Sample representativeness and influence of attrition on longitudinal data collected as part of a national medical career tracking project.

BACKGROUND: The Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) in New Zealand is one example of a national survey-based resource of medical student experiences and career outcomes. Longitudinal studies of medical students are valuable for evaluating the outcomes of medical programs against workforce objectives. As a prospective longitudinal multiple-cohort study, survey response rates at each collection point of MSOD vary. This paper assesses the effects of participant non-response rates on MSOD data. METHODS: Demographic variables of MSOD respondents between 2012 and 2018 were compared to the distribution of the demographic variables in the population of all NZ medical graduates to ascertain whether respondent samples at multiple survey collection points were representative of the population. Analysis using logistic regression assessed the impact of participant non-response on variables at collection points throughout MSOD. RESULTS: 2874 out of a total population of 2939 domestic medical students graduating between 2012 and 2018 responded to MSOD surveys. Entry and exit surveys achieved response rates around 80% and were broadly representative of the total population on demographic variables. Post-graduation survey response rates were around 50% of the total population of graduates and underrepresented graduates from the University of Auckland. Between the entry and exit and the exit and postgraduation year three samples, there was a significant impact of non-response on ascribed variables, including age at graduation, university, gender and ethnic identity. Between the exit and postgraduation year one sample, non-response significantly impacted ascribed and non-ascribed variables, including future practice intentions. CONCLUSION: Samples collected from MSOD at entry and exit are representative, and findings from cross-sectional studies using these datasets are likely generalisable to the wider population of NZ medical graduates. Samples collected one and three years post-graduation are less representative. Researchers should be aware of this bias when utilizing these data. When using MSOD data in a longitudinal manner, e.g. comparing the change in career intentions from one collection point to the next, researchers should appropriately control for bias due to non-response between collection points. This study highlights the value of longitudinal career-tracking studies for answering questions relevant to medical education and workforce development.

Women's interest in surgery as a career in the early postgraduate period: a national longitudinal study.

BACKGROUND: Women remain underrepresented in Surgery in Aotearoa New Zealand (AoNZ). This study described interest in surgical careers by gender in the early postgraduate period and associated influencing factors. METHODS: AoNZ medical graduates between 2012 and 2016 responding to an Exit Questionnaire (EQ) at graduation and 3 years later (PGY3) as part of the Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) were included. Analyses of specialty preferences and influences by gender were performed. RESULTS: Of 992 participants, 58% were women. At EQ, 158 participants (16%) had a surgical preference: 21% of men and 14% of women (P < 0.01). By PGY3, this was 20% of men and 10% of women (P < 0.01). A logistic regression found women were half as likely as men to have a surgical preference at PGY3. Those with a surgical preference at EQ were over 23 times more likely to have a surgical preference at PGY3, irrespective of gender. There were significant differences in self-reported career influencing factors between women and men at EQ and PGY3, as well as between PGY3 women with a surgical and those with a non-surgical preference. These included nature of the specialty, training requirements, lifestyle, family and personal factors. CONCLUSIONS: Increasing the proportion of women in Surgery requires a multifaceted approach starting during medical school and continuing through early postgraduate years. More needs to be done to make surgical experiences as an undergraduate and junior doctor appealing to women.

How rural is rural? The relationship between rural background of medical students and their career location intentions.

OBJECTIVE: Rural background is associated with greater interest in rural practice. However, there is no universally agreed definition of 'rural' background used in medical school selection. This study explored the association between definitions of 'rural' background and students' intended career locations. DESIGN: Prospective cohort study using survey data on career intention, hometown size, rurality of background, home address, high school and intended career location. SETTING: University of Auckland, New Zealand (NZ). PARTICIPANTS: Commencing medical students 2009-2017, inclusive. MAIN OUTCOME MEASURES: Univariate associations between student background according to 7 definitions of 'rural', and 3 definitions of intended practice location based on population size: urban intention (>100 000); regional intention (25 000-100 000); rural intention (<25 000). RESULTS: The sample size was 1592 students. 27.4% had a rural background by at least one definition. All definitions of rural background were associated with a greater rural intention. Applying a restrictive definition of rural (population<25 000) was associated with a higher likelihood of rural intention, but captured a smaller number of students. There was strong agreement between the population size of a student's background and intended practice location (chi-square P < .0001). CONCLUSION: Rural intention varies by definition, but the number of students captured by each definition is important. Applying a binary or overly restrictive definition may limit interested students. Medical schools should adopt a definition of 'rural' that optimises the number of eligible students and their propensity to work rurally. Further, alternative ways of identifying students with rural intentions without a rural background should be explored.

National study of the impact of rural immersion programs on intended location of medical practice in New Zealand.

INTRODUCTION: New Zealand (NZ) faces an ongoing shortage of rural medical professionals. In an effort to increase interest in rural practice, both of the medical schools in NZ offer rural immersion programs as well as rural entry pathways. The aim of this study was to compare the effect of long (>33-week) rural immersion with a short (5-week interprofessional) rural immersion or no rural immersion on the career location intentions of NZ medical students. METHODS: This observational study used linked data from the Commencing Medical Students Questionnaire (CMSQ) and Exit Questionnaire (EQ), collected between 2011 and 2017 as part of the Medical Schools Outcomes Database project, along with information on whether or not a student undertook a rural immersion program. The main outcome measure was EQ career location intention (Rural (population 100 000)). The explanatory variables were rural immersion (long, short, none), age, ethnicity, background, CMSQ career location intention, gender, specialisation preferences and interest in rural medicine. In addition to univariate analysis, data were used to build a multinomial model to determine relative associations of these variables with the outcome. RESULTS: Full data were available for 1367 NZ medical students (47% of all students during the time period). Of these, 17.4% had undertaken a long or short rural immersion program. In univariate analysis, age was the only variable that did not significantly predict EQ rural intention outcome. In the multivariate model, rural immersion was a significant independent predictor of EQ career location intention. Students taking a long rural immersion were 6.4 and 4.4 times more likely to select a Rural or Regional intention, respectively, than those with no rural immersion. This strong effect on rural intentions was seen regardless of background. CMSQ career location intention, background, ethnicity, rural club membership and preference for general practice were also significant predictors. While short rural immersion did not have an independent effect, this finding should be interpreted with caution given the smaller number of students and the response rate. CONCLUSIONS: Long rural immersion is highly beneficial for increasing interest in rural work, increasing the likelihood that medical students will intend to work outside an urban setting. Students who signal an early rural intention are strong candidates for such programs later in their course, regardless of their background. A three-category classification for geographic background and career location intention permitted a more detailed understanding of the interplay among demographic variables and rural immersion in influencing career intentions. Following cohorts into their postgraduate years is needed to ascertain if these career location intentions persist.

Career interests of undergraduate nursing students: A ten-year longitudinal study.

An understanding of students' career interests at entry and exit from undergraduate nursing programmes could inform decisions regarding curricula and clinical placements. Since 2006, the University of Auckland has surveyed healthcare students at entry to and exit from their respective programmes, collecting information on a range of demographic, and career-related factors. This article describes career interests of over 500 undergraduate nursing students in New Zealand over a ten-year period. All Bachelor of Nursing cohorts commencing between 2006 and 2016 were invited to complete a questionnaire which included questions about their career interests. In total 1875 questionnaires were completed (89% response rate). Among the overall cohort at entry, there was strongest interest for emergency care and child health, and least interest in older person's health. At exit, child health and surgery (general) were of strongest interest to the cohort, while older person's health remained of least interest. The analysis of the paired data (n = 564) identified decreases in interest for mental health and child health over the course of the programme, while there was an increased interest in primary health care. Changes in career interests indicate that education and clinical exposure to specialty areas during the programme may influence career interests.

The employment gap: the relationship between medical student career choices and the future needs of the New Zealand medical workforce.

AIMS: To determine the career decision intentions of graduating doctors, and the relationship between these intentions and the predicted medical workforce needs in New Zealand in 10 years' time. METHODS: A workforce forecasting model developed by the Ministry of Health (MOH) has been used to predict the proportion of doctors required in each medical specialty in 2028 in New Zealand. The future work intentions of recently graduated doctors at the Universities of Auckland and Otago were collected from the Medical Student Outcomes Data (MSOD), and compared with these predicted needs. RESULTS: Between 2013 and 2017, 2,292 doctors graduated in New Zealand, of whom 1,583 completed the MSOD preferences section (response rate 69%). Of these only 50.1% had decided on a future medical specialty. The most popular were surgical specialties (26.2%), general practice (20.7%), and internal medicine (11.0%). Compared to the MOH workforce forecast model there appears to be insufficient interest in general practice at the time of graduation. CONCLUSIONS: To shape the medical workforce to meet forecast needs, multiple stakeholders will need to collaborate, with a special focus on the early postgraduate years, as many doctors have yet to decide on specialisation.

Developing New Zealand's medical workforce: realising the potential of longitudinal career tracking.

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.

Capturing the experience of the hospital-stay journey from admission to discharge using diaries completed by patients in their own words: a qualitative study.

OBJECTIVE: To capture and better understand patients' experience during their healthcare journey from hospital admission to discharge, and to identify patient suggestions for improvement. DESIGN: Prospective, exploratory, qualitative study. Patients were asked to complete an unstructured written diary expressed in their own words, recording negative and positive experiences or anything else they considered noteworthy. PARTICIPANTS AND SETTING: Patients undergoing vascular surgery in a metropolitan hospital. PRIMARY OUTCOME MEASURES: Complete diary transcripts underwent a general inductive thematic analysis, and opportunities to improve the experience of care were identified and collated. RESULTS: We recruited 113 patients in order to collect 80 completed diaries from 78 participants (a participant response rate of 69%), recording patients' experiences of their hospital-stay journey. Participating patients were a median (range) age of 69 (21-99) years and diaries contained a median (range) of 197 (26-1672) words each. Study participants with a tertiary education wrote more in their diaries than those without-a median (range) of 353.5 (48-1672) vs 163 (26-1599) words, respectively (Mann-Whitney U test, p=0.001). Three primary and eight secondary themes emerged from analysis of diary transcripts-primary themes being: (1) communication as central to care; (2) importance of feeling cared for and (3) environmental factors shaping experiences. In the great majority, participants reported positive experiences on the hospital ward. However, a set of 12 patient suggestions for improvement were identified, the majority of which could be addressed with little cost but result in substantial improvements in patient experience. Half of the 12 suggestions for improvement fell into primary theme 1, concerning opportunities to improve communication between healthcare providers and patients. CONCLUSIONS: Unstructured diaries completed in a patient's own words appear to be an effective and simple approach to capture the hospital-stay experience from the patient's own perspective, and to identify opportunities for improvement.

Keeping them interested: a national study of factors that change medical student interest in working rurally.

INTRODUCTION: In most countries it remains a challenge to sustain the rural medical workforce. Based on evidence that medical students with rural backgrounds are more likely than their urban peers to enter rural practice, medical schools may have rural entry pathways. It is less well established what happens to career intentions during medical school. This study assessed how rural intentions persist or change during medical school and sought factors associated with either persistence or change in rural intention. METHODS: Students who participate in the Medical Schools Outcomes Database and Longitudinal Tracking project complete surveys at entry to and exit from medical school. They are asked about demographics, career intentions and influencing factors. This study used data from students at both of New Zealand's medical schools from 2006 to 2016. Participants were placed into one of four groups: rural intention at entry and rural intention at exit (R-R), urban at entry and rural at exit (U-R), rural at entry and urban at exit (R-U) or urban at entry and urban at exit (U-U). 'Rural' was defined as an area with a population of 100 000 or fewer. Differences among the groups in demographics and influencing factors were analysed. RESULTS: Overall, 4368 students completed an entry survey (response rate 85.9%), and 2243 students completed an exit survey (response rate 66.4%). A third intended to work in a rural area; of these, 49% had a rural background and 51% an urban background. From the linked entry and exit data (n=1114), there were 239 (21.4%), 188 (16.8%), 135 (12.1%) and 552 (49.5%) students in the R-R, U-R, R-U and U-U groups respectively (p<0.001). Most students had a stable geographical career intention. Of those who changed, more moved towards a rural intention than away from it. Medical students with a persistent rural pattern had characteristics of a rural background (70%), being female (68%), New Zealand European (76%) or having involvement with a rural club for at least 1 year (45%). These students were also more likely to express a GP career intention as their first choice (25%). There were small differences in age, but otherwise no particular demographic factors were associated with students who changed intention. Similarly there were only small differences in perceived career influencing factors among groups. CONCLUSION: This large national study shows a stability of career location intention for the majority of students. It confirms earlier findings of the importance of rural background in rural career preference, but shows that women may have a higher propensity for a persisting rural interest. Apart from providing quality experience in rural areas for all students, and facilitating rural clubs, the study did not reveal any other strategies that might be used by medical schools to either increase or prevent the loss of rural interest.

Influence of student debt on health career location and specialty.

INTRODUCTION In New Zealand (NZ), there are shortages of health professionals in rural areas and in primary care. AIM This study aims to examine the association of student debt levels of medical, nursing, pharmacy and optometry students with: (1) preferred geographical location of practice, specifically preference to work in urban vs. rural areas; and (2) preferred career specialties, specifically interest in primary health care. METHODS Medical, nursing, pharmacy and optometry students completed a questionnaire at graduation that included questions about levels of New Zealand Government Student Loan debt and preferences regarding location of practice and career specialty. In an additional survey, medical students were asked to self-rate the effect of financial factors on their career choices. RESULTS Debt patterns varied across programmes. Medical and pharmacy students with high debt were significantly more likely than students with low debt to prefer rural over urban practice (P = 0.003). There was no difference in level of interest in a primary care specialty by debt level for any programme. Medical students reported little influence of debt on career choice, although students with high debt levels were less concerned over career financial prospects than students with lower levels of debt. DISCUSSION Current levels of student debt do not deter students from planning a career in rural or primary care settings. Somewhat surprisingly, higher levels of debt are associated with greater rural practice intentions for medical and pharmacy students, although the underlying reasons are uncertain.

Rising levels of New Zealand medical student debt.

AIM: There is little recent data on the debt levels accrued by New Zealand medical graduates. We aimed to quantify the level of student loan debt accrued by medical graduates upon completion of their medical degree, and to investigate the association of New Zealand Government Student Loan (GSL) debt with gender and age. METHODS: At graduation each year from 2006-2015, students from one New Zealand medical programme were invited to complete a career intention survey that included information on levels of GSL debt and the number of income sources used. RESULTS: The overall response rate was 83.8%. On average, 92% of domestic students reported having some student loan debt, with 28% a debt of $90,000 or more. The proportion of students reporting a student loan debt of $90,000 or more increased over the period of the study (P<0.0001). While older students were more likely to have a larger student loan debt than younger students, there was no difference in debt levels by gender. Students with larger student loans were more likely to rely on a larger number of financial sources to fund their studies. CONCLUSIONS: New Zealand medical students are carrying higher levels of student loan debt year on year. The effect of this on the future medical workforce is not certain; however, this could be negative if graduates choose to enter careers that are more highly paid over areas of high need. The full impact of large loans on individuals and the health system will take years to determine.

Medical students: where have they come from; where are they going?

AIMS: There remain shortages of doctors in rural areas. This study aimed to describe the location and size of New Zealand medical students' hometowns over the past decade; to document changes in intended practice location between entry and graduation; and to explore the relationship between background and intended location of practice. METHODS: All commencing and graduating students from one New Zealand medical programme from 2006-2015 were invited to complete a career intention survey. Students' reported background and practice location intention at entry were compared with intention at exit. RESULTS: Response rates were 92% for entry and 84% for exit surveys. On average, 21% of medical students were from regional-rural (RR) backgrounds, with no significant change over time (p= 0.4036). Most were admitted via a designated rural entry pathway. Students from RR backgrounds were four times more likely at entry, and nearly three times more likely at exit, to have an RR intention than urban students. Those with an RR intention at entry were three times more likely to have an RR intention at exit than students with an urban intention. CONCLUSION: Medical students from an RR background, or with RR intention at entry to medical school, are more likely to indicate a RR intention upon graduating. Yet students of an urban background with an RR career intention are important to consider. Future research might explore factors which help consolidate RR career choices in both groups.