Abstract
Background
There is an unmet need for internal medicine physicians in Uganda owing to the growing burden of diseases. This study aimed at evaluating the factors associated with career choices of undergraduate medical students regarding internal medicine in Uganda.
Methods
We conducted a cross-sectional study in the first 3 weeks of October 2021 via WhatsApp messenger. Medical students in the 3rd to 5th year of study who had completed internal medicine clinical rotations and pursuing a Bachelor of Medicine and Bachelor of Surgery (MBChB) degree at 7 Ugandan universities (4 public and 3 private) were enrolled. Multivariable logistic regression model was constructed to determine factors associated with a career choice in internal medicine.
Results
We enrolled 418 participants, median age was 24 (interquartile range (IQR): 23–26) years, 67.7% were male, and 36.1% had a family member or relative who was a doctor. Most of the students (84.0%) were interested in research. The top three most preferred specialties were internal medicine (52.6%), surgery (51.2%), and obstetrics and gynaecology (51.0%). Overall, 186 (44.5%) participants reported plans to pursue a Master of Medicine degree in internal medicine. Interest in research was the only factor independently associated with 2.5-fold higher odds of pursuing a career in internal medicine (adjusted odds ratio: 2.5, 95% CI: 1.4–4.6, p = 0.003). About 73% of the participants strongly agreed that internal medicine requires wide reading.
Conclusion
There is a strong interest to pursue a career in internal medicine among Ugandan medical students. We recommend an increase in training opportunities in Internal Medicine, especially in view of the growing disease burden and increasing population growth.
Keywords: internal medicine, career choices, Uganda
Background
Internal medicine is one of the oldest medical specialities.1,2 The American College of Physicians (ACP) describes an internal medicine physician as a specialized medical practitioner who applies scientific knowledge and clinical expertise to the diagnosis, treatment, compassionate and comprehensive care of adults across the spectrum from health to complex illness affecting internal organs and systems.3 World over, internal medicine physicians play an important role in the management of acutely ill, hospitalized patients as well as those receiving primary care (outpatient) for stable chronic illnesses, general checkups and general wellness consultations.3
With the increasing burden of communicable and non-communicable diseases, emerging and re-emerging diseases and pandemics,4,5 it is important that there is a corresponding increase in the number of physicians to meet the health demand of the growing population. The future of internal medicine specialty depends on the success of the harmonization of postgraduate training programs and continued interest and mentorship of undergraduate medical students to train and practice in the specialty.
Despite an unmet need for more internal medicine physicians globally,6 the number of medical students interested in pursuing a career in internal medicine has substantially declined in the last few decades. For example, in the United States (US), the number of medical students matching into internal medicine residency positions declined by 32% between 1985 and 2008.7 Even worst, the number of US students choosing residency training in primary care internal medicine declined by 54% within the same period.7 Uganda has an unmet need for physicians with less than 400, majority of whom are practicing in hospitals in major cities and towns or teaching at universities. The intake of students into internal medicine training has been very low over the years and only recently had a slight increase for the internal medicine programme at Makerere University, but this is not enough to meet the demand of the growing population and increasing disease burden and complexity.
Several individual and contextual factors have been found to affect medical students’ career preferences in clinical medicine.8 A study of 1177 fourth-year medical students at 11 US medical schools found that medical students valued the teaching during internal medicine clerkships but expressed serious reservations about internal medicine as a career.9 Students who reported more favorable impressions of the patients cared for by internal medicine physicians, the internal medicine practice environment, and the internal medicine physicians’ lifestyle were more likely to pursue a career in internal medicine. Students were discouraged from internal medicine by their experiences with elderly and chronically ill patients.9
A recent study conducted among 5th year medical students of Makerere University, the major and oldest medical training institution in Uganda, showed that only 12.6% of the 135 students surveyed selected internal medicine as their preferred career choice. Our study aimed to explore interest and factors associated with medical students’ career choices regarding internal medicine to inform short- and long-term strategies to optimize internal medicine training programs in Uganda.
Methods
Study Design
A descriptive, cross-sectional study was conducted in the first 3 weeks of October 2021.
Study Setting
The study was conducted at 7 of the 10 accredited universities offering an undergraduate Bachelor of Medicine and Bachelor of Surgery (MBChB) in Uganda; four public universities, namely, Makerere University (Mak), Mbarara University of Science and Technology (MUST), Gulu University (GU), and Busitema University (BU); and three private universities, namely, Kampala International University (KIU), Islamic University in Uganda (IUIU), and King Caesar International University (KCU) were included. Of these, Mak, MUST, BU and KIU offer postgraduate training in internal medicine.
Students pursuing the MBChB course take a minimum of 5 years to complete their training in Uganda. In some universities, clinical training is done in third-, fourth- and fifth-years (Mak, MUST), whereas in the rest, the training is offered in fourth- and fifth-year. The seven selected universities together had an estimated number of 3880 students pursuing MBChB and in clinical years of study in the academic year 2020/2021.
Study Population
We included all medical students, 18 years or older in clinical years of training and pursuing MBChB program who had attended internal medicine rotations in the selected universities. Those not in class WhatsApp groups or who declined to participate were excluded.
Sample Size Estimation
The sample size was estimated using Epi Info StatCal for population survey. Using an estimated prevalence of internal medicine choice of 12.6%,15 acceptable margin of error of 5%, design effect of 1.0 at 95% confidence interval, design effect of 2 and 20% non-response rate, a sample size of 422 was calculated.
Data Collection
The following data were collected: demographics and factors associated with career choice in internal medicine by employing purposive sampling. Independent variables were demographic characteristics including sex, age, year of study, mentorship, and role model. Dependent variable was a career choice in internal medicine as measured by a dichotomous question (Yes/No). Data were collected using a questionnaire designed in a KoboTool Box app (Harvard Humanitarian Initiative, Cambridge, Massachusetts), whose link was shared to students via WhatsApp (Meta, California, USA).
Attitude Score
Attitudes were scored as; strongly agree (5 points), agree (4 points), neutral (3 points), disagree (2 points), and strongly disagree (1 point). The mean attitude score was calculated by dividing the total scores of the participants by the total possible score and results multiplied by 5. A score close to 1 indicated negative attitude, and those near 5 reflect positive attitude towards internal medicine.
Data Analysis
Completed questionnaires were extracted to a Microsoft Excel 2016 spreadsheet for cleaning and coding. Cleaned data were exported to STATA version 16.0 for further analyses. Numerical data were summarized as means (standard deviations) or median (interquartile range) as appropriate and categorical data as frequencies and proportions. Association between career interest in internal medicine and independent variables were assessed using Chi-square or Fisher's exact tests for categorical and Mann–Whitney U or independent sample t-test for numerical variables. A multivariate logistic regression analysis model was constructed and included all variables with p < 0.2 from bivariate analysis. Results were presented as adjusted odds ratio with their corresponding 95% confidence Interval. A P < 0.05 was considered statistically significant.
Results
Demographic Characteristics
Overall, 418 responses (99% response rate) from medical students in the 7 medical schools were received. The median age was 24 (interquartile range (IQR): 23–26) years. Two-thirds (67.7%) of the students were male and most were single (87.6%). There was a good representation from all the seven medical schools, with each contributing over 10% to the overall responses. About 39% were final year students in their fifth year of study and 92.6% were Ugandans by nationality. Some 151 students (36.1%) had a family member or relative who was a doctor, and most of them were practicing general medicine (45%), Table 1.
Table 1.
Characteristics of the Study Participants
| Variable | Frequency | Percent |
|---|---|---|
| Age (median, IQR) | 24 | 23–26 |
| 18–35 years | 228 | 54.5 |
| ≥36 years | 190 | 45.5 |
| Sex | ||
| Female | 135 | 32.3 |
| Male | 283 | 67.7 |
| Marital status | ||
| Divorced / widower | 1 | 0.2 |
| Married / cohabiting | 51 | 12.2 |
| Single | 366 | 87.6 |
| University | ||
| Busitema University | 76 | 18.2 |
| Gulu University | 48 | 11.5 |
| Islamic University in Uganda | 54 | 12.9 |
| Kampala International University | 45 | 10.8 |
| King Caesar University | 43 | 10.3 |
| Makerere University | 81 | 19.4 |
| Mbarara University of Science and Technology | 71 | 17.0 |
| Year of study | ||
| III | 107 | 25.6 |
| IV | 148 | 35.4 |
| V | 163 | 39.0 |
| Nationality | ||
| International | 31 | 7.4 |
| Ugandan | 387 | 92.6 |
| Region of origin if Ugandan | ||
| Central | 114 | 29.5 |
| Eastern | 103 | 26.7 |
| Northern | 52 | 13.5 |
| Western | 117 | 30.3 |
| Type of sponsorship in the current degree | ||
| Government loan scheme | 24 | 5.7 |
| Government merit | 151 | 36.1 |
| Private - NGO | 31 | 7.4 |
| Private - parents | 136 | 32.5 |
| Private - self | 76 | 18.2 |
| Family member is a doctor | ||
| No | 267 | 63.9 |
| Yes | 151 | 36.1 |
| Family members’ specialty (n = 151) | ||
| General medicine | 68 | 45.0 |
| Internal medicine | 22 | 14.6 |
| Surgery | 22 | 14.6 |
| Not sure | 17 | 11.3 |
| Paediatrics | 15 | 9.9 |
| Obstetrics and gynaecology | 14 | 9.3 |
| Other specialty | 14 | 9.3 |
| Radiology | 9 | 6.0 |
| Ophthalmology | 4 | 2.6 |
| Anaesthesia | 3 | 2.0 |
| Otolaryngology | 2 | 1.3 |
| Emergency medicine | 1 | 0.7 |
Career Preferences
Nearly all the students (n = 400, 95.7%) had plans to pursue postgraduate training with 23.4% willing to undertake it in Uganda (Table 2). The top three most preferred specialties were internal medicine (52.6%), surgery (51.2%), and obstetrics and gynaecology (51.0%). About 52.6% of the participants were interested in practicing in the public service, while only 15.1% were interested in administration.
Table 2.
Career Preference Among the Participants
| Variables | Frequency | Percent |
|---|---|---|
| Plans to pursue postgraduate training | ||
| No | 18 | 4.3 |
| Yes | 400 | 95.7 |
| Preferred place to pursue postgraduate training | ||
| Anywhere | 171 | 43.0 |
| Abroad | 134 | 33.7 |
| Uganda | 93 | 23.4 |
| Top 3 specialty preference currently | ||
| Internal medicine | 220 | 52.6 |
| Surgery | 214 | 51.2 |
| Obstetrics and gynaecology | 213 | 51.0 |
| Paediatrics | 149 | 35.6 |
| Public health | 86 | 20.6 |
| Emergency medicine | 70 | 16.7 |
| Ophthalmology | 37 | 8.9 |
| Oncology | 37 | 8.9 |
| Pathology | 35 | 8.4 |
| Others | 6 | 1.4 |
| Anaesthesia | 27 | 6.5 |
| Forensic medicine | 25 | 6.0 |
| Otolaryngology | 19 | 4.5 |
| Radiology | 19 | 4.5 |
| Psychiatry | 20 | 4.8 |
| Anatomy | 12 | 2.9 |
| Pharmacology | 7 | 1.7 |
| Microbiology | 6 | 1.4 |
| Physiology | 5 | 1.2 |
| Palliative care | 3 | 0.7 |
| Biochemistry | 2 | 0.5 |
| Family medicine | 1 | 0.2 |
| Preferred field of practice | ||
| Public service | 219 | 52.4 |
| Private service | 153 | 36.6 |
| Research | 111 | 26.6 |
| Academia teaching | 105 | 25.1 |
| Administration | 63 | 15.1 |
Career in Internal Medicine
Overall, 186 students (44.5%) had plans to pursue a master’s degree in internal medicine. Majority were male (70.4%) and in the fifth year of study (36.6%). Makerere (21.5%) and Busitema (19.4%) universities had the highest number of students with interests in pursuing internal medicine. Students who had passion for becoming a doctor constituted 81.2% of those interested in pursuing internal medicine. At bivariate analysis (Table 3), interest in pursuing internal medicine was significantly associated with preference in practicing in the academia (p = 0.035) and students’ interests in research (p = 0.001). Age, sex, marital status, students’ institution, and year of study were not significantly associated with interest in pursuing internal medicine.
Table 3.
Distribution of Interests to Pursue Internal Medicine Across Students’ Demographics, Motivation, and Practice Preference
| Variable | Yes (n = 186) Frequency (%) | No (n = 232) Frequency (%) | P-value |
|---|---|---|---|
| Age, years | 24 (23–26) | 24 (23–26) | 0.243 |
| 18–35 | 107 (57.5) | 121 (52.2) | 0.273 |
| >36 | 79 (42.5) | 111 (47.8) | |
| Sex | |||
| Female | 55 (29.6) | 80 (34.5) | 0.286 |
| Male | 131 (70.4) | 152 (65.5) | |
| Marital status | |||
| Divorced / widower | 0 (0) | 1 (0.4) | 0.200 |
| Married / cohabiting | 18 (9.7) | 33 (14.2) | |
| Single | 168 (90.3) | 198 (85.3) | |
| University | |||
| Busitema University | 36 (19.4) | 40 (17.2) | 0.259 |
| Gulu University | 20 (10.8) | 28 (12.1) | |
| Islamic University in Uganda | 24 (12.9) | 30 (12.9) | |
| Kampala International University | 19 (10.2) | 26 (11.2) | |
| King Caesar University | 24 (12.9) | 19 (8.2) | |
| Makerere University | 40 (21.5) | 41 (17.7) | |
| Mbarara University of Science and Technology | 23 (12.4) | 48 (20.7) | |
| Year of study | |||
| III | 57 (30.6) | 50 (21.6) | 0.106 |
| IV | 61 (32.8) | 87 (37.5) | |
| V | 68 (36.6) | 95 (40.9) | |
| Nationality | |||
| International | 15 (8.1) | 16 (6.9) | 0.651 |
| Ugandan | 171 (91.9) | 216 (93.1) | |
| Region of origin if Ugandan | |||
| Central | 48 (25.8) | 66 (28.4) | 0.680 |
| Eastern | 48 (25.8) | 55 (23.7) | |
| Northern | 20 (10.8) | 32 (13.8) | |
| Western | 55 (29.6) | 62 (26.7) | |
| Type of sponsorship in the current degree | |||
| Government loan scheme | 12 (6.5) | 12 (5.2) | 0.964 |
| Government merit | 67 (36) | 84 (36.2) | |
| Private - NGO | 15 (8.1) | 16 (6.9) | |
| Private - parents | 59 (31.7) | 77 (33.2) | |
| Private - self | 33 (17.7) | 43 (18.5) | |
| Family member is a doctor | |||
| No | 123 (66.1) | 144 (62.1) | 0.390 |
| Yes | 63 (33.9) | 88 (37.9) | |
| Family members’ specialty | |||
| Internal medicine | 174 (93.5) | 222 (95.7) | 0.330 |
| Other | 12 (6.5) | 10 (4.3) | |
| Reason for pursuing MBChB | |||
| Persuaded by family and relatives | 16 (8.6) | 25 (10.8) | 0.458 |
| To make more money | 19 (10.2) | 23 (9.9) | 0.919 |
| Grades dictated admission | 20 (10.8) | 25 (10.8) | 0.944 |
| To make my parents proud | 26 (14) | 33 (14.2) | 0.943 |
| Passion to become a doctor | 151 (81.2) | 170 (73.3) | 0.057 |
| Preferred field of practice | |||
| Public service | 100 (53.8) | 119 (51.3) | 0.615 |
| Private service | 62 (33.3) | 91 (39.2) | 0.214 |
| Research | 53 (28.5) | 58 (25) | 0.421 |
| Academia teaching | 56 (30.1) | 49 (21.1) | 0.035 |
| Administration | 22 (11.8) | 41 (17.7) | 0.097 |
| Interest in research | |||
| No | 17 (9.1) | 50 (21.6) | 0.001 |
| Yes | 169 (90.9) | 182 (78.4) |
At multivariable logistic regression (Table 4), students with interest in research were 2.5-fold more likely to pursue a career in internal medicine (adjusted odds ratio: 2.5, 95% CI: 1.4–4.6, p = 0.003).
Table 4.
Factors Associated with Interest in Internal Medicine
| Variables | Adjusted Odds Ratio (95% CI) | P-value |
|---|---|---|
| Age | 0.9 (0.9–1) | 0.105 |
| Sex | ||
| Female | 1.0 | |
| Male | 1.1 (0.7–1.8) | 0.548 |
| Year of study | ||
| I | 1.0 | |
| IV | 0.7 (0.4–1.1) | 0.134 |
| V | 0.8 (0.5–1.3) | 0.379 |
| Motivation to pursue MBChB | ||
| Passion | 1.5 (0.9–2.5) | 0.092 |
| Practice preference | ||
| Academia/teaching | 1.5 (0.9–2.3) | 0.108 |
| Administration | 0.6 (0.3–1) | 0.069 |
| Interests in research | 2.5 (1.4–4.6) | 0.003 |
Attitudes Towards Internal Medicine
Table 5 shows the attitudes of the participants towards internal medicine. Majority of the students strongly agreed that internal medicine requires wide reading (n=303,72.5%) and patient problems in internal medicine are so diverse (n = 212, 50.7%). About half of the participants agreed that there is an excellent opportunity for inpatient (n = 213, 51.0%) and outpatient care (n = 196, 46.9%) in internal medicine. More students agreed that the call schedule in internal medicine was flexible (n = 180, 43.1%), and that internal medicine would allow one to have academic/teaching roles (n = 173, 41.4%).
Table 5.
Attitudes of the Participants Towards Internal Medicine
| Attitude | Strongly Disagree | Disagree | Neutral | Agree | Strongly Agree | Mean (SD) |
|---|---|---|---|---|---|---|
| Internal medicine requires wide reading | 3 (0.7) | 4 (1.0) | 25 (6.0) | 83 (19.9) | 303 (72.5) | 4.6 (0.7) |
| Patient problems in internal medicine are so diverse | 0 (0) | 13 (3.1) | 36 (8.6) | 157 (37.6) | 212 (50.7) | 4.4 (0.8) |
| Internal medicine makes you a good researcher | 5 (1.2) | 18 (4.3) | 81 (19.4) | 159 (38) | 155 (37.1) | 4.1 (0.9) |
| Internal medicine will allow me to have academic / teaching role | 12 (2.9) | 12 (2.9) | 75 (17.9) | 173 (41.4) | 146 (34.9) | 4 (0.9) |
| I admire physicians | 16 (3.8) | 39 (9.3) | 90 (21.5) | 147 (35.2) | 126 (30.1) | 3.8 (1.1) |
| There is an excellent opportunity for inpatient care in internal medicine | 10 (2.4) | 26 (6.2) | 98 (23.4) | 213 (51) | 71 (17) | 3.7 (0.9) |
| Patients die often in internal medicine | 12 (2.9) | 46 (11) | 109 (26.1) | 127 (30.4) | 124 (29.7) | 3.7 (1.1) |
| There are good opportunities to work as a physician abroad | 7 (1.7) | 21 (5) | 158 (37.8) | 141 (33.7) | 91 (21.8) | 3.7 (0.9) |
| There is an excellent opportunity for outpatient care in internal medicine | 8 (1.9) | 34 (8.1) | 111 (26.6) | 196 (46.9) | 69 (16.5) | 3.7 (0.9) |
| There are many future job opportunities to a physician in Uganda | 12 (2.9) | 43 (10.3) | 143 (34.2) | 141 (33.7) | 79 (18.9) | 3.6 (1) |
| Joining Internal medicine requires a very high cumulative grade point average | 5 (1.2) | 38 (9.1) | 166 (39.7) | 143 (34.2) | 66 (15.8) | 3.5 (0.9) |
| Internal medicine will allow me to have time for my family and spouse | 21 (5) | 52 (12.4) | 133 (31.8) | 131 (31.3) | 81 (19.4) | 3.5 (1.1) |
| There are less procedures in internal medicine | 19 (4.5) | 88 (21.1) | 75 (17.9) | 153 (36.6) | 83 (19.9) | 3.5 (1.2) |
| Call schedule in internal medicine is flexible | 17 (4.1) | 54 (12.9) | 126 (30.1) | 180 (43.1) | 41 (9.8) | 3.4 (1) |
| Support network in internal medicine is excellent | 11 (2.6) | 47 (11.2) | 169 (40.4) | 143 (34.2) | 48 (11.5) | 3.4 (0.9) |
| Internal medicine training facilities are of excellent quality | 11 (2.6) | 76 (18.2) | 149 (35.6) | 128 (30.6) | 54 (12.9) | 3.3 (1) |
| The quality of current internal medicine trainees has encouraged me to pursue a career in internal medicine | 21 (5) | 87 (20.8) | 149 (35.6) | 112 (26.8) | 49 (11.7) | 3.2 (1.1) |
The mean attitude scores are presented in Table 5. The mean attitude scores were highest for internal medicine requiring a lot of time (4.6 ± 0.7), patients’ problems being diverse (4.4 ± 0.8), making one a good researcher (4.1 ± 0.9), and allowing one to have academic/teaching career (4.0 ± 0.9), indicating overall agreement with the statements. The mean attitude scores were lowest for internal medicine having low patient load (2.2 ± 1.0), being boring to practice (2.3 ± 1.1), physicians having a lot of free time (2.6 ± 1.0) and having attractive salaries (2.7 ± 0.9), indicating overall disagreement.
Motivation to Undertake Research
Most of the students (84.0%) were interested in research (Table 6). Among these, the desire to discover new things (74.1%), passion (31.6%), mentorship (31.6%), income (29.1%), and need for collaborations (29.1%) were the top five reasons for interests in research. Among the 67 students not interested in research, long time required, hectic research processes, and the need for wide reading were the most frequent reasons.
Table 6.
Interests in Undertaking Research Among the Study Participants
| Variable | Frequency | Percent |
|---|---|---|
| Interested in research | ||
| Yes | 351 | 84.0 |
| No | 67 | 16.0 |
| Reason for interest | ||
| Discovering new things | 260 | 74.1 |
| Passion | 111 | 31.6 |
| Mentorship | 111 | 31.6 |
| Money | 102 | 29.1 |
| Collaborations | 102 | 29.1 |
| Academic promotion | 100 | 28.5 |
| Awards and recognition | 90 | 25.6 |
| Travel | 67 | 19.1 |
| Others | 10 | 2.8 |
| Reason for lack of interest | ||
| Research requires a lot of time | 32 | 47.8 |
| Research is hectic | 31 | 46.3 |
| It requires a lot of reading | 16 | 23.9 |
| I am not good at writing | 15 | 22.4 |
| I lack mentors | 14 | 20.9 |
| Research requires a lot of money | 11 | 16.4 |
| Publishing is a hard process | 10 | 14.9 |
| Others | 5 | 7.5 |
Discussion
We aimed to explore interest and factors associated with medical students’ career choices regarding internal medicine in Uganda. Majority of study participants strongly agreed that internal medicine is diverse and requires wide reading. Overall, 186 (44.5%) participants reported plans to pursue a Master of Medicine degree in internal medicine and this was significantly associated with interest in research. Majority of the participants had interest in pursuing a career in research. Our findings reflect a positive response to the growing demand for research due to the increasing burden of both communicable and non-communicable diseases, emerging and re-emerging diseases and pandemics. Puertas et al argue that limited research opportunities10 affect students’ choice of graduate training. Understanding features of medical students that favors the choice of internal medicine would guide development of interventions to recruit more students in postgraduate training and a career in internal medicine.
Almost all students expressed interest in postgraduate training, although only about a quarter were interested in training from Uganda. The interest in postgraduate training is similar to findings from a study among Nigerian medical students.11 It would be interesting to explore reasons for lack of interest in training in the country, but a possible reason is the desire for higher income as demonstrated in one study among Malawian medical students.12 A multisite study conducted in selected medical schools in Uganda found that 44.65% of final year medical students were interested in leaving Uganda after their graduation.13 Eastwood et al14 report that the lack of opportunities for post-graduate training is one of the major factors for the migration of health workers to foreign countries. There is a need to increase collaborative relationships between foreign and local institutions for training healthcare workers in sub-Saharan Africa.
Our findings contrast with a recent study conducted among 5th year medical students of Makerere University which showed that only 12.6% of the students surveyed selected internal medicine as their preferred career choice15 and a 2006 career intentions study among medical students from 6 sub-Saharan countries which found the top most desired specialities to include surgery (20%), internal medicine (16.7%), and paediatrics (9%).16 We found that the top three most preferred specialties were internal medicine (52.6%), surgery (51.2%), and obstetrics and gynaecology (51.0%). These disciplines have been reported as preferences by medical students in several other studies with surgery usually ranking first in order of choice.17–19 The training curriculum provides more exposure to these four major disciplines. In addition, many teaching hospitals in Uganda like other low-resource countries have low capacity, hence limited exposure for students to other disciplines.
The choice of internal medicine was significantly associated with preference for academia and research. This was contrary to a US study, which found educational experiences, the nature of patient care in internal medicine, and lifestyle as associated factors.9 According to a systematic review by Lei and Chuang, both academic and non-academic factors determine graduate studies selection.20 Academic factors include institutional, departmental, and faculty factors, whereas non-academic factors include factors related to personal reasons and the impact of other people. Other factors influencing career choice include undergraduate medical course performance, positive experience during a discipline’s clerkship.15,21 Influences from media for example watching medical series such as the “House” series has also inspired some students to pick interest in internal medicine. Besides, several barriers exist towards medical student’s preference for postgraduate training. Students with a preconception of the low financial status of specialists of a given discipline, unfavorable lifestyles of a career, and inadequate exposure to a specialty in clinical rotations are key barriers to choosing a medical postgraduate career path.15
Medical students require career guidance from their academic medical centers. Interventions such as Internal Medicine Interest groups can help foster strong relationships with significant outcomes for proper mentorship of medical students interested in pursuing a residency program in internal medicine.22 The Association of Physicians of Uganda could take on this role. The public service was the most desired field of practice by more than half of the participants. This could be due to anticipation of Government of Uganda training scholarship opportunities. This finding is consistent with that of Bailey et al12 who found Malawian medical students desired to work for the government for reasons such as availability of training opportunities for public service workers. Also, job security in public service is perceived to be more stable than in private service. It also offers one an opportunity to receive a gratuity and pension at the end of the service, which is unlikely in private practice in Uganda.
This study has some limitations. It was conducted in 7 medical schools, with a vast experience of teaching systems and learning environments therefore provides generalizable findings among medical students across Uganda. However, consecutive sampling and the online data collection could have introduced selection and information bias among participants.
Conclusions
Majority of medical students in Uganda are interested in specializing after their undergraduate medical degree. A significant proportion of medical students are interested in pursuing internal medicine motivated by interest in research and joining academia. The findings provide some insight into how the undergraduate curriculum and internal medicine clinical exposure in particular can be leveraged to interest students to enroll for specialist training and a career in internal medicine.
Acknowledgments
We acknowledge the heads of department of the internal medicine of the selected medical school for their initial review of the study protocol.
Funding Statement
This study was non-funded.
Abbreviations
ACP, American College of Physicians; MBChB, Bachelor of Medicine and Bachelor of Surgery; NGO, Non-Governmental Organisation; Mak, Makerere University; MUST, Mbarara University of Science and Technology; GU, Gulu University; BU, Busitema University; KIU, Kampala International University; IUIU, Islamic University in Uganda (IUIU); KCU, King Caesar International University.
Data Sharing Statement
Data are available upon reasonable request from the first author at drbongomin@gmail.com.
Ethics Approval and Consent to Participate
The study was conducted in accordance with the principles of the Declaration of Helsinki. Approval to conduct the study was sought from the Makerere University School of Medicine Research and Ethics Committee (Mak-SOMREC-2021-161). Prior to enrollment, written informed consent was obtained from all study participants.
Consent for Publication
All study participants provided written informed consent for their data to be published in a peer-reviewed journal.
Author Contributions
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
Disclosure
The authors declare that they have no conflicts of interest in relation to this work.
References
- 1.de la Blanchardière A, Le Dinh T. History of internal medicine. La Rev Med Interne. 1994;15(10):690–693. doi: 10.1016/S0248-8663(05)82185-X [DOI] [PubMed] [Google Scholar]
- 2.Reyes H. Qué es medicina interna? [What is internal medicine?] Rev Med Chil. 2006;134(10):1338–1344. doi: 10.4067/S0034-98872006001000020 [DOI] [PubMed] [Google Scholar]
- 3.ACP. ACP: who we are. [Internet]. American College of Physicians; 2021. Available from: https://www.acponline.org/about-acp/who-we-are. Accessed October 11, 2022. [Google Scholar]
- 4.Dhama K, Khan S, Tiwari R, et al. Coronavirus disease 2019–COVID-19. Clin Microbiol Rev. 2020;33(4):e00028–20. doi: 10.1128/CMR.00028-20 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2163–2196. doi: 10.1016/S0140-6736(12)61729-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Byhoff E, Kangovi S, Berkowitz SA, et al. A Society of General Internal Medicine position statement on the internists’ role in social determinants of health. J Gen Intern Med. 2020;35:2721–2727. doi: 10.1007/s11606-020-05934-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.NRMP. The national residency matching program; 2019. Available from: https://www.nrmp.org/. Accessed October 11, 2022.
- 8.Ahmed SMM, Majumdar MAA, Karim R, Rahman S, Rahman N. Career choices among medical students in Bangladesh. Adv Med Educ Pract. 2011;2:51. doi: 10.2147/AMEP.S13451 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students’ career choices regarding internal medicine. JAMA. 2008;300(10):1154–1164. doi: 10.1001/jama.300.10.1154 [DOI] [PubMed] [Google Scholar]
- 10.Puertas EB, Arósquipa C, Gutiérrez D. Factors that influence a career choice in primary care among medical students from high-, middle-, and low-income countries: a systematic review. Rev Panam Salud Pública. 2013;34(5):351–358. [PubMed] [Google Scholar]
- 11.Ossai EN, Uwakwe KA, Anyanwagu UC, Ibiok NC, Azuogu BN, Ekeke N. Specialty preferences among final year medical students in medical schools of southeast Nigeria: need for career guidance. BMC Med Educ. 2016;16(1):1–8. doi: 10.1186/s12909-016-0781-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Bailey N, Mandeville KL, Rhodes T, Mipando M, Muula AS. Postgraduate career intentions of medical students and recent graduates in Malawi: a qualitative interview study. BMC Med Educ. 2012;12(1):1–10. doi: 10.1186/1472-6920-12-87 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Kizito S, Mukunya D, Nakitende J, et al. Career intentions of final year medical students in Uganda after graduating: the burden of brain drain. BMC Med Educ. 2015;15(1):1–7. doi: 10.1186/s12909-015-0396-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Eastwood JB, Conroy RE, Naicker S, West PA, Tutt RC, Plange-Rhule J. Loss of health professionals from sub-Saharan Africa: the pivotal role of the UK. Lancet. 2005;365(9474):1893–1900. doi: 10.1016/S0140-6736(05)66623-8 [DOI] [PubMed] [Google Scholar]
- 15.Kuteesa J, Musiime V, Munabi IG, et al. Specialty career preferences among final year medical students at Makerere University College of health sciences, Uganda: a mixed methods study. BMC Med Educ. 2021;21(1):1–12. doi: 10.1186/s12909-021-02630-x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Burch VC, McKinley D, Van Wyk J, et al. Career intentions of medical students trained in six sub-Saharan African countries. Educ Heal. 2011;24(3):614. [PubMed] [Google Scholar]
- 17.Bittaye M, Odukogbe A-TA, Nyan O, Jallow B, Omigbodun AO. Medical students’ choices of specialty in The Gambia: the need for career counseling. BMC Med Educ. 2012;12(1):1–9. doi: 10.1186/1472-6920-12-72 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Gazibara T, Kurtagić I, Marić G, et al. Perception of first-year versus sixth-year medical students in Serbia on studying medicine and postgraduate career. Acta Clin Croat. 2019;58(2):371. doi: 10.20471/acc.2019.58.02.23 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Mariolis A, Mihas C, Alevizos A, et al. General Practice as a career choice among undergraduate medical students in Greece. BMC Med Educ. 2007;7(1):1–8. doi: 10.1186/1472-6920-7-15 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Lei SA, Chuang N-K. Demographic factors influencing selection of an ideal graduate institution: a literature review with recommendations for implementation. Coll Stud J. 2010;44(1):1. [Google Scholar]
- 21.Ko HH, Lee TK, Leung Y, Fleming B, Vikis E, Yoshida EM. Factors influencing career choices made by medical students, residents, and practising physicians. B C Med J. 2007;49(9):482. [Google Scholar]
- 22.Dorrance KA, Denton GD, Proemba J, et al. An internal medicine interest group research program can improve scholarly productivity of medical students and foster mentoring relationships with internists. Teach Learn Med. 2008;20(2):163–167. doi: 10.1080/10401330801991857 [DOI] [PubMed] [Google Scholar]