudice. N Engl J Med 1981; 304:1161–3.
  15. Baroness Deech. Women in medicine: making a difference. London: Department of Health; Oct 2009.
  16. Parker J, Hudson B, Wilkinson TJ. Influences on final year medical students’ attitudes to general practice as a career. J Prim Health Care 2014; 6:56–63.
  17. Lambert TW, Smith F, Goldacre MJ. Trends in attractiveness of general practice as a career: surveys of views of UK-trained doctors. Br J Gen Pract 2017; 67:e238–e24.
  18. Parker J, Hudson B, Wilkinson TJ. Influences on final year medical students’ attitudes to general practice as a career. J Prim Health Care 2014; 6:56–63.
  19. Rourke J, Asghari S, Hurley O, Ravalia M, Jong M, Graham W, et al. Does rural generalist focused medical school and family medicine training make a difference? Memorial University of Newfoundland outcomes. Rural Remote Health. 2018 Mar; 18(1):4426.
  20. Goldacre M, Turner G, Lambert T. Variation by medical school in career choices of UK graduates of 1999 and 2000. Med Educ 2004; 38:249–58.
  21. Rabinowitz H. Recruitment, retention, and follow-up of graduates of a program to increase the number of family physicians in rural and underserved areas. N Engl J Med 1993; 328:934–9.
  22. Rabinowitz H, Diamond J, Markham F, Santana A. The relationship between entering medical students’ backgrounds and career plans and their rural practice outcomes three decades later. Acad Med 2012; 87:493–7.
  23. Rabinowitz H, Diamond J, Markham F, Santana A. Retention of rural family physicians after 20–25 years: outcomes of a comprehensive medical school rural program. J Am Board Fam Med 2013; 26:24–7.
  24. McManus I, Smithers E, Partridge P, Keeling A, Fleming P. A levels and intelligence as predictors of medical careers in UK doctors: a 20 year prospective study. BMJ 2003; 327:139–42.
  25. Goldacre M, Laxton L, Lambert T. Medical graduates’ early career choices of specialty and their eventual specialty destinations: UK prospective cohort studies. BMJ 2010; 341:c3199.
  26. Lambert T, Goldacre M, Davidson J, Parkhouse J. Graduate status and age at entry to medical school as predictors of doctors’ choice of long-term career. Med Educ 2001; 35:450–4.
  27. Lambert T, Goldacre M. Trends in doctors’ early career choices for general practice in the UK: longitudinal questionnaire surveys. Br J Gen Pract 2011; 61:e397–e403.
  28. Medical Deans Australia and New Zealand. Overview of Medical Deans Australia & New Zealand Medical Schools Outcomes Database (MSOD) & longitudinal tracking project. Sydney: Medical Deans Australia and New Zealand; 2008.
  29. Kaur B, Roberton D, Glasgow N. Evidence-based medical workforce planning and education: the MSOD project. Med J Aust 2013; 198:518–9.
  30. Medical Deans Australia and New Zealand. Medical Schools Outcomes Database. National Data Report 2013-2017. Sydney: Medical Deans Australia and New Zealand 2018. Available from http://www.medicaldeans.org.au/projects-activities/msodproject/
  31. Poole P, Stoner T, Verstappen A, Bagg W. Medical students: where have they come from; where are they going? NZ Med J 2016; 129:1435.
  32. Kent M, Verstappen A, Wilkinson TJ, Poole P. Keeping them interested – a national study of factors that change medical student interest in working rurally Rural Remote Health 2018; 18(4):4872.
  33. Hays R. The utilisation of the health care system for authentic early experience placements. Rural Remote Health 2013; 13:2328.

Contact diana@nzma.org.nz
for the PDF of this article

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