|ORIGINAL RESEARCH ARTICLE
|Year : 2016 | Volume
| Issue : 2 | Page : 82-88
Reducing the physician workforce crisis: Career choice and graduate medical education reform in an emerging Arab country
Halah Ibrahim1, Satish Chandrasekhar Nair1, Sami Shaban2, Margaret El-Zubeir2
1 Department of Academic Affairs, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates
2 Department of Medical Education, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, Abu Dhabi, United Arab Emirates
|Date of Web Publication||19-Aug-2016|
Department of Academic Affairs, Tawam Hospital, P.O. Box 15258, Al Ain, Abu Dhabi
United Arab Emirates
Source of Support: None, Conflict of Interest: None
Background: In today's interdependent world, issues of physician shortages, skill imbalances and maldistribution affect all countries. In the United Arab Emirates (UAE), a nation that has historically imported its physician manpower, there is sustained investment in educational infrastructure to meet the population's healthcare needs. However, policy development and workforce planning are often hampered by limited data regarding the career choice of physicians-in-training. The purpose of this study was to determine the specialty career choice of applicants to postgraduate training programs in the UAE and factors that influence their decisions, in an effort to inform educational and health policy reform. To our knowledge, this is the first study of career preferences for UAE residency applicants. Methods: All applicants to residency programs in the UAE in 2013 were given an electronic questionnaire, which collected demographic data, specialty preference, and factors that affected their choice. Differences were calculated using the t-test statistic. Results: Of 512 applicants, 378 participated (74%). The most preferred residency programs included internal medicine, pediatrics, emergency medicine and family medicine. A variety of clinical experience, academic reputation of the hospital, and international accreditation were leading determinants of career choice. Potential future income was not a significant contributing factor. Discussion: Applicants to UAE residency programs predominantly selected primary care careers, with the exception of obstetrics. The results of this study can serve as a springboard for curricular and policy changes throughout the continuum of medical education, with the ultimate goal of training future generations of primary care clinicians who can meet the country's healthcare needs. As 65% of respondents trained in medical schools outside of the UAE, our results may be indicative of medical student career choice in countries throughout the Arab world.
Keywords: Career choice, educational policy, international medical education, medical education, workforce planning
|How to cite this article:|
Ibrahim H, Nair SC, Shaban S, El-Zubeir M. Reducing the physician workforce crisis: Career choice and graduate medical education reform in an emerging Arab country. Educ Health 2016;29:82-8
|How to cite this URL:|
Ibrahim H, Nair SC, Shaban S, El-Zubeir M. Reducing the physician workforce crisis: Career choice and graduate medical education reform in an emerging Arab country. Educ Health [serial online] 2016 [cited 2017 Sep 21];29:82-8. Available from: http://www.educationforhealth.net/text.asp?2016/29/2/82/188716
| Background|| |
Medical educators, healthcare policy makers, economists and government regulators all warn of a worsening global healthcare manpower shortage. ,, For many countries, the globalization and feminization of medical education further threaten the supply of practicing physicians. , Continued reduction in the number of primary care physicians adds an additional burden. , Emerging and developed nations, including many in the Middle East, do not train sufficient numbers of clinicians to meet population demands and have historically imported their physician manpower. This international migration of doctors and nurses has crippled health systems in many poor countries. In wealthier nations, socioeconomic and political issues have made the recruitment of skilled healthcare professionals increasingly difficult. Also, inconsistencies in the quality of medical training and the lack of uniform global accreditation standards have created significant disparities in the competency of the available physician pool. In an effort to promote quality and consistency in patient care and to assure the public of a sustainable and competent future physician workforce, many countries are actively restructuring their graduate medical education (GME) systems to be more responsive to their population's healthcare needs. ,
The United Arab Emirates (UAE), similar to many of its Gulf neighbors, has primarily relied on expatriate physicians to provide care for its citizens. Previous reports estimate that less than 10% of the healthcare workforce is composed of UAE nationals.  Yet, despite the large-scale importation of physicians, access to skilled health professionals is inconsistent, especially in the remote regions of the country, and the UAE continues to struggle with clinician shortages, with significant deficiencies in the primary care fields.  This issue is compounded by the fact that the country's rapid growth and urbanization have resulted in a sharp increase in lifestyle related diseases, including obesity, diabetes and cardiovascular disease, making the need for competent primary care physicians a matter of great national concern. In addition to ongoing health policy reforms, there have been recent calls to improve the quality and competency of locally trained physicians through reform of the GME system. In response, in 2009, the government of Abu Dhabi, the capital and largest emirate in the UAE, mandated a wide-scale expansion and restructuring of the postgraduate medical training system to structured competency-based education grounded in the framework of the United States-based Accreditation Council for Graduate Medical Education-International (ACGME-I). Other countries, including Singapore and Qatar, are undergoing similar educational reform.  Any successful initiative, however, must take into account the career preferences of the future workforce. The purpose of this study was to examine the specialty career choice of applicants to postgraduate training programs in the UAE and the factors that influence their decisions. To our knowledge, this is the first study of physician career choice in the UAE.
| Methods|| |
The survey instrument was developed through review of the medical literature, identifying 17 distinct factors that have been shown to contribute to medical student career choice. ,, The survey was then revised after piloting on a cohort of program directors and current residents. Applicants to UAE residency programs must have completed medical school and internship, and must successfully have completed a residency entrance exam. Each academic year, the residency entrance exam is administered monthly for four months at a single examination site in the UAE. From December 2012 through March 2013, all applicants to all residency-training programs in the UAE were asked to electronically answer the 11 question survey after completing the residency entrance examination. Participation was anonymous and voluntary, and the students were informed that survey completion did not affect their examination scores or residency match results. The questionnaire collected demographic data, along with information on specialty preference, and the factors that significantly affected their choice.
We adopted the United States Institute of Medicine's definition of primary care, which includes family medicine, general pediatrics, internal medicine, obstetrics and gynecology, and accordingly these specialty preferences were labeled primary care choices.  Given the limited number of residency choices in the UAE, participants were asked if they would have changed their primary career choice if other options were available.
The questionnaire was administered electronically and the collected data were exported into Microsoft Excel where data cleanup was performed ensuring consistency in several open-ended questions, including nationality, name of medical school, and other career choice. Descriptive statistics were produced using SPSS statistical software. Differences in residency choice and in factors influencing residency choice between gender were calculated using the t-test. The study was approved by the Al Ain Medical District Research Ethics Committee.
| Results|| |
Of the 512 applicants to the residency entrance examination, 378 completed the survey (74% response rate). Participant demographics are listed in [Table 1]. Residency program preferences are shown in [Figure 1]. The most preferred residency programs were internal medicine, pediatrics, emergency medicine and family medicine, in order of preference. The least preferred disciplines included urology, ophthalmology and obstetrics.
|Figure 1: Rank order and rank mean of residency choice of applicants to residency programs in the UAE (n = 378)|
Click here to view
|Table 1: Demographic data of survey participants applying to residency in the United Arab Emirate|
Click here to view
[Table 2] shows differences in rank order of residency choice of applicants to residency programs in the UAE. Comparisons between gender, UAE graduates versus non-UAE graduates and marital status were performed (n = 378). Statistically significant differences were noted between gender in career preferences, with more women preferring family medicine (P = 0.009), pediatrics (P = 0.011), dermatology (P = 0.022) and obstetrics (P = 0.001). When compared to female applicants, male preferences reached statistical significance for the disciplines of general surgery (P = 0.003), radiology (P = 0.006), emergency medicine (P = 0.010) and urology (P = 0.001). UAE medical school graduates showed significant preference for family medicine (P = 0.001), dermatology (P = 0.002), and ophthalmology (P = 0.016), versus non-UAE medical school graduates who showed significant preference for obstetrics (P = 0.001). Married applicants showed significant preference for family medicine (P = 0.001) and obstetrics (P = 0.001) versus single applicants who showed significant preference for emergency medicine (P = 0.018) and surgery (P = 0.006).
|Table 2: Differences in rank order and rank mean of residency choice of applicants to residency programs in the United Arab Emirate. Comparison between gender, graduating from the United Arab Emirate and marital status (n=378)|
Click here to view
The variety of clinical experience, procedure-oriented field, academic reputation of the hospital, experience during clerkship and international accreditation of the program were the leading determinants of specialty choice, in order of preference. In contrast, working with primarily female patients, spouse and parental influence, resident morale, and distance from family had minimal influence on specialty choice. Potential future income and having a role model in the field were also not considered important factors in determining career choice [Figure 2].
|Figure 2: Rank order and rank mean of factors influencing career choice of applicants to residency programs in the UAE (n = 378)|
Click here to view
[Table 3] shows differences in rank order of factors influencing residency choice of applicants to residency programs in the UAE. Comparisons between gender, UAE graduates versus non-UAE graduates, marital status and primary versus specialty care were performed. Only two statistically significant differences were noted between gender in the factors related to career choice. Females preferred to work with a primarily female patient populations (P = 0.001) and males ranked potential future income significantly higher than female participants in importance (P = 0.006), although both these factors were not ranked as important determinants of career choice with both groups combined. UAE medical school graduates showed significant influence of experience during clerkship in their decision (P = 0.026) versus non-UAE medical school graduates who showed significant influence of research opportunities (P = 0.004). Married applicants showed significant influence of spouse preference (P = 0.001) versus single applicants who showed significant influence of academic reputation of hospital (P = 0.001), experience during clerkship (P = 0.007), academic reputation of program (P = 0.007), resident morale (P = 0.015) and parental preference (P = 0.27). Additionally, there were few factors influencing primary versus specialty care. Those who chose a specialty care field as their first choice indicated that on call schedule and distance from family had significant influence in their choice (P = 0.030 and P = 0.037, respectively) relative to those who chose a primary care field.
|Table 3: Differences in rank order and rank mean of factors influencing residency choice of applicants to residency programs in the United Arab Emirates. Comparison between Gender, United Arab Emirates graduates versus non-United Arab Emirates Graduates, marital status and primary versus specialty care (n=378)|
Click here to view
Finally, 34% of applicants reported that they would have changed their first choice of residency programs to a different specialty if it were available.
| Discussion|| |
This study of medical student residency choice in the UAE reveals several significant findings that have implications for workforce and medical education planning. Our findings reveal that women applicants to residency programs outnumber men by 3:1. This ratio remains consistent in the country's medical schools and residency training programs. Although similar trends have also been observed in the United States and Europe, , the preponderance of female trainees in the UAE is likely due to social and cultural forces that encourage women to pursue careers in health care and education to the exclusion of most other fields. Studies reveal that women physicians communicate better with patients and provide more preventive services, but women work fewer years as a result of child-rearing and earlier retirement. , As the numbers of female trainees increase in medical schools and residency programs worldwide, it is unclear how the preponderance of women entering medicine will impact the global physician workforce. This remains an important area for future research.
In our survey, participants overwhelmingly selected the primary care fields of internal medicine, pediatrics and family medicine, along with the specialty of emergency medicine. This is in contrast to career choice data from many countries in the West, including Canada, the United Kingdom and the United States, ,, where interest in general and primary care careers is less common than in subspecialty medicine. This is a positive trend as studies have demonstrated that countries with strong primary care programs have improved health outcomes.  However, 34% of our respondents admitted that they would have changed their first choice if other options were available.
As educators consider developing more residency programs in the UAE, it is possible that the quantity and quality of applicants to the primary care disciplines may decline. Although it is preferable to expand residency-training options, educators should work with policy makers to develop postgraduate training programs that produce a professional workforce that is well aligned with population health needs. The literature suggests that medical school variables, including school culture and exposure to positive aspects of primary care careers during family medicine, pediatrics and internal medicine clerkships play a role in specialty preferences.  As such, promoting positive clerkship experiences in the primary care fields may improve recruitment.
An interesting finding in this study is the importance of international accreditation in determining medical student career choice. Accreditation reassures the public that the institution and training program are delivering safe patient care and structured training, culminating in the graduation of competent physicians. Currently, the United States-based Accreditation Council for Graduate Medical Education (ACGME), the Royal College of Physicians and Surgeons of Canada (Royal College) and several of the United Kingdom-based Royal Colleges offer international accreditation services. Accreditation systems can serve as powerful change agents. The World Health Organization  defines the social accountability of accreditation as "directing education, research and service activities towards addressing the priority health concerns of the community, region and/or nation they have the mandate to service." Educators must work with accrediting agencies to inculcate greater social responsibility into the accreditation criteria. Western-based accreditation systems should adapt to the local contexts and population needs of the systems they are entering.
In the UAE, expanding accredited training positions in the needed primary care disciplines can improve recruitment into those fields. For example, the field of obstetrics and gynecology has suffered from low recruitment and retention rates worldwide.  In our study, participants ranked obstetrics as one of the least preferred careers. Although 76% of survey respondents were women, working with primarily female patients was ranked as the factor least likely to influence career choice. Inadequate access to maternal and reproductive care can pose significant healthcare challenges globally. Addressing these concerns requires an emphasis on innovative models to incentivize trainees to select obstetrics as a career.
It is noteworthy that potential future income was not an important determinant of career choice in our survey. Given this, non-financial incentives are also necessary. Some studies in the United States have however found that both life style and income are important concerns in medical students' specialty choices, with students who choose internal medicine subspecialties, orthopedics, general surgery, and obstetrics and gynecology significantly more likely to value income over life style.  Other researchers report that perceptions of life style characteristics developed during training influence primary care interest.  At the undergraduate clerkship level, effort should be made to improve attitudes and perceptions influenced by supervisors, residents and other peers within the community of practice.
Additionally, the quality of the medical student clerkships should engage students early through mentorship programs. Survey participants ranked the variety of clinical experience and entering a procedure-oriented field as the most important factors influencing career choice. By engaging medical students in all the different aspects of obstetrics and gynecology and encouraging students to actively participate in procedures, clerkship directors can attract greater interest in the discipline. Also, policies of bonding trainees to underserved disciplines in return for medical training have been successfully implemented in other countries.  In addition to these long-term strategies, the provision of primary care services in women's health and maternity care can be supplemented through advanced training in obstetrics for family physicians. Appropriately trained family medicine physicians can provide routine maternity care and help to fill this gap. 
While our study offers several important insights, there are some limitations. These include reliance on individual applicants' self-reporting of specialty preferences and unavailability of follow-up data on actual residency numbers to confirm the career preferences and trajectories of the medical students in our sample. Notwithstanding these limitations, to the best of our knowledge, there are no other published studies of residency preferences guiding educational reform in the UAE. Additionally, data collection was anonymous and independent of employing organizations with potential to influence careers. Since 65% of respondents graduated from international medical schools outside the UAE, similar trends are likely throughout the Arab world.
| Conclusion|| |
In today's interdependent world, issues of physician shortages, skill imbalances and maldistribution affect all countries, rich and poor. In the United Arab Emirates, a nation that has historically imported its physician manpower, there is sustained investment in educational reform to meet the population's healthcare needs. Knowledge of medical student career choice is a critical first step. Applicant interest in the primary care fields is important as the country works to strengthen its primary care workforce.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Crisp N, Chen L. Global supply of health professionals. N Engl J Med 2014;370:950-7.
Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M, et al.
Human resources for health: Overcoming the crisis. Lancet 2004;364:1984-90.
Sheldon GF, Ricketts TC, Charles A, King J, Fraher EP, Meyer A. The global health workforce shortage: Role of surgeons and other providers. Adv Surg 2008;42:63-85.
Chen LC. Striking the right balance: Health workforce retention in remote and rural areas. Bull World Health Organ 2010;88:323, A.
Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al.
Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-58.
Garibaldi RA, Popkave C, Bylsma W. Career plans for trainees in internal medicine residency programs. Acad Med 2005;80:507-12.
West CP, Dupras DM. General medicine vs. subspecialty career plans among internal medicine residents. JAMA 2012;308:2241-7.
Abdel-Razig S, Alameri H. Restructuring graduate medical education to meet the health care needs of Emirati citizens. J Grad Med Educ 2013;5:195-200.
Ibrahim H, Al Tatari H, Holmboe ES. The transition to competency-based pediatric training in the United Arab Emirates. BMC Med Educ 2015;15:65.
Eze BI, Okoye OI, Maduka-Okafor FC, Aguwa EN. Factors influencing choice of medical specialty of preresidency medical graduates in Southeastern Nigeria. J Grad Med Educ 2011;3:367-71.
Saigal P, Takemura Y, Nishiue T, Fetters MD. Factors considered by medical students when formulating their specialty preferences in Japan: Findings from a qualitative study. BMC Med Educ 2007;7:31.
She L, Wu B, Xu L, Wu J, Zhang P, Li E. Determinants of career aspirations of medical students in Southern China. BMC Med Educ 2008;8:59.
Donaldson M, Yordy K, Vanselow N, editors. Defining Primary Care: An Interim Report. Institute of Medicine. Washington, DC: National Academy Press; 1994. p. 9.
McMurray JE, Cohen M, Angus G, Harding J, Gavel P, Horvath J, et al.
Women in medicine: A four-nation comparison. J Am Med Womens Assoc 2002;57:185-90.
Phillips SP, Austin EB. The feminization of medicine and population health. JAMA 2009;301:863-4.
Horn L, Tzanetos K, Thorpe K, Straus SE. Factors associated with the subspecialty choices of internal medicine residents in Canada. BMC Med Educ 2008;8:37.
Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83:457-502.
Erikson CE, Danish S, Jones KC, Sandberg SF, Carle AC. The role of medical school culture in primary care career choice. Acad Med 2013;88:1919-26.
WHO. Division of Development of Human Resources for Health. Defining and Measuring the Social Accountability of Medical Schools. Geneva: World Health Organization; 1995. Available from: http://www.whqlibdoc.who.int/hq/1995/WHO_HRH_95.7.pdf
. [Last accessed on 2013 Dec 19].
Loafman M, Nanda S. Who will deliver our babies: Crisis in the physician workforce. Am J Clin Med 2009;6:11-5.
Newton DA, Grayson MS, Thompson LF. The variable influence of lifestyle and income on medical students′ career specialty choices: Data from two U.S. medical schools, 1998-2004. Acad Med 2005;80:809-14.
Clinite KL, DeZee KJ, Durning SJ, Kogan JR, Blevins T, Chou CL, et al.
Lifestyle factors and primary care specialty selection: Comparing 2012-2013 graduating and matriculating medical students′ thoughts on specialty lifestyle. Acad Med 2014;89:1483-9.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]