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| Journal of the New Zealand Medical Association,
10-October-2003, Vol 116 No 1183
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|
The demographic characteristics of New Zealand medical
students: the New Zealand Wellbeing, Intentions, Debt and Experiences (WIDE)
Survey of Medical Students 2001 study
Julie Fitzjohn, Tim Wilkinson, Denzil Gill and Roger
Mulder
Problems exist with the composition and distribution of the
New Zealand medical workforce. The current New Zealand medical workforce is
predominantly composed of medical practitioners who have graduated from a
medical school in New Zealand; however, a significant number (34%) are
overseas-trained doctors.1 While it is thought
that the current workforce of medical practitioners is sufficient to meet the
needs of the New Zealand population,2
maldistribution of practitioners has led to shortages in some specialty areas.
Furthermore, there are documented shortages of practitioners of Maori and
Pacific Island ethnicity to work with these communities, practitioners working
in areas of low socioeconomic status, and practitioners in rural
areas.3 The shortage of practitioners working
with Maori and Pacific Island patients and those of low socioeconomic status is
of particular concern as these populations have been documented to have poorer
health than other New Zealanders.4 These areas
of shortage are expected to be a continuing problem in New Zealand and future
medical practitioner requirements are being considered by the Health Workforce
Advisory Committee.3
The demographic composition of classes in New Zealand
medical schools has an impact on the characteristics of the future medical
workforce. Selecting medical students with particular characteristics may be
seen as an avenue for addressing shortages in the medical workforce to fill
areas of need. Currently, there is an intention to change the criteria of entry
into New Zealand medical schools with the hope of producing ‘good
doctors’ suited to the New Zealand
environment,5 rather than a move to address
areas of shortage. The required attributes of a ‘good doctor’ are
difficult to define; however, the ability to effectively communicate and
empathise with patients is regarded as important for all doctors as it underlies
the doctor–patient relationship. Hence, patients may prefer a practitioner
with a similar background to themselves, or at least a good understanding of
their experiences. Further, it is thought that students are more likely to
return to environments similar to their own backgrounds to practise, as is often
seen for students of rural background in Australian
studies.6 As well as the requirements for study
of a demanding course, entry criteria to medical school could include
considerations of the types of practitioners needed for the future medical
workforce. Before changes can be made it is necessary to know the demographic
composition of medical classes selected using current criteria and to understand
how that composition differs from that of the general New Zealand
population.
Medical training in New Zealand is a six-year degree. New
Zealand has two medical schools. The University of Auckland has 110
government-funded places per annum. Students at the University of Otago begin
their training in Dunedin, and then attend one of three schools (Dunedin School
of Medicine, Wellington School of Medicine and Christchurch School of Medicine)
for the final three years. The University of Otago has 170 government-funded
places per annum. Additionally, the medical schools may provide a small number
of additional ‘full-fee-paying’ places to international
students.
The selection process varies slightly between the two
schools and is currently being modified at both. Auckland has been using an
interview for many years, Otago is introducing an interview. Otago has been
selecting students from a first-year health sciences course; Auckland is
changing from using high school grades to performance within the health sciences
course format. There are alternative entry places for postgraduate students and
those with special circumstances, which are similar at the two schools. Maori
and Pacific Islander students may apply for entry to either medical school with
less competitive grades (that must meet a minimum standard) than others, if they
have proven links to their communities. This entry scheme is intended to try to
redress the shortage of culturally similar practitioners for these population
groups. There is no practical limit to the numbers of students that can enter
under the Maori and Pacific Island scheme at this time (due to the limited
number of applications). Consideration has been given to offering rural students
medical school quota places or bonded schemes to encourage future rural
practitice;5 however, no such schemes are
currently in operation. The Government has recently announced a bonded
scholarships scheme offering reduced fees (in return for postgraduate service)
to applicants whose parents have a low income in an attempt to encourage
students from lower socioeconomic backgrounds to train in health
professions.7
Students of the University of Otago Medical School have been
shown in previous work to be more likely to be
urban,8 socioeconomically
privileged,9 and non-Maori than the general
population. These studies have shown these characteristics to be stable over the
years 1987–2000. A previous study of Auckland medical students, who gained
entry between 1968 and 1993 revealed students were more likely to be male than
female, and a majority had a parent who had attended
university.10
A number of other medical student demographic features may
have an impact on the future New Zealand medical workforce. New Zealand policy
allows permanent residents who have been in New Zealand for two years the same
access and same government funding for courses as New Zealand citizens. Those
students who are New Zealand citizens may be more likely to stay in New Zealand
to practise than those with only New Zealand permanent residency or significant
offshore interests. The proportion of female graduates may also have an impact
on the number of hours worked by New Zealand medical practitioners. It has
already been noted that female graduates more often seek part-time work and
career breaks to have children.11
The aims of this study are to describe the demographic
characteristics of all New Zealand medical students studying during 2001 and to
compare these with the wider New Zealand population. This study includes both of
the medical schools in New Zealand, and allows comparison of the characteristics
between the schools. This paper also introduces the Wellbeing, Intentions, Debt
and Experiences (WIDE) survey of New Zealand medical students. It explains the
methodology of the study, and the characteristics of the sample.
MethodsQuestionnaire
development and pilot study The New Zealand WIDE Survey of Medical
Students is a questionnaire-based survey that was developed to collect
information on New Zealand medical students. The topics covered in the survey
include: medical student demographics; student debt, career intentions and
factors influencing career choice; student health and wellbeing including mental
health, drug and alcohol consumption; and student experiences during medical
training. This paper relates to questions about demographic data, which were
worded in a similar way to questions from the New Zealand Census questionnaire.
For the question on rural background, students were asked to indicate the
specified population size group (categorised as for the Census) for the
community in which they had spent most of their life. Students were asked to
select their nationality from the options ‘New Zealand citizen’,
‘permanent resident’ and ‘international student’. The
question on ethnicity allowed students to specify multiple ethnicities, which
were not prioritised. An ethnicity variable was derived from this as
follows:
Many questions for
other sections were taken directly, or adapted from, previous studies carried
out in New Zealand,12 including the
Christchurch Health and Development Study, a general cohort of similar age to
the majority of medical students who participated in the present
study.13 A copy of the Alcohol Use Disorders
Identification Test (AUDIT) was included in the
questionnaire.14 Questions on student
experiences at medical school were based on overseas
studies.12 The survey questionnaire was
developed in consultation with the student associations representing New Zealand
medical students. Input from Maori medical student representatives was sought.
Ethical approval from the University of Otago Ethics Committee was obtained. A
pilot study was conducted of all medical students at the Christchurch School of
Medicine from September to October 2000. This confirmed the appropriateness of
the survey tool and the data
gathered.12,15
Data collection and
analysis Data collection was performed in 2001 as a census of all medical
students in New Zealand at each of the medical school sites, Auckland,
Wellington, Christchurch, and Dunedin. To ensure that trainee interns, ie,
sixth-year medical students, who might be overseas on elective were surveyed,
the survey period extended from May 2001 to October 2001. Students were asked in
advance to collect information on levels of debt from all sources. Participation
was voluntary. The survey was administered and completed by class groups, where
possible, during a specifically allocated one-hour period, after scheduled
classes. To ensure anonymity students were not required to record their name or
other identification information on the questionnaires. Participants deposited
completed questionnaires into a box and then crossed their name off a class
list. Those students not wishing to participate were asked to hand in a blank
survey and cross their names off. Trainee interns, and those students absent
from class collection times had surveys sent to them via internal mail, with a
request to return surveys to a collection point and cross their names off a
list. Students whose names were not crossed off the list were sent reminders by
internal mail three times before being considered unwilling to
participate.
To determine if the responders were representative of
the entire medical school classes, the medical schools provided information on
the gender, ethnic and residency status of the 2001 class years (personal
communications: Bruce Savage, University of Otago, 2003; Kate Kilkenny,
University of Auckland, 2003).
Information on the New Zealand population for the year
2001 was taken from official sources. Data from the New Zealand Census 2001 was
taken from tables on the web site of Statistics New
Zealand.16 Where necessary, categories in the
published raw tables were collated to make data comparable. Information on
secondary school attendance in New Zealand was sought from the Ministry of
Education web site. Data from 1995 were used, as all trainee interns who entered
medical school directly after leaving secondary school would have been in their
final year at secondary school at this time. Attempts were made to obtain the
proportion of the New Zealand population who are permanent residents; however,
discussion with the Department of Immigration confirmed this statistic is not
kept (personal communication, Michael Sheridan, Department of Immigration,
2003).
Analyses of the data were performed using SPSS version
7.5. P values for heterogeneity were used unless otherwise specified.
Significance was taken as p <0.05.
ResultsOf the 1660 students studying at New
Zealand medical schools in 2001, 1384 (83.4%) completed the survey. Response
rates by year and location are shown in Table 1. A small number of
questionnaires were incomplete, or responses were indecipherable, hence the
variation in denominators for some variables. Table 2 compares the demographic
characteristics of those students completing the WIDE survey in 2001, with the
medical schools’ demographic data for the student population in 2001. This
shows that the WIDE sample is representative of the student body at each school.
Permanent residents appeared slightly under-represented in the Auckland survey,
whilst students of Asian ethnicity appeared slightly over-represented.
Table 1. Response rates by year of study and site of
medical school attended
Table 2. Comparison of demographic characteristics of
the WIDE sample with medical schools’ data on all medical students
attending in 2001
*years 2–6 only; data supplied by personal
communication, Kate Kilkenny, University of Auckland,
2003
†data supplied by personal communication, Bruce Savage, University of Otago, 2003 ‡ethnicity data not directly comparable due to different data handling: in the WIDE survey anyone who identified as Maori/Pacific Islander was categorised as such; in the schools data students were classified according to their first choice of ethnicity Of the surveyed students, 55.9% (772/1381) were female.
There was no gender difference between schools. Only 6.8% (94/1380) identified
as Maori, and 4.3% (60/1380) identified as Pacific Islander. A further seven
students identified as both Maori and Pacific Islander, resulting overall in 147
students (10.7%) identifying as Maori or Pacific Islander. Of these 147
students, 86 gained entry through the Maori or Pacific Island admission system,
the remainder gaining entry through the other general categories. Students of
Maori or Pacific Island descent are more prevalent at the University of Auckland
(Table 2). The overall proportion of Maori and Pacific Islanders in the sample
(9.7%) is much lower than that in the general population (20.3%). However,
proportions of Maori and Pacific Island students are higher in year 2 (12.8%)
and year 3 (13.7%) than in years 5 (5.8%) and 6 (5.6%). New Zealand Europeans
are also under-represented when compared with the general population (50.9%
compared with 72.7%). Students from Asia and the subcontinent are represented in
the medical classes (31.4% of all students, 27.4% of all New
Zealand-government-subsidised students) in proportions many times their
prevalence in the New Zealand population (3.4%).
New Zealand citizens make up 82.0% (1127/1375) of the class,
with similar proportions of NZ citizens at Auckland and Otago. There are more
international full-fee-paying students at Auckland, and a greater proportion of
permanent residents studying at Otago (Table 2). The proportion of permanent
residents in the class is much higher than that expected in the general
population.
Students’ ages ranged from 17 to 43 years. The
majority of students (86.4%) were aged under 25 years. Those aged 25 to 29 years
made up 9.8% of the classes, with 2.3% of the group aged between 30 and 34
years. Only 0.9% of the class were 35 or older.
The majority of New Zealand students came from major urban
backgrounds as shown in Table 3. Those at Otago University were significantly
more likely to come from an area categorised as rural. Of those surveyed, 18.7%
(258/1377) reported attending a private secondary school for the bulk of their
secondary schooling compared with 2.7% of the general
population.17 A further 11.9% (164) attended an
integrated secondary school (a school that was previously private but now
partially integrated into the public system, often charging partial fees). This
compares with 12.8% of the general population attending integrated secondary
schools.17
Table 3. Background characteristics of medical students
by medical school attended, compared with NZ Census (whole population)
2001
*p values for comparison of Auckland vs Otago
Half the students (51.0%) surveyed reported both their
parents had tertiary qualifications, and an additional 24.9% reported that
either their mother or father had a tertiary qualification. In comparison, the
2001 Census shows 12% of New Zealanders aged 35–60 have a tertiary
qualification.16 Overall, 17.5% (242/1380)
reported at least one parent who was a medical practitioner. Forty three
students (3.1%) reported that both their parents were doctors. Less than one
fifth (19.3%) of respondents estimated their parents’/caregivers’
income as less than $30 000 per annum, whilst 27.2% (357/1314) estimated it as
exceeding $100 000 per annum.
Table 4. Current living circumstances of medical
students by medical school attended
NB: p <0.001 (p value for comparison Auckland to
Otago)
Current living circumstances are shown in Table 4. There is
little difference in home ownership or hostel dwelling between students of the
two schools; however, Auckland students are significantly (p <0.001) more
likely to live with their parents, whilst their Otago counterparts are more
likely to be flatting or boarding. Only 47 of 1377 students (3.4%) reported they
were married. Twenty five students reported having dependent children, with
three being the greatest number of dependent children.
DiscussionThis is the first census of all
medical students in a single country. The comparison of the gender, ethnicity
and residency data gathered in this survey with the data held by the medical
schools showed that the sample was generally representative. Permanent residents
were under-represented in the WIDE sample from both schools, which causes some
bias in the survey results. Some permanent residents may not have perceived the
survey as relevant to them, because they believed it to be a survey of debt
(which they may not have had), or for ‘New Zealand’ medical
students. If these students did not complete surveys because they have little
intent to be New Zealand doctors, their under-representation in the survey does
not stop the survey achieving its aims. The slight over-representation of Asian
students in the Auckland sample may represent different handling of ethnicity
data by WIDE compared with the school. Overall, these small differences suggest
that the information in the WIDE survey can be taken as very representative of
the New Zealand medical student group.
This study confirmed that medical students in New Zealand do
vary in demographic characteristics from the general population and that this
holds across the two medical schools. However, there are some significant
differences between the characteristics of students at each school.
Women are now over-represented at medical school compared
with male students. As compared with their male counterparts, who historically
work long hours, these women may seek shorter working hours, or breaks from
practice for family or social reasons. This may have implications for workforce
planning, and these women may expect work hours and training schemes to become
more flexible to accommodate their social goals.
Students identifying as Maori (6.8%) or Pacific Islander
(4.3%) make up a sizeable minority of students. However, in the general
population 14.7% identify as Maori and 6.5% as Pacific
Islanders.18,19 These populations already have
a shortage of practitioners, and this situation will worsen if there continue to
be fewer medical students from these communities than population data would lead
us to expect. As New Zealand supplements its trained doctors with foreign
graduates, the proportion of practising doctors of Maori or Pacific Island
descent is lower still. Population projections expect the Maori and Pacific
Island populations to grow rapidly over coming years. By 2020, when these
students will be in the middle of their practising life, it is estimated that
around 17% of the general population will be Maori New Zealanders, while 9% will
be Pacific Islanders.18,19 Auckland Medical
School appears to be recruiting more Maori and Pacific Island students than
Otago Medical School, both through general entry and the special admission
scheme. This may, at least partly, be explained by the higher geographical
distribution of Maori in New Zealand’s North Island. Maori and Pacific
Island students may be aware of the higher Maori and Pacific Island student
population within Auckland Medical School and attend there, perceiving greater
support from fellow students and closer tribal affiliations. However, even at
Auckland Medical School, proportions of Maori and Pacific Island students are
less than those in the general New Zealand population. The medical schools have
already been working with government ministries to look at ways to encourage
more Maori and Pacific Island students to enter medical school. Whilst this
study shows a higher proportion of Maori and Pacific Island students in the
early years of the course, suggesting the situation may be improving, they are
still not present in sufficient numbers to meet current or predicted populations
needs. These data suggest that efforts are necessary and urgent, and may need
more resources.
Rural students are also under-represented when compared with
the general New Zealand population. Otago Medical School has substantially more
students from rural areas. This may reflect a geographical difference, since the
University of Otago is based in Dunedin in the South Island of New Zealand,
which is largely composed of rural communities. Dunedin is also a smaller city
and therefore may be more appealing to those from smaller towns and communities.
These differences in medical school composition offer a choice if changes to
admission systems are made. Either each school may be expected to actively work
to recruit Maori and Pacific Island students (and possibly those from rural or
low socioeconomic backgrounds) or recruitment could be looked at nationally,
with Auckland Medical School being encouraged to build on its current student
population to recruit more Maori and Pacific Island students. However, the
medical schools can only recruit if there are interested students with
appropriate academic backgrounds from those under-represented communities, which
is an issue for Government, society and those communities, not just the medical
schools.
International students are full-fee paying and are expected
to leave New Zealand. Permanent residents, however, have their training
subsidised by the New Zealand Government to the same degree as New Zealand
citizens. New Zealand allows new migrants to access subsidised tertiary training
and local quotas after two years’ residency. With 11.1% of this sample
(which may under-represent the class compositions), having permanent residency
status, it needs to be established if these students intend to stay in New
Zealand after completing training. An exodus of New Zealand-trained doctors with
permanent resident status would further contribute to shortages in the medical
workforce.
Three quarters of medical students reported that at least
one of their parents had a tertiary qualification. This compares with only 12%
of adults aged 35–60 in the 2001 Census16
having a tertiary qualification. Medical students were also shown to be six
times as likely to have attended a private secondary school as the census
population. More than one quarter of students estimated their family income as
exceeding $100 000 per annum. A direct comparison with census data is not
possible for this statistic; however, this income distribution is much higher
than the general New Zealand household income
distribution.16 Together, these data suggest
that medical students are more likely to come from a socioeconomically
privileged background than members of the general population. Studies at the
University of Otago have shown that increasing fees over recent years has not
changed the socioeconomic mix in the medical
classes.9 However, high fees may be deterring
more students from a less privileged background from entering the
class.
Anecdotally, flatting during training allows medical
students to gain awareness of lower standards of housing and budgetary
constraint compared with what they may have experienced during home life.
Evidence from this sample suggests that, especially in Auckland, large numbers
of students may be completing much of their education whilst living at home.
This may mean that students from privileged backgrounds are missing this
opportunity to gain important life experiences that may help them empathise with
lower income patients.
The differences between medical students and the general
population may have an impact on the ability of the future medical workforce to
respond to those groups in most need in the community. More concerted efforts to
attract more students of Maori and Pacific Island ethnicity are needed to
prevent worsening shortages of Maori and Pacific Island
doctors. Schemes to encourage students
of low socioeconomic background or rural origin may also have merit. Schemes may
include targeted scholarships, quota places and preferential entries. The number
of permanent residents, who may choose not to practise in New Zealand, and an
increasing proportion of females, who may work fewer hours than their male
counterparts, may fuel expected future workforce shortages. We plan to analyse
further data from this study to provide more information on the characteristics
of these students and their future intentions.
Author information:
Julie Fitzjohn, House Surgeon, Canterbury District Health Board; Tim Wilkinson,
Associate Dean (Undergraduate Education); Denzil Gill, House Surgeon, Canterbury
District Health Board; and Roger Mulder, Associate Professor of Psychological
Medicine, Christchurch School of Medicine and Health Sciences,
Christchurch
Acknowledgements:
The authors thank Professor John Campbell and Professor Peter Smith for comments
on an earlier draft. Claire Palmer assisted with the drafting of the initial
questionnaire. The New Zealand Medical Students Association supervised the
administration and collection of surveys. We thank all the medical students who
completed this survey.
Correspondence:
Associate Professor Tim Wilkinson, Associate Dean (Undergraduate
Education), Christchurch School of Medicine and Health Sciences, PO Box 4345,
Christchurch. Fax: (03) 337 7975; email: tim.wilkinson@chmeds.ac.nz
References:
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