Exploring medical students' perceptions of family medicine in Kyrgyzstan: a mixed method study

Abstract

Background: Despite knowing that health systems with strong primary care improve overall health outcomes within a population, many countries are facing a global trend of declining interest and shortage of family doctors. This is the case of the Kyrgyz Republic, in which rural areas are struggling to attract and retain family medicine (FM) doctors. This study aims to explore how Kyrgyz medical students perceive FM and the factors that influence their specialty choice.

Methods: This study used a cross-sectional explanatory sequential design, including quantitative survey and focus group discussions that were carried out at the Kyrgyz State Medical Academy (KSMA) in Bishkek in 2017. Overall, 66% (953 out of 1449) of medical undergraduate students registered in year 1, 4 and 6 completed the survey, and 42 participated in the focus groups. The results were organized around 7 factors influencing perceptions and attitudes towards FM identified through a qualitative systematic review.

Results: The interest of Kyrgyz students for FM was the lowest of all specialties. Access to high medical technologies, career opportunities, salary, patient interaction and possibility to work abroad were the five most important factors influencing specialty choice. FM was perceived as a difficult profession, yet with poor prestige, insufficient remuneration, limited career possibilities and poor working conditions, especially in rural areas. The academic discourse, which disregards FM specialty had a negative influence on student's perceptions and prevented students' ability to identify with the practice of family medicine. However, students' awareness of their social accountability arose as a positive leverage to increase the choice of FM, provided other problems were solved.

Conclusion: This study highlighted key factors responsible for the low number of students choosing to become FM in Kyrgyzstan. The first major factor, presumably specific to many low- and lower-middle- income countries was the poor working conditions in remote areas. The second factor, common to many countries, was the distorted image of FM and its specialty transmitted through the medical schools' institutional culture which does not value FM through positive role models. This study served as a basis to establish a strategy to promote FM within the KSMA and potentially at National level.

Keywords: Developing country; Family Medicine; Medical education; Medical students; Mixed-methods; Primary care; Qualitative research.

Fig. 1

Flow-chart of data collection

Fig. 2

Timeline of Medical Education Reform in KSMA Medical School, Kyrgyzstan Description: The reform started to be implemented in September 2012 and the first graduates of this reform received the certificate in June 2018. The survey was conducted in autumn 2017, interviewing students from Y1, Y4, Y6, all having benefited from the reformed programme. Since 2017, the post-graduate training is under the responsibility of the Ministry of Health. Until that year it was under the responsibility of the Minister of Education and Medical Schools. This shift was an important milestone as it links the training content to health issues and not just education. Important efforts to promote family medicine through advocacy and communication strategies, video, leaflets, conference were implemented since 2014 in parallel to reforming the curriculum. The package of measures bared its fruits with number of residents increasing in the subsequent years, – 150 – choosing FM in 2019 with over 50% going to the regions.

Fig. 3

Percent of Kyrgyz medical students interested in working in different specialties at 3 different times of their medical training Legend to table: The vertical axis presents the percent of students interested, neutral or not interested in seven main specialties including FM/GP at year 1, 4 and 6 of their medical training. Total N = 953 students from KSMA (year 1: 270, 4: 368 and 6: 315). They were surveyed in 2017 and answered the question “How much are you interested in working in each of the following specialties/career options after your studies”. Fam Med = Family Medicine; Psy = Psychiatry; Int Med = Internal Medicine; Ped = Paediatric; Emerg Med = Emergency Medicine; Ob-Gyn = Obstetrics-Gynaecology; Surg = Surgery.

Fig. 4

Ranking each of 12 factors from the most important to the least important for their specialty choice by Kyrgyz medical students Legend to table: N = 315 6th year students from KSMA surveyed in 2017.