15th March 2013, Volume 126 Number 1371

David Perez, Alison Belton

Change in New Zealand society continues unabated1, reflected in demographic change and evolving expectations of health service delivery. The proportions of Maori and Pacific peoples continues to rise as illustrated by Māori rising from 13.0% to 14.7% and Pacific from 5.0% to 6.5% respectively between the 1991 and 2001 censuses.<.p>

There is a common view that the demography of the medical workforce should reflect the community that we serve2 although there is little research attempting to show that better outcomes ensue. Previous comparisons of medical student and general New Zealand demography have shown large discrepancies in educational and socioeconomic status of parents3, domicile in main urban areas4 and ethnic origins, specifically Māori and Pacific Island.5,6<.p>

To address these discrepancies a preferential Māori and Pacific Island scheme has been in place for many years to provide affirmative opportunities for entry to the University of Otago Medical School. Moreover, since 2004, the Government sponsored rural origin preference programme has been in place for an extra 20 students who have spent significant periods in pre-secondary or secondary education in rural schools.<.p>

A further innovation implemented at Otago since 2004 has been the incorporation of the aptitude test for medicine, the Undergraduate Medical Admissions Test [UMAT] as part of the entry selection process. Although there is uncertainty as to whether UMAT has an impact on medical student demography, it should be borne in mind when interpreting any changes in the backgrounds of students.<.p>

Finally the continuing burden of medical student fees, which rose from $9750 to $10,762 between 2004–2008, also needs to be acknowledged when interpreting the data.<.p>

Methods

Between 1982 and 2008 all domestic students, including NZ citizens and residents, entering the University of Otago Medical School have been asked to complete a demographic survey. The questionnaire is voluntary and has been approved for use by the Faculty of Medicine, University of Otago.<.p>
The questionnaire covered age, marital status, country of birth, first language, citizenship, place of residence between ages 5–12, 13–18 and the year prior to entry, the year 13 school, year 13 subjects, state/private and single sex/coeducational status of the school, parents’ highest qualifications, parents’ attendance at university, parents’ occupations and parents or relatives as doctors.<.p>
Ethnicity was not surveyed in the questionnaire so ethnicity data in this report were obtained from the admissions data base. In the period 2004–2008 approximately 10–15% of Otago’s students had international origins with most sponsored by their governments. The sponsored students have not been included in this analysis as they usually return to their home countries after graduation and therefore do not impact on the New Zealand medical workforce.<.p>
When the demographic questionnaire was developed the structure of the questions was determined by the classifications used in the New Zealand census current at the time. The data in this analysis were compared to the 2001 Census data for the usually resident population.Although a further census was carried out in 2006 there were changes in classification which made comparisons with some questionnaire categories impossible. Where concordant 2006 Census data categories are available they have been included.<.p>
Age-specific comparisons were made whenever possible. The classification of occupations in the questionnaire used the New Zealand Standard Classification of Occupations, NZSCO90 whereas the 2001 Census used the NZSCO99 classification.8 However, these classifications were comparable as the NZSCO99 is similar to NZSCO90 apart from more detailed sub-categorisation.<.p>
In relation to the urban status of the student’s home town, we have used the town identified for ages 13-18 on the grounds that this age range is likely to be the most formative in the individual’s choice of career. The numbers of registered Medical Practitioners in New Zealand between 2004 and 2008 were obtained from the Medical Council of New Zealand website.9<.p>
Trends across the years were evaluated using regression coefficients.<.p>

Results

Student demography—The numbers of students entering the University of Otago Medical School between 2004 and 2008 are listed in Table 1 along with demographic details. The numbers of students rose in 2008 as government funding for domestic places rose in response to doctor shortages partly resulting from difficulties in retaining graduates in the New Zealand workforce. The proportions of competitive graduate entrants, gender ratios and age characteristics remained relatively stable over this period.<.p>

Table 1. Entry categories and personal demographics for Year 2 University of Otago medical students: 2004–2008<.p>
Variables<.p>
Year of entry
2004<.p>

2005<.p>

2006<.p>

2007<.p>

2008<.p>
Average
2004–8<.p>
Total students entering Year 2<.p>
222<.p>
232<.p>
235<.p>
236<.p>
248<.p>
235<.p>
Number of domestic students<.p>
194<.p>
192<.p>
193<.p>
197<.p>
211<.p>
197<.p>
Response rate to questionnaire<.p>
94.3%<.p>
96.4%<.p>
89.1%<.p>
99.0%<.p>
89.6%<.p>
93.7%<.p>
Graduate entrants<.p>
17.5%<.p>
17.2%<.p>
23.3%<.p>
21.3%<.p>
21.3%<.p>
20.1%<.p>
Sex: male/female<.p>
46%/54%<.p>
41%/59%<.p>
43%/57%<.p>
47%/53%<.p>
46%/54%<.p>
45%/55%<.p>
Age range
Median<.p>
17–41 yr
19 yr<.p>
17–32 yr
19 yr<.p>
17–35 yr
19 yr<.p>
17–28 yr
19 yr<.p>
17–34 yr
19 yr<.p>
17–34 yr
19 yr<.p>
<.p>

The ethnicity, country of birth and citizenship status of domestic students is shown in Table 2. Students were permitted to list multiple ethnic attributions and the majority of students with Māori ancestry listed themselves as European/Māori. The proportions of all ethnic groups changed little over the 2004–2008 period. Compared to the census data the most striking features were the under-representation of Māori and Pacific students and the over-representation of ethnic Chinese.<.p>

Although ethnic Chinese students remained over-represented a high majority were New Zealand citizens. There was a non-significant trend to more students holding New Zealand citizenship [p value for trend = 0.067] which will hopefully translate into more students choosing to practice in New Zealand.<.p>

The country of birth data showed that approximately a third of students were born outside the country and this proportion was considerably greater than for the same age group in the usually resident population, i.e. 36.9% vs 21.3%.<.p>

Table 2. Ethnicity, citizenship and country of birth for Year 2 University of Otago medical students: 2004–2008<.p>
Variables<.p>
Year of entry 2004<.p>

2005<.p>

2006<.p>

2007<.p>

2008<.p>
Average
2004–8<.p>
Census 2001 (2006)<.p>
Ethnicity
NZ European
NZ Māori
Eur/Māori
Pacific
Chinese
Other<.p>

60%
0.5%
4%
2%
13%
20.5%
n=183<.p>

62%
2%
5%
0.5%
8%
22.5%
n=185<.p>

55%
1%
3%
0%
13%
28%
n=172<.p>

56%
0%
5%
2%
13%
24%
n=191<.p>

66%
3%
3%
0%
11%
17%
n=189<.p>

59.8%
1.3%
4.0%
0.9%
11.6%
22.4%
n=920<.p>

62.6% (59%)
9.8%
7.9%
5.5% (9.2%)
4.8% (4.0%)
N/A
[15–19 yrs]<.p>
NZ citizenship<.p>
79%
n=183<.p>
84%
n=185<.p>
87%
n=172<.p>
84%
n=191<.p>
90%
n=189<.p>
84.8%
n=920<.p>
N/A<.p>
Born in NZ<.p>
59.3%
n=182<.p>
64.3%
n=185<.p>
61.6%
n=172<.p>
62.1%
n=195<.p>
68.3%
n=189<.p>
63.1%
n=923<.p>
78.7%
(77.0%)
[15–19 yrs]<.p>
<.p>

Rural and mental health pathways—Since 2004 the Government has funded 20 extra domestic places for students with a rural background or experience in mental health care. There is consistent evidence that a rural origin increases the probability of a subsequent career in rural practice.10–12<.p>

The affirmative rural programme was available to students who had spent a major part of their pre-secondary or secondary education in a town with a population of 20,000 or less. The mental health provision was more likely to apply to mature entrants who have a greater variety of work experiences.<.p>

Table 3 shows the numbers of students who met the rural entry criteria along with the urban [home town] status of students. The urban status was listed as the student’s home town between the ages of 13 and 18, an age when career choices are being actively considered.<.p>

The urban status was compared to the previous demographic report by Heath et al4 covering the 1987–2000 period and also to the 2001 Census data. The nearest comparable age category from the Census was 15–19 years.<.p>

The mental health provision has had little impact. By contrast there has been an encouraging steady trend upwards in students who reported that they had a rural background [p value for trend = 0.025]. Although there were 20 extra places funded for the rural scheme at Otago, there were 51 students in the 2008 class who met the rural criteria.<.p>

If the rural scheme did not exist 20 of these students would not have gained admission. The Statistics New Zealand categories of urban status are listed as main [>30,000 population], secondary [10,000–29,999], minor [1000–9,999] and rural [areas not listed as urban].<.p>

The proportion of students from main urban areas remained higher than the general New Zealand population. However there may have been a re-distribution towards greater numbers coming from minor urban towns which are our typical country towns.<.p>

Table 3 Entry via the rural and mental health schemes for year 2 University of Otago medical students: 2004–2008<.p>

1987-2000
[Heath et al4]<.p>
Year of entry
2004<.p>

2005<.p>

2006<.p>

2007<.p>

2008<.p>
Average
2004-8<.p>
Census 2001<.p>
Mental health experience<.p>
N/A<.p>
0.5%<.p>
0%<.p>
0.5%<.p>
0%<.p>
0.5%<.p>
0.3%<.p>
N/A<.p>
Rural background<.p>
N/A<.p>
10.8%<.p>
15.1%<.p>
13.3%<.p>
18.8%<.p>
24.2%<.p>
16.4%<.p>
N/A<.p>
Urban status at 13–18 yr
Main
Secondary
Minor
Rural<.p>

79.0%
7.4%
9.1%
4.5%<.p>

82%
7%
7%
4%
n=183<.p>

80%
10%
7%
3%
n=185<.p>

84%
8%
6%
2%
n=171<.p>

86%
7%
7%
2%
n=181<.p>

80%
6%
14%
0%
n=185<.p>

82.4%
7.6%
8.2%
2.2%
n=905<.p>

74.0%
5.8%
7.5%
12.8%
[15-19 yrs]<.p>
<.p>

Parental occupations—Selected occupations of mothers and fathers according to the NZSC090 classification are listed in Table 4. The striking feature remained the high representation of professional parents compared to the 2001 Census data. This was particularly marked with ethnic Chinese students as 60% had a professional father. There was a marked increase in the proportion of professional mothers since the publication by Heath et alfor the 1987–2000 period.<.p>

Professional occupations hold the highest ranking on the New Zealand Socio-economic Index.13 There was little change in the technical, sales or agricultural occupations since the 1987-2000 data were reported [data not shown]. In the 2004-2008 period the proportion of students with one or both parents practising medicine remained high and ranged from 15–20% with an average of 18.8%. This contrasts with 12.5% for fathers and 2.3% for mothers in the 1987-2000 cohort. In 2001 the proportion of registered doctors in the usual resident population was 0.23%.<.p>

Table 4. Parental occupations for year 2 University of Otago medical students: 2004-2008<.p>
Occupation<.p>
Father’s occupation<.p>
Mother’s occupation<.p>
1987-2000
[Heath et al3]<.p>
Average
2004-2008<.p>
Census
2001
[males]<.p>
1987-2000
[Heath et al2]<.p>
Average
2004-2008<.p>
Census
2001
[females]<.p>
Professionals

Trades/Machinists

Not in paid workforce<.p>
42.3%

6.6%

9.4%<.p>
45.4%

7.8%

6.2%
n=872<.p>
11.5%

24.8%

5.8%
[all ages]<.p>
32.1%

1.3%

26.2%<.p>
45.2%

4.0%

19.8%
n=859<.p>
16.6%

9.6%

5.0%
[all ages]<.p>
<.p>

Finally Table 5 shows the low proportion of medical students’ parents with no formal tertiary qualifications and the correspondingly high proportion with university degrees. These proportions are almost the inverse of the general population.<.p>

Table 5. Parental tertiary qualifications for year 2 University of Otago medical students: 2004-2008<.p>
Father’s highest qualification<.p>
Average
2004–2008<.p>
Census
2001
(2006)<.p>
Mother’s highest qualification<.p>
Average
2004–2008<.p>
Census
2001 (2006)<.p>
No tertiary qualification

Bachelor’s degree

Postgraduate degree<.p>
10.6%

30.8%

32.0%

n=873<.p>
57.1% (49.2%)

7.1% (9.3%)

3.6% (4.4%)

[all ages]<.p>
No tertiary qualification:

Bachelor’s degree:

Postgraduate degree<.p>
14.8%

29.8%

21.8%

n=858<.p>
59.2% (52.6%)

6.8% (10.6%)

2.1% (4.0%)

[all ages]<.p>
<.p>

Discussion

This review of the demographic spectrum of the University of Otago Medical School year 2 students from 2004-2008 is derived from an established, longitudinal data-set and does not address a priori hypotheses but provides a useful status update of our medical student population in this period. The data do not show a general shift towards the demography of the New Zealand community. However, there have been some specific positive changes in relation to entrants with a rural background and the proportion of students who are New Zealand citizens.<.p>

The gender balance appears to have stabilised around the 55% female/45% male split. The Australasian Medical Schools Outcomes Database14reported the 2010 gender split for domestic students in Australasian medical schools to be 54% female/46% male. The data presented do not show any obvious trends in medical student demography resulting from the introduction of the UMAT aptitude test, however, prospective analyses on more mature data will be required to address this issue.<.p>

Despite the long existence of the affirmative Māori and Pacific Island scheme the numbers of Māori and Pacific Island students in the 2004-2008 cohort remain lower than population percentages. These affirmative programmes allow all Māori and Pacific students who meet the academic entry criterion to enter medical school without being subjected to competitive ranking. One aspect of the problem lies in the under-representation of science literacy among Māori and Pacific secondary school students.<.p>

The University of Otago Medical School has responded to this challenge by appointing Associate Deans and more academic staff in Hauora Māori and Pacific Health, by devoting more curriculum time to these areas and by offering support programmes to Māori and Pacific Island students. In addition the Tū Kahika foundation programme for Māori students and the POPO Initiative to support Pacific students during Health Sciences First Year provide academic and social support to students in their initial years at university.<.p>

Encouragingly these measures appear to be helping with the percentage of Māori students rising from the 2004-2008 average of 5.3% to 15.9% in 2012 [personal communication].15 The same comparison for Pacific students showed a rise from 0.9% to 3.3%. Australian medical schools also have under-representation of indigenous students with 0.9% identifying as Aboriginal or Torres Strait Islanders compared to the general population percentage of 2.7 %.13<.p>

The affirmative rural scheme introduced in 2004 appears to be gaining traction. The 24.1% of students in the 2008 class who had rural origins is similar to the population percentage for secondary and minor urban towns and rural areas. The success of this scheme may relate in part to the emphasis that the University of Otago’s Dunedin School of Medicine has placed on rural attachments in the 4th and 5th years of the medical course. In 2000 a 7-week rural attachment was introduced for 5th year students.<.p>

In 2007 a Rural Medicine Immersion Programme [RIMP] was offered to 5th year students across the Faculty of Medicine whereby they could complete all their clinical attachments in primary care practices in secondary or minor urban towns. From small beginnings this programme now has 20 participants and there is a prospect for further expansion.<.p>

Other measures the University of Otago Medical School has used in an attempt to expand the demography of students is the ‘Other Categories’ admission pathway for mature students. In addition up to 30% of students enter as graduates. Medical Schools in other countries have attempted to broaden their student base but with limited success.16,17<.p>

A limitation of these analyses relates to the data categories being obtained from the 2001 Census which limits comparison with more contemporary census data. This applies to ethnic categories, designation of rural origins and categories of employment. In addition, the response rate to the questionnaire was incomplete raising the possibility of selection bias. Despite this, the trends reported give a useful insight into the origins of New Zealand’s medical workforce.<.p>

Clearly there needs to be continuing focus on innovations in our admission processes, policies and evaluations to provide a medical workforce which reflects and can serve the needs of our changing community. Further research in New Zealand is required to understand the perceptions of our differing communities about the nature of medical practice and the motivators or obstacles to gaining entry to medical training. We also need more information on whether doctors who come from lower socioeconomic communities ultimately practice in more deprived areas.<.p>

Summary

Using a questionnaire we reviewed the demography of University of Otago Year 2 medical students for 2004–2008 to see whether our graduates reflect the changing demography of New Zealand society. The demographic spectrum of the University of Otago Medical School Year 2 students does not show a general shift towards the demography of the New Zealand community. However, there have been specific positive changes for entrants with a rural background and the proportion of students who are New Zealand citizens. Of concern Māori and Pacific Island students and students from families with lower socioeconomic and educational status are under-represented in the reported period although there has been more recent improvement. In addition the proportion of students with a parent as a doctor has risen compared to the 1987–2000 cohort. In conclusion further initiatives are needed to improve the numbers of Māori and Pacific Island students and students from lower socioeconomic backgrounds.

Abstract

Aim

To review the demography of University of Otago Year 2 medical students for the period 2004–2008 to determine whether our graduates reflect the changing demography of New Zealand society.

Method

A demographic questionnaire was completed by students entering Year 2. This paper reviews data collected from 2004–2008 and compares the results with data collected between 1987–2000 and also with New Zealand census data.

Results

The demographic spectrum of the University of Otago Medical School Year 2 students does not show a general shift towards the demography of the New Zealand community. However, there have been specific positive changes for entrants with a rural background and the proportion of students who are New Zealand citizens. Of concern Māori and Pacific Island students and students from families with lower socioeconomic and educational status are under-represented in the reported period although there has been more recent improvement. In addition the proportion of students with a parent as a doctor has risen compared to the 1987-2000 cohort.

Conclusion

Further initiatives are needed to improve the numbers of Māori and Pacific Island students and students from lower socioeconomic backgrounds.

Author Information

David Perez, Associate Dean and Director, Early Learning in Medicine; Alison Belton, Associate Dean Medical Admissions, Faculty of Medicine, University of Otago Medical School, Dunedin

Acknowledgements

We thank Professor Peter Herbison for statistical assistance.

Correspondence

Associate Professor David Perez, Faculty of Medicine, University of Otago, PO Box 913, Dunedin 9016, New Zealand. Fax: +64 (0)3 4709689

Correspondence Email

david.perez@otago.ac.nz

Competing Interests

Nil.

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