Perceptions of Malaysian medical students from different academic years on primary care: a qualitative research

Introduction

The Alma-Ata Declaration (WHO, 1978),1 reaffirmed in Astana, (October 2018),2 stated that primary care plays a critical role and is the basis for effective delivery of health services around the world. In Malaysia, primary care services are provided by Ministry of Health (MOH) public primary care clinics (PPCC) and by general practitioners (GPs) in the private sector. These clinics provide first contact care, acute and chronic diseases management, preventive care and health promotion, coordinating and integrating patient care with the rest of the health system.

Postgraduate training is by the local public universities’ Masters in Medicine (Family Medicine (FM)) programme3 and the Academy of Family Physicians of Malaysia advanced training programme leading to the Conjoint Member of the Academy of Family Physicians of Malaysia/Fellow of the Royal Australian College of General Practitioners examinations.4 In MOH, these graduates become FM specialists in PPCC. However GPs with the same postgraduate degree currently have no additional incentives. Jenn Ng et al in their study on ‘The Status of Family Medicine Training Programs in the Asia Pacific’ indicated that the majority of medical schools (n=71/75) who responded had a FM department/unit, teaching FM in 92% of participating medical schools’ undergraduate programme.5 Although 20 out of 25 countries recognised FM as a specialist degree, only 53% reported conducting a postgraduate programme in FM.5

A survey among senior medical students from a private medical college in Melaka, Malaysia, showed that the majority (75%) chose internal medicine, surgery, paediatrics, orthopaedics and obstetrics and gynaecology (OG) as their choice of specialty. Primary care was listed among ‘others’ in the lowest category (2.7%).6 Another survey on factors affecting first year medical students choice of future specialisations done in China, Malaysia, India, Nepal and Sri Lanka, again indicated their preferred future specialisations were in surgery, internal medicine, paediatrics and OG.7 A study published in 2005 on the perceptions of Malaysian final year medical students on primary care showed mixed perception with some students perceiving primary care as a ‘non-discipline’ lacking depth, and associated primary care to soft skills such as communication skills and not core knowledge. The students noted disparity between the theoretical teaching and its actual practice in the community, resulting in students losing interest in FM.8 In March 2019, Malaysia’s Health Minister, in launching the fifth Association of South East Asian Nations (ASEAN) Regional Primary Care Conference, stated that the FM fraternity must work harder to promote and encourage young doctors to take up FM as their future career pathway. Malaysia had nearly 500 FM specialists but needed at least 1500 in the next few years.9

Choice of specialty by medical students affects society as a whole, as the pattern of residency selection shapes the long-term composition of the medical work force in the country.10 Studies in USA, Canada, Australia and UK showed the reasons for a declining interest in primary care/FM by medical school graduates were due to lack of recognition by medical schools and healthcare systems, been given subtle advice from other specialists that FM was less prestigious with low intellectual content, looked down by other colleagues and that family physicians could not master the content of the specialty. Other deterrents included the wide scope of the field, excessive workload, poor remuneration and lack of support from the ministry as well as the community.11–13

There are no studies in Malaysia exploring the medical students’ year of study and their perception of primary care practice and primary care as a career choice. The objective of this present study was to explore the perception of medical students from a private medical college in Perak, Malaysia on primary care practice by assessing the students’ perceptions according to their year of study; evaluating their attitude and perceptions about primary care in the health system and exploring the factors affecting medical students’ perception on primary care practice. This study also aimed to construct the understanding of the conceptions of primary care practice by medical students and whether they would want to consider taking up primary care as a specialty on graduation.

Methods

This is a qualitative participatory research on the perception of primary care practice among medical students in a private medical college in Perak, Malaysia (Royal College of Medicine Perak) using focus group discussions (FGDs). The medical college is the second oldest private medical college in Malaysia established in 1996. Under a subsidiary owned by the Perak state government, it initially offered twinning programmes with an overseas and a local university, with its first intake in 1998. Since 2006, under Universiti Kuala Lumpur, it started its own medical degree programme.

FGDs were used to gain an in-depth understanding of medical students’ knowledge, attitudes and perceptions on primary care practise. Interpretivist research paradigm was used.

Research was done as part of a 7-week student research project module. The proposal was presented to the committee in charge of student research projects and approval obtained. Data collection was carried out by the second and third authors who were year 4 medical students (one male and one female student). Purposive sampling was used with eight groups of participants (a total of 46). Six students each in seven groups and four students in one group were selected for FGD with two groups of equal number of participants from each academic year from year 2 to year 5. The initial target was 48 participants, 12 participants from each student year. However, only 10 students volunteered from year 3. The researchers were unable to recruit more because of time constraints and the year 3 students were in various clinical postings in the hospital.

All medical students were informed through the respective student leader of each year from year 2 to year 5 about the FGD. This was done to get participants as heterogeneous and unbiased as possible from each year. Year 1 was excluded as the medical students had just joined the university and was undergoing orientation. The participation in this study was voluntary. Students received a participant information form containing information about the study and an informed consent form to complete and return if they decided to participate.

Prior to the study, some year 4 students who were not part of the research and the supervisors (first and fourth authors, lecturers from primary care and public health disciplines respectively) had gone through the questions and themes prepared by the second and third authors. After discussion and amendments, the questions were finalised and included in FGD (refer to table 1). Those who were interested to participate received a focus group protocol which gave the list of questions and prompts to be asked during FGD along with guides provided by the authors (refer to table 1).

The questions under each theme included engagement questions, exploration questions and exit questions. Questions were open ended questions.

The FGDs were conducted on the medical school campus in a non-threatening environment in the presence of students only (second and third authors) without the presence of lecturers. After an introduction to the research and its objectives by the second and third authors, participants were encouraged to give their opinions and comments to each question. Participants were probed till adequate responses were obtained under different themes. When there were no more responses, the group went on to the next question. Each FGD was conducted in one sitting. The FGDs were conducted until the researchers agreed that all the participants expressed their views and data saturation achieved. Each FGD lasted about average 1 hour. Repeat FGDs were not conducted. Since the perceptions of students on selecting primary care as a specialty, based on their real-life experiences and perceptions on social status, phenomenology concept was used with content analysis for our research.

Responses of the participants were audio recorded, transcribed, grouped into various domains and analysed by two researchers independently and then verified for differences. One of the two authors who conducted the FGD (recorder) also noted down the main points on the responses of participants, while the other was the moderator who asked and clarified questions. Transcripts were not returned to the participants for further comments or feedback.

Content analysis was done manually based on the responses obtained under each domains or minor themes, using thematic analysis. Responses were categorised based on the year of study and analysed. Students who were involved in data collection had received training in qualitative data collection during the public health posting during which they had a hands-on experience in community settings.

Two coders coded the data and categorised the responses into three themes (knowledge, perception and attitude to primary care). Knowledge had four domains (primary care setting in Malaysia, services by primary care practitioners, information of primary care subject, quantity and exposure on primary care), perception had three domains (attractive factors, uninviting factors, how to make more attractive) while attitude two domains (primary care as specialisation and career path with reasons). Participant checking was not done. Quotations from each major themes and minor themes were presented. The final report was submitted at the end of year 4 Student Research Project module in 2016.

Results

Forty-six students participated. Altogether there were eight focus groups. Students from each year of study (year 2, year 4 and year 5) had 12 participants each with 6 students representing each focus group making a total number of 36 participants. However, for the year 3 students, only 10 students participated in FGD in two groups (n=10, four and six participants in each group).

The three main themes and questions under each theme (refer table 1) were covered in each FGD. The findings from FGD were summarised below with relevant quotes of the participants. Although separate analyses were done on each year, the findings on medical students from different years of study from year 2 to year 5 were described together because they were quite similar.

Discussion

This study showed that the students’ lack of interest in taking up primary care as a career option related with its social setting by (1) a lack of exposure/misconceptions as shown by the years 2 and 3 students; (2) excessive workload, wide scope, poor remuneration for primary care practitioners; (3) lack of support, influence and prejudice against primary care from community/other health professionals. Similar findings were seen in studies from USA, Canada, Australia and UK.11–13 Senior medical students (years 4 and 5) showed more interest in primary care as a career option, it appeared as (1) more exposure to primary care giving them a better understanding especially in aspects such as continuity of care and whole person care (2) the challenging nature of managing a wide range of illnesses encountered and (3) a balance between family, social life and work.

Some students suggested that the university provides a shorter or introductory primary care posting earlier in year 3 to generate more interests towards primary care practice, reduce the students’ perception that primary care was not an important discipline and to increase their level of understanding and exposure to this specialty.

Students in the Commonwealth Medical College (TCMC) in Pennsylvania had early exposure to primary care, accompanying primary care physicians and following a cohort of patients in a community-based experience that focused on continuity of care during first year in medical school. As a result, one-third of TCMC’s 2013 graduates selected FM, internal medicine and paediatrics as their residency programmes.14 15

In the previous Malaysian qualitative study,8 students developed an interest in FM when they encountered good GP role models. An American study also showed that 75% of medical students prioritised role models on their specialty choice compared with 71% stating lifestyle factors and 51% reporting future income as being important.16

Students in this study did not specifically mention primary care role models influencing their career choice but were attracted to become primary care practitioners because to them the key of being a good doctor was being able to provide continuous care to their patients for a long time, being able to build a strong doctor patient relationship and to keep up with a wide array of medical knowledge and not lose their medical, practical and communication skills due to daily practice. Besides finding the wide scope of primary care challenging, some found altruistic appeal ‘Treating patient as a whole and build up rapport with them, I would consider it more humane although the pay is low’.

Other factors attracting students to primary care included flexible and shorter working hours with no on-calls duties. Negative factors included low pay, heavy workload, high administrative burden and GPs not always regarded highly by the public as compared with other specialists. Similar findings were found in other studies.17–19

Conclusion

This study showed that the medical students’ level of exposure to primary care played a crucial role in determining their understanding and their choice of career in primary care. To make primary care more attractive, issues to address include remuneration, workload, the prejudice against primary care and efforts to produce well trained, skilled and enthusiastic role models with fun and challenging primary care postings, early in the medical curriculum.