Marketing family medicine

According to the Canadian Resident Matching Service, 31.7% of Canadian medical school graduates chose family medicine (FM) as their first-choice discipline in 2006. This is an improvement from 24.8% in 2003 but still represents a substantial drop from the early 1990s when more than 35% of students fell into this category.

As medical students, we have seen considerable misrepresentation of FM and regard this as a marketing failure in the early years of medical school. Negative aspects are often exaggerated, and positive characteristics are downplayed. Undersold features include FM’s opportunity for diversity and flexibility of career, challenge of practice, and ability to “hold its own” alongside any other medical specialty. In light of this, we propose a new method to make FM the top career choice for more medical students: better marketing.

Hidden curriculum

Many of the reforms made to date can be summarized as largely financial and practice-oriented incentives for practising doctors. These reforms, however, do not directly address the core issue of how we can encourage more medical students to select FM as a career. Despite (or possibly because of) the changes, many medical students do not choose FM because they see it as a specialty going through a tumultuous time.¹ More importantly, many are influenced early on by what is often called the “hidden curriculum” of misrepresentations about the nature of the specialty as presented throughout medical school.

A hidden and pernicious opinion pervades many of the hospital medical services (to which medical students are most frequently exposed) that FM is a land populated with people who “couldn’t do better.” As insulting as this opinion is, it is no secret that it exists within the hidden curriculum.² Many medical students do not have any exposure to family practice beyond their own personal experiences as young, often healthy, patients. Hence, preconceived notions about FM are limited, and students develop opinions based on their peers and role models. In an environment like that, negative attitudes and misinformation are self-perpetuating without strong, consistent messages to contest them.

The best defence against the hidden curriculum is a good offence, and our goal is to change the perception of FM. Interested stakeholder groups should actively challenge the hidden curriculum by illustrating the features that students will find most attractive about a career in FM; however, this is not an unprecedented suggestion. The American Academy of Family Physicians recently released a tool kit³ that recognizes and refutes many of the erroneous concerns students have about FM.

Change in perception can best be accomplished in the cultural language with which 20- to 30-year-olds are most familiar: the language of advertising and marketing. This too is not unprecedented; the Family Medicine Department at the University of Manitoba in Winnipeg commissioned a marketing report to help improve their recruitment.⁴ A professional marketing report for the entire specialty should identify what moves, drives, and interests medical students, and this information can then be used to form an effective campaign to market FM and aggressively challenge the hidden curriculum.

Target audience

The first step in marketing FM is to delineate a target audience within the general population of medical students. A single product cannot be successfully sold to everybody—even Coca Cola has a target market. In fact, when it became obvious to the company that there was a large population for whom Coke was unappealing, they created Diet Coke, and the company continues to try to appeal to subgroups with a variety of products. The same concepts could apply to FM. For example, the various third-year residency options and other opportunities (eg, general practitioner in oncology or hospitalist) could be promoted to subgroups of students who are less interested in exclusively practising office-based FM. Portrayal of FM as much more than the classic “Norman Rockwell” imagery would illustrate its potential as a career as exciting, flexible, and challenging as any other specialty.

The first challenge is to understand which groups of students deserve the most attention. Medical students can be divided into 3 groups: pro-FM, anti-FM, and undecided “swing voters.” The first group represents students who are interested in careers in FM from the start, who might or might not meet all the selection criteria (eg, rural background, female, older, married, people-oriented) that schools use as predictors of choosing FM.⁴ The second group represents students who strongly want to pursue other areas of medicine from the start. The third group, much like in politics, represents students who are undecided about their future careers, and this group has the greatest potential to increase FM recruitment by actively challenging its misconceptions.

Marketing science tells us that, within every target group, there are influential individuals—these are the leaders. Leaders are often at the centre of their social groups, and their opinions are respected by their peers. A properly targeted campaign could alter the career choices within groups of swing voters in part by influencing the beliefs of the leaders. At present, it is unknown which of the varied features of FM appeal most to the leaders or the swing voters. Some suggest that formally recognizing family doctors as specialists might help with medical student recruitment.⁵ This might be intuitive but is not evidence-based. In clinical practice, we try to understand the evidence before offering a treatment. The same process must hold true for promotion and recruitment: a more scientific understanding of medical students is necessary.

Once the target audience is identified and understood, the next step is to use advertising techniques to communicate and change perceptions. Promotional material about FM has, for years, been sent out, and every FM department has flyers waiting to be picked up by students motivated to refute the hidden curriculum. Some might ask, “Why invest money in getting this message out if it is already there?” It is because those who are not actively considering a future in FM must have the message brought to them. Any message put forward is competing with hundreds of other messages. In this case, perception is reality; by effectively challenging the hidden curriculum in the minds of swing voters, we can change a future in FM from a back-up plan to a top choice.

Techniques worth pursuing

This commentary reflects our observations during the last 4 years of medical school. Rather than propose specifically what is to be done, we suggest only that applying the techniques of marketing and advertising is worth pursuing. We recognize the ethical issues inherent in treating a career in FM as a commodity. Given the gravity of the current situation, however, we believe that a properly targeted campaign is a worthwhile endeavour that would add more family physicians to the system from a pool of students who could be happy in that career. Comprehensive primary care by family doctors has been shown to correlate closely with the success of a health care system in terms of its ability to deliver improved, equitable, and cost-effective health outcomes.⁶ Policy changes and pamphlets that go unnoticed do not have the same potential to reach medical students and counter negative stereotypes about FM that a well-marketed and well-articulated challenge to the hidden curriculum might have.

We want to generate discussion within the community of stakeholders interested in ensuring a strong future for FM recruitment. It is important to emphasize our belief that the initiatives taken thus far to solve the FM crisis are valuable and effective. We encourage discussion and further research to better understand how medical students feel about FM and how to encourage more students to consider why a future in FM might be right for them.