Impact of Curricula and Electives on Primary Care Specialty Choice: A Narrative Synthesis

Primary care (PC) that is longitudinal, comprehensive, coordinated, and person-centered decreases disparities, improves health system performance, and reduces mortality.1–3 PC supports the quintuple aim of enhanced patient outcomes, population health, health equity, and clinician well-being at lower costs.4 Despite these benefits, the United States faces a PC shortage.5,6 To address this gap, increased attention to the PC workforce is needed.7,8 One way to develop the PC workforce is through medical education programs.

Medical school electives are common, positively reviewed, and effectively increase student knowledge.9 However, the influence of electives on PC specialty choice is uncertain. Additionally, medical education programs contain components within courses or clerkships that could impact specialty choice. While knowledge, attitudes, and satisfaction have been assessed for some educational components,10–13 their impact on PC selection is less certain. We explored how electives and other educational components impact student choice of PC specialties.

We performed a review and narrative synthesis of relevant literature.14 Starting with publications identified by a scoping review,15 we searched MEDLINE (PubMed) and Education Resources Information Center (ERIC) databases for additional original research focused on electives and educational components from index inception to April 14, 2020, using search terms developed with a language mapping process.15 We used keywords and database-specific controlled vocabulary to describe concepts of choice behavior, family and PC physicians, medical education, curricula, and electives with subsequent citation chaining in Scopus to ensure comprehensiveness. Inclusion and exclusion criteria are shown in Figure 1 and search terms are shown in Appendix A (https://journals.stfm.org/media/4917/nguyen-fm-v54appendixa.pdf).

All articles were independently assessed for inclusion by two authors. When assessments differed, authors discussed to reach consensus. We defined electives as optional educational experiences led by institutions; and educational components as modules, class sessions, or other elements within a course, clinical rotation, or educational program. We categorized studies by theme, study design, institutional characteristics, and effectiveness.

We assessed the quality of included articles using the 16-item quality assessment tool (QATSDD; maximum possible score=48), that was developed to examine studies with varied methodologies.16 Each article was evaluated by two authors, who discussed scoring discrepancies larger than one standard deviation until consensus was achieved.

Our study was determined to be non-human subjects research by the Michigan State University Institutional Review Board.

The scoping review identified 33 articles. Our secondary search found 1,784 articles post-deduplication, including nine that met inclusion criteria, for a total of 42 included studies. Most used cross-sectional or cohort designs and were conducted at US public medical schools (Table 1). Less than one-third described funding sources or were multi-institutional, and the specialties included as PC varied. More than half were published in four journals (Table 2). About half described electives and half described other educational components.

Quality scores ranged from 4 to 34 with a mean (SD) score of 18.6 (6.2) and a median score of 19 (Figure 2). Six articles found no benefit17–22 or a negative impact23 from the studied intervention; all others described interventions that appeared to have a positive influence on PC specialty choice.

International health and summer preclinical experiences were the most described electives. Outpatient clinical rotations were the most studied educational components. All showed an association between participation and interest in, or selection of, a PC residency. One study found that intention to participate had as much impact on specialty choice as actual participation, suggesting the experience reflects student interests, but may not influence specialty choice.21 Another noted the difference in FM specialty choice was not significant between program participants and those who applied, but were not accepted.24

Studies examining preclinical exposure to generalist courses or longitudinal FM experiences had mixed results. One article did not find preclinical exposure to FM faculty to be influential17 while others did.25,26 Another study reported a longitudinal clinical experience during preclinical years did not increase students’ interest in or selection of a PC career,21 whereas others were successful.27,28

Studies conducted prior to the widespread adoption of required FM clerkships found some benefit from ambulatory experiences on PC specialty choice.29,30 Nonetheless, more recent studies showed no effect.20,21 Furthermore, a survey of 123 departments found that community medicine experiences in private schools may be associated with lower family medicine match rates.23

Most electives and educational components studied were associated with PC specialty choice. While this may reflect a publication bias toward positive findings, seven of 42 did not show a benefit of the studied intervention.

International health and summer preclinical electives were positively associated with FM specialty choice; however, most studies did not control for initial student interest. Few articles examined obstetrics, community medicine, or domestic service-learning experiences. We found no studies that measured the impact of FM electives in addiction medicine, adolescent medicine, hospice/palliative care, integrative health, geriatrics, public health, sleep medicine, sports medicine, or women’s health. Future studies should assess the impact of such electives on PC specialty choice.

Another area that was not explored in the included articles was the potential influence of working with physician faculty or volunteer preceptors who were burned out or dissatisfied with their work. Examining the impression of overworked doctors on learners could be a future consideration.

Many of the interventions described are now common elements of medical education programs. Despite widespread adoption, the PC workforce shortage persists, suggesting the need for further curricular innovation. While some interventions were designed to produce more PC physicians,21,23,27,28,31–33 others reflected shifts in clinical practice20 or did not describe intent in their development.17,30,34,35

Given most studies were descriptive, cross-sectional, or single institution, results are difficult to generalize and causality cannot be determined. Few studies were funded and most of those were cross-sectional surveys. Increased support for PC educational research could improve its scope and quality.

This study is limited by the heterogeneity and methodological rigor of the identified articles. Also, 33 of the studies were published before 2010, and their relevance to contemporary medical education is uncertain.

We conclude that some electives and educational components are associated with PC specialty choice. However, the current literature is limited, contemporary electives have not been adequately studied, and none describe clear causation between intervention and specialty choice. Increased attention and funding are needed to develop more robust research in this area. Career choice is a complex issue and electives and educational components are only one contributing factor.

• NAPCRG Annual Meeting, November 20-24, 2020 (virtual)
• STFM Conference on Medical Student Education, February 1-4, 2021 (virtual)
• STFM Annual Spring Conference, May 3-7, 2021 (virtual)