Given that many low income countries have insufficient doctors to meet their needs, particularly in rural areas, the authors suggest that policy makers could use this evidence to adjust entrance criteria for medical schools that favour subsequent practice in less well served areas of their country.
Previous studies have shown that, in high income countries, doctors with rural backgrounds are more likely to work in rural locations of their own countries. So could certain characteristics of medical students in low income countries be associated with graduate doctors staying to practice in that country or in its rural areas?
A team of researchers based in Nepal set out to test this theory. They tracked 710 graduate doctors from the first 22 classes (1983-2004) of Nepal's first medical college, the Institute of Medicine, to their current practice locations. To determine which characteristics predicted working in underserved areas, they analysed seven factors including sex, age entering medical school, place of birth, place of high school, type of pre-medical education, and academic rank.
A total of 193 (27%) doctors were working in Nepal's rural districts, 261 (37%) were working in the capital Kathmandu, and 256 (36%) were working abroad. Of those working abroad, 188 (73%) were in the United States and later graduating classes were more likely to be working in foreign countries. Those with pre-medical education as paramedics (a common route into medicine in Nepal) were twice as likely to be working in Nepal and 3.5 times as likely to be in rural Nepal, compared with students with a college science background. Students who were academically in the lower third of their medical school class were twice as likely to be working in rural Nepal as those from the upper third. After adjusting for all variables, a paramedical background was independently associated with a doctor remaining in Nepal, while rural birthplace and older age entering medical school were each independently associated with a doctor working in rural Nepal.
The authors say that their findings need to be validated in other settings, but they suggest that policy makers in medical education who are committed to producing doctors for underserved areas of their country could use this evidence to revise entrance criteria for medical school. This may result in more of the graduating class "staying home," they conclude.