Recruiting Rural Students To Medicine

MUMJ

Original Research

17

ORIGINAL RESEARCH

Recruiting Rural Students to Medicine: When Best to Intervene to Improve the Odds? Pamela, E. Aird, BHSc Nicole S. Shadbolt, BSc Elaine M. Blau, MD, CCFP, FCFP

ABSTRACT Purpose: The objective of this study was to compare rural and non-rural high school students’ application rates to an undergraduate university program in health sciences between 2001 and 2005. As graduates of the program have an exceptionally high rate of admission to medical school, the level of interest in the undergraduate program may be indicative of high school graduates’ interest in a future career in medicine. Methods: We undertook a retrospective analysis of applicant demographics to the Bachelor of Health Sciences program at McMaster University. We examined the postal codes of all applicants, designating as “rural” those with “0” as the second character, calculated the percentage of rural applicants, and compared this to the proportion of Canada’s population which is rural, according to Statistics Canada data. Results: Application rates to the BHSc program from rural students were significantly lower than expected, even given the already lower rates of post-secondary participation among rural students. Conclusions: A significant body of existing evidence suggests that medical graduates who were raised in rural communities are far more likely than their non-rural counterparts to practice in a rural community. As a result, recruitment strategies which encourage rural students at the high school and university levels to consider medicine as a career are increasing and at least one country (Australia) has moved toward granting preferential admission to medical school to students from rural communities. These results imply that a significant number of potential applicants are lost before they even reach the undergraduate level, suggesting that future recruitment strategies aimed at high school students would likely be of higher yield.

R

INTRODUCTION ural Canadian youth have been found to have lower expectations than their urban counterparts about their likelihood of obtaining a university education.13 Studies of university attendance and graduation rates confirm that these expectations are realistic.11-13 The likelihood that a Canadian high school graduate will go on to post-secondary education is inversely proportional to the distance of his or her home from a post-secondary institution.12,13 A Statistics Canada paper proposes three explanations for this finding. First, financial costs are increased when the student must move out of the family home to attend school, a problem which is exacerbated by the fact that average family incomes in rural areas are lower than those in urban areas. Second, the emotional costs of leaving behind family, friends and community may prevent rural students from moving away to attend school. Finally, it is proposed that students living in rural areas do not see the benefit of university education because fewer people around them hold a degree. Similarly, other studies show that while parental educational attainment is known to relate to the educational attainment of a child, this effect is greater on rural

youth than it is on urban youth.13 Hutten-Czapski found that undergraduate students who were raised in rural communities are less likely than their urban counterparts to apply to medical school. However, rural and urban applicants have comparable grade-point averages, MCAT scores and acceptance rates.11 A 2005 survey of Canadian medical students showed that rural students are indeed under-represented in Canadian medical schools.14 Using the Canada Post definition of rurality (a Canadian postal code with the second character of “0”), they found that approximately 11% of Canadian medical students lived in a rural community when they completed high school.15 By comparison, this definition describes approximately 22.4% of Canada’s population as “rural”.16 Given the shortage of physicians in rural Canada, discovering the factors which motivate physicians to practice rurally has become a focus of research in Canada and abroad.1-9 Numerous studies in Canada have concluded that rural upbringing is a strong predictor for a physician’s eventual return to a rural community.1-6 Research in Australia also cited rural upbringing as the strongest predictor of rural practice.7-9 The

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Original Research

Task Force for the Society of Rural Physicians of Canada (SRPC) has made recommendations to increase medical school enrolment of students of rural origin.6,10 These recommendations include initiatives targeting high school students, undergraduate students, medical school admissions policies, medical school curricula and funding issues. The goal of this research is to examine student interest and motivation towards medicine as a career in the high school years in order to discover whether recruitment initiatives for rural students at the high school stage are likely to have a high yield. The expectation is that findings will eventually be useful to direct funding and resources differentially to the highest-yield recruitment strategies. Established in 2000, the BHSc program at McMaster is a unique degree that focuses on the areas of health, wellness and illness from a variety of perspectives. It draws on all departments within the faculty of health sciences, and aims to expose undergraduates to practitioners and researchers in the field of health sciences in order to make their studies relevant. Throughout the four year honours degree, core courses are offered in a variety of teaching styles. Many courses are offered in the small group, inquiry (problem-based learning) format which fosters investigational skills, critical evaluation, independent learning, interdependent group learning and collaboration. This program allows extensive flexibility in elective time so that students are able to complete “minors” and explore subspecialty areas of interest. Although this is a relatively new program, it has already received international attention and has become an exceedingly popular and competitive choice for applicants. Currently 160 students are accepted into the incoming class each year from a field of over 2,400 applicants. The McMaster BHSc program was selected for this research as it represents an essentially “pre-medical” program. Although the program itself professes that it will not necessarily help students gain entrance into professional programs, it does acknowledge that the curriculum and teaching philosophies are consistent with the qualities that medical programs are seeking in their applicants. The program administration reports that 70% of its graduates gain acceptance into medical schools in Ontario. This is an astonishing proportion considering that it is unlikely that all BHSc graduates apply to medical school. METHODS The present study examined the choice of a “pre-medical” undergraduate degree program as a marker for interest in a medical career upon graduation from high school. A retrospective analysis of applicant demographics to the Bachelor of Health Sciences program at McMaster University was performed. Databases obtained from the BHSc program, detailing applicant demographics between 2001 and 2005 (Table 1), were examined. Rurality was defined based on the home address postal code provided by applicants. In the analysis, international applicants were excluded and totals were based solely on Canadian applications. Application rates of rural students, as defined by postal code, were established to determine the proportion of applicants coming from communities of population less than 10 000. The pro-

Volume 4 No. 1, 2007

portion of rural applicants was compared to national estimates of the rural population,14 in order to establish whether there were significantly less rural applicants than expected. Table 1. Application demographics reported by the BHSc program from 2001-2005 Year

Total applicants

2002

1825

2001

2003 2004 2005

INTL

Rural

Non-Rural

1351

19

109

1223

1842

31

111

1700

22

2081

34

2505

43

123

109 137

1680

1938 2325

INTL = international

Table 2. Statistical Analysis Assuming 22.4% rural population 2001 2002 2003

2004

2005

Obs. Exp.

Obs. Exp.

Obs. Exp.

Obs. Exp.

Obs. Exp.

# of applicants NonRural Rural

1223 1034

1680 1399

1700 1405

1938 1588

2325 1911

109 290

123 404

111 406

109 459

137 511

p-value % Rural Pearson Fischer’s 8.18% 22.40%

6.82% 22.40%

6.13% 22.40%

5.32% 22.40%

5.56% 22.40%

.000*

.000*

.000*

.000*

.000*

.000*

.000*

.000*

.000*

.000*

* Pearson Chi-Square test, or Fischer’s Exact 2-sided test, show a statistically significant difference between groups

RESULTS Table 2 shows the Pearson Chi-Square and Fischer’s exact test results for application rates. Expected rates were extrapolated from the total number of Canadian applicants in a given year multiplied by the Statistics Canada figure of 22.4% rural population. Every year showed a significant difference (p<0.01) between the observed and expected rates. Further statistical analysis (not illustrated here) showed that even given a more conservative estimate of rural population (10%), the application rate was still significantly lower than expected for the years 2002 through 2005. DISCUSSION Previous research has shown that rural Canadian students are less likely to attend university than non-rural students.12 This study shows that the application rate of students of rural origin to

MUMJ

Original Research

the BHSc program at McMaster University is significantly lower than would be expected. Given that students from McMaster’s BHSc program have a high rate of progression to medical school, the relative lack of interest from rural students may suggest that they are less likely to pursue medicine as a career than are urban students. The large amount of available applicant data for the BHSc program lends power to the results of this study. A significant challenge in rural research is the issue of defining rurality. “Rural” can describe a community’s population, its distance from a major centre, its available resources, or even whether or not it has a Tim Horton’s donut shop.17 Even if population alone is used to designate a community as “rural,” no consensus exists about a population cutoff.17 The Canada Post definition is perhaps the simplest, and the easiest to implement based on available data. The inclusion of applicant data from only one “pre-medical” undergraduate program has its own inherent limitations. Applicant rates may be influenced by the characteristics of this particular program or by willingness to travel to this university. An interesting additional observation is that as the number of applicants to the program rose (possibly a marker of competitiveness), the number of rural applicants decreased. The implications of this finding have not yet been fully considered. In order to truly gauge the relative interest of rural and urban high school students in medicine, the province-wide application rates to undergraduate programs in general and “pre-medical” programs specifically need to be studied. The possibility exists that these low rates reflect a generally lower drive for post-secondary education, which has not been adequately studied. These data are available through the Ontario Universities’ Application Centre, and the Ontario Medical School Application Service. Research is underway to examine these databases. It is the goal of the current research group to then apply these results to creating an effective recruitment strategy for Rural Family Medicine. A significant body of existing evidence suggests that medical graduates who were raised in rural communities are far more likely than their non-rural counterparts to practice in a rural community. As a result, recruitment strategies which encourage rural students at the high school and university levels to consider medicine as a career are increasing and at least one country (Australia) has moved toward granting preferential admission to medical school to students from rural communities. The results shown here imply that a significant number of potential applicants are lost before they even reach the undergraduate level, suggesting that future recruitment strategies aimed at high school students would likely be of high yield. In

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the future, organizations which promote rural medicine should consider providing funding to programs which encourage rural students to attend university, and to consider medicine as a realistic career option. This strategy would help to provide physicians who are more likely to practice permanently in rural areas, helping to provide a stable physician base. REFERENCES

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Author Biographies Nicole Shadbolt is a third year medical student at McMaster Univeristy and previously completed her Bachelor of Science in Pre-Optometry/Pre-Health at the University of Waterloo. She plans to pursue a career in Rural Family Medicine. Pamela Aird is a third year medical student at McMaster University and previously studied Health Sciences at McMaster. She plans to pursue a career in Rural Family Medicine. Elaine M. Blau, MD, CCFP, FCPC is a family physician and faculty member of the Department of Family Medicine, McMaster University.