Demographics and motives of medical school applicants in Croatia

Abstract

Background: According to data regarding number of physicians per 100 000 inhabitants, Croatia is below the European average. Under those circumstances, more attention needs to be devoted to Croatian medical schools and their applicants.

Aims: This study sought to investigate admission trends of applicants to Croatian medical schools, analyse their demographics and motives for medical school enrollment.

Methods: We collected admissions data of applicants to Croatian medical schools from 1979 to 2006. Motives for and against medical school enrollment were assessed in a survey of 1146 applicants (response rate 84%, 966/1146) and 98 final-year medical students (response rate 82%, 80/98) during July 2006.

Results: The number of applicants to Croatian medical schools had been declining until 1995, it was lowest during the 1991–1995 war in Croatia and it has been rising from 1996 onwards. Majority of applicants in 2006/07 were women (69%). Most of the applicants attended general high schools. The applicants profess choosing a certain medical school for its quality and reputation, but we showed that they actually chose the closest school. The main motives for medical school enrollment were humanitarian and scientific, while main reasons against were perceived difficulty and financial burden. We showed that final-year medical students profess significantly lower interest in science and that they are less interested in altruistic aspects of medicine. Instead, great number of them would reconsider choosing medical studies again because of the corruption in medicine, fear of mistakes and uncertainty of employment.

Conclusions: Following the admission trends in medical schools on a national level gives insight into the prospects of health care. Analysis of motives for and against medical school enrollment can provide guidelines for their improvement. Unless Croatia and other countries in transition devote more attention to recruitment, education and retention of physicians, the prospects of our healthcare are poor.

Introduction

A high quality medical care and patient safety depends on the availability of a sufficient number of physicians. According to data regarding number of physicians per 100,000 inhabitants, Croatia is below the average for majority of European countries (Forgacs 2002; World Health Organization 2007). Taking into account that medical studies last six years and specialist training takes on average another four years, even with immediate actions at least ten years would be necessary to reach the desired standards (Rulebook on the specialization of healthcare providers 2003; Rulebook on minimum requirements regarding premises; medical-technical equipment and staff for performance of healthcare activity 2004).

Under the circumstances, special attention should be given to both recruitment and retention of physicians. Recruitment policies can only be effective when there is a pool of appropriately qualified candidates to recruit from (New Zealand Ministry of Health 2006). As for the retention, although a very low emigration rate has been recorded over the past few years, the possibility that emigration may increase after Croatia joins the EU is alarming (Kolcic et al. 2005). Therefore, Croatia and other countries where the cost of medical training for the majority of its medical students is sustained by government funds, should find more reliable ways of retaining their health professionals.

Table

Practice points
•This is a 27-year retrospective study (1979-2006) of applicants to Croatian medical schools.
•War negatively affects the medical school applicant pool.
•Final-year medicals students in Croatia would not choose medical school again due to financial reasons and they are less motivated by science and altruistic motives when compared to medical school applicants.
•Actions are needed to prevent loss of interest in science during medical school.
•Promotional campaigns of medical schools in Croatia should be redesigned.

Imminent lack of physicians invariably turns public attention to medical schools, which are expected to produce enough medical doctors. Students’ motives for and against applying to medical schools become an important factor that existing medical schools should be aware of when trying to recruit the best possible candidates. Knowing these motives may be important for attracting the best students that will be the real participants and partners in a process of revitalization of academic medicine (Clark 2005).

The purpose of this study was the analysis of admission trends of applicants to Croatian medical schools, analysis of their demographics and motives for and against studying medicine.

There are no data published about the historical dynamics of medical school applicants in Croatia. Knowing the trends in the number of prospective students is necessary for evidence-based discussion and planning future admissions. Thus we searched archives of all four medical schools in Croatia to generate insight into the admission trends over the last 27 years, as there is no systematic follow-up of such data. We also wanted to see whether 1991–1995 war in Croatia had any effect on the applicant pool.

The archives of University of Split Medical School were searched for high school grades and admission test scores of all of its 4186 applicants in the period 1979–2006 in order to investigate quality of applicants. This school was chosen for detailed admissions’ analysis because it had these data readily available.

Finally, a survey was administered to medical school applicants in all four medical schools to find out their demographics and motives for and against choosing a medical school. The same questionnaire was administered to the final-year medical students to examine their motives for and against choosing a medical school in a hypothetical situation of enrolling the medical school again.

Methods

Archival data

We searched archives of all four Croatian medical schools to find out the number of applicants. Medical school in Zagreb was founded in 1917, the one in Rijeka in 1955, while medical schools in Osijek and Split began enrolling students in the first year of studies in 1979. Our data search encompassed 27 years during the 1979–2006 period. The archives of medical schools in Zagreb and Osijek lack complete data on the number of admission test candidates for the whole period of 1979–2006; there is no legal requirement for them to safeguard these data and that could be an explanation why their archives are incomplete.

Archives of the medical school in Split were also searched for high school grade averages and admission test results of all the 4186 admission test candidates that the School has had from 1979 to 2005. Since the schools changed the maximum number of points a candidate can have at the admission test several times, we calculated success percentage for each candidate, depending on the scoring system that was used for the respective admission year.

Survey

Design

We analysed applicants’ motives associated with their decision to apply for medical school. Applicants in all four Croatian medical schools were surveyed during admissions in July of 2006. We also surveyed sixth-year medical students in the University of Rijeka School of Medicine to see whether their motives for or against medical school will be comparable to those of the applicants.

Setting

Physicians’ education in Croatia is based on a six-year undergraduate curriculum offered in four medical schools at Universities of Osijek, Rijeka, Split and Zagreb. In the academic year of 2006/2007 these schools enrolled a total of 567 medical students in the first year of studies; 75 in Osijek, 135 in Rijeka, 75 in Split and 282 in Zagreb. The number of applicants to Croatian medical schools exceeds the number of available places for students; therefore a limited number of students is admitted each year and this number is decided by the government. The selection of medical students is based on both high school grade averages and the admission test score to yield final ranking and identify the best candidates. All four Croatian medical schools were in full operation during the 1991–1995 war in Croatia (Marusic 1994; Marusic & Marusic 2004).

Subjects

Medical school applicants received questionnaire in the Student Offices during the admissions in July of 2006. Sixth-year medical students in Rijeka also received a questionnaire in the Student Office in July of 2006.

A self-administered questionnaire for medical school applicants consisted of 8 questions about city where they live, gender, average grade in high school, reasons for choosing a specific Croatian medical school, their motives for and against enrollment to a medical school.

A self-administered questionnaire for sixth-year medical students consisted of questions about motives for or against studying medicine, if they had a chance to choose again.

The questionnaire included 16 motives in favor of medical school enrollment and 13 reasons against it; we chose motives for which we believed might be important to prospective students. Each of these motives was rated on a 5-point Likert scale (agree strongly to disagree strongly). For data presentation we grouped ‘agree strongly’ and ‘agree somewhat’ into ‘agree’, while ‘disagree strongly and disagree somewhat’ were grouped into ‘disagree’.

Grades: Croatian education system is using grades 1–5, where 1 (insufficient) is not a passing grade, while 2 (sufficient), 3 (good), 4 (very good) and 5 (excellent) are passing grades.

Analysis

Every questionnaire was marked with a serial number and responses entered in a spreadsheet (Excel 2004, Microsoft, USA). Archives’ data were also entered in the Excel spreadsheet. Data were analysed using Pivot Table Reports. The internal consistency was examined using Cronbach's alpha.

Results

Archives’ results

The data of the Croatian medical school applicants from 1979 to 2006 showed a continuous downward trend towards an all-time low in 1995 (Figure 1). From 1996 to 2006 the number of students applying to Croatian medical schools has had an upward swing, and in some schools it has reached its initial levels (Figure 1). The lowest number of applicants was observed during the 1991–1995 war in Croatia.

Figure 1. Number of admission test candidates in all four medical schools in Croatia, 1979–2006. Each line represents one medical school, as indicated by a legend.

Survey results

In all four Croatian medical schools there were total of 1146 prospective students at the admissions in July of 2006. The applicants’ survey response rate was 95% in Osijek (141/148), 96% in Rijeka (171/179), 92% in Split (122/132) and 77% in Zagreb (532/687). The overall response rate among applicants was 84% (966/1146).

Among applicants who responded to our survey, women were in majority (69% women vs. 31% men). The ratio between women and men respondents was similar in all four medical schools. The dominance of female respondents ranged from 67.1% at Zagreb to 74.3% at Osijek medical school (Table 1).

Table 1.  Sex of admission test candidates surveyed in all four medical schools in July of 2006

	♀n (%)	♂n (%)	Total n
Osijek	36 (25.7)	104 (74.3)	140
Rijeka	51 (29.8)	120 (70.2)	171
Split	33 (27.0)	89 (73.0)	122
Zagreb	175 (32.9)	357 (67.1)	532
Total	295 (30.6)	670 (69.4)	965

Most of the applicants came from two types of high schools: general high schools or vocational high schools for education of middle-level medical personnel (nurses, physiotherapy, laboratory and pharmaceutical technicians).

When high school success was evaluated, medical school in Zagreb had the highest number of applicants with excellent grades (72%), and Rijeka the lowest (58%). Rijeka also had the most applicants with grades below 4.

We also investigated which medical school was the most popular. For this, medical school applicants were asked to rank all four Croatian medical schools according to their preferences. For majority (60.9%), the first choice was the oldest medical school in Croatian capital of Zagreb, followed by the medical school in Rijeka as a second (42.4%) school of choice.

Choice of a medical school was mostly based on the quality of the school (85%) and its reputation (38%) (Table 2). Only 3.8% of respondents considered promotional campaigns of the schools an important factor when making a choice in which school to study.

Table 2.  Reasons for choosing a certain medical school in Croatia among medical school applicants surveyed in July of 2006 (in percent)

	Osijek	Rijeka	Split	Zagreb	Total
Quality of the studies	84.3	79.5	82.8	88.9	85.8
Reputation of a specific medical school	32.9	28.7	32.0	42.9	37.5
Cost of studying	22.1	19.3	17.2	5.1	11.6
Friends’ recommendations	16.4	21.6	6.6	8.0	11.5
Quality of the student life	8.6	11.1	9.8	8.8	9.3
Promotional campaign of the medical school	3.6	5.3	9.8	2.0	3.8

Although quality and reputation of the medical school were the most cited factors for choosing a certain medical school, when we compared in which city they live and what school they chose, it turned out that majority of our respondents chose geographically closest school, i.e. the school in the domicile or a neighboring county (Figure 2). This, however, does not apply to Zagreb Medical School, which had a number of applicants from all over Croatia (Figure 2D).

Figure 2. The counties are primary territorial and administrative subdivisions of Croatia. The maps depict the counties that were the major source of 2006/07 applicants in the medical schools in (A) Osijek, (B) Rijeka, (C) Split and (D) Zagreb.

Analysis of applicants’ reasons for entering medicine found five main factors: “love for medical profession”, “humanity of medicine”, “interest in human body structure and function”, “interest in science” and “opportunity to work with people” (Table 3).

Table 3.  Motives for choosing medical school among medical school applicants and final-year medical students surveyed in July of 2006 (in percent)

	Medical school applicants			Final-year medical students
Motives	Agree	Neutral	Disagree	Agree	Neutral	Disagree
Love for medical profession	95.2	3.8	1.0	92.4	6.3	1.3
Humanity of medicine	96.4	2.6	1.0	82.3	11.4	6.3
Interest in human body structure and function	94.1	4.5	1.5	84.2	7.9	7.9
Interest in science	93.3	4.7	2.0	63.1	19.7	17.1
An opportunity to work/interact with people	91.2	5.6	3.2	76.0	10.7	13.3
MD's degree is valid in the whole world	87.9	6.7	5.4	45.5	11.7	42.9
I always wanted to be a physician	77.3	12.5	10.2	74.9	9.2	15.8
I want to test myself in a competitive field	70.8	17.0	12.3	43.4	35.5	21.1
Role models in medical profession	51.9	16.9	31.2	23.7	6.6	69.7
Personal or family experience with diseases	39.9	13.7	46.5	34.6	6.7	58.7
Possibility of high earnings	53.0	14.4	32.7	23.7	17.1	59.2
Power associated with physician's social status	42.8	17.0	40.2	23.7	14.5	61.9
Privileged position in a society	37.1	16.6	46.3	26.3	13.2	60.5
Family tradition	22.7	4.8	72.6	15.4	7.7	76.9
Family or parents’ wish	17.7	6.2	76.1	5.2	5.3	89.4

The greatest concerns of applicants regarding entering medical school were: “life-long learning”, it is difficult to enroll in medical school”, “medical studies are too long”, “medical studies are too expensive”, and “need for residency after finishing medical school” (Table 4). Cronbach's alpha was 0.89 in the applicants’ survey of motives.

Table 4.  Reasons against entering medical school among medical school applicants and final-year medical students surveyed in July of 2006 (in percent)

	Medical school applicants			Final-year medical students
Reasons	Agree	Neutral	Disagree	Agree	Neutral	Disagree
Life-long learning	51.1	13.6	35.3	52	13.3	34.7
It is difficult to enroll in medical school	65.3	13.0	21.6	31.1	9.5	59.4
Medical school is too long	61.9	12.4	25.7	65.3	6.7	28.0
Medical school is expensive	59.5	19.8	20.8	76.6	7.8	15.6
Need for residency after finishing school	50.1	14.7	35.2	57.5	10.9	31.5
Corruption in health care, residency placement and career advancement	41.2	24.7	34.2	69.7	13.2	17.1
Fear of mistakes and malpractice law suits	41.1	20.0	39.0	60.5	19.7	19.7
Difficult financial situation in health care	39.1	23.7	37.3	75.3	11.7	13
Uncertainty of employment	30.8	19.1	50.1	81.3	8	10.7
No time for family and private life	32.7	17.1	50.2	56.6	13.2	30.3
Fear of contracting an infection from patients	27.3	20.3	52.4	21.6	16.2	62.1
My grades are not good enough	24.9	11.1	63.9	9.3	6.7	84

To investigate whether motives for and against medical studies differ by the end of the medical school, we surveyed sixth-year medical students in one of the Croatian medical schools. The survey was performed in Rijeka and had a response rate of 82% (80/98). Cronbach's alpha was 0.88 in this survey.

The main reasons of final-year medical students for enrolling medicine again would be “love for medical profession”, “humanity of medicine”, “interest in human body and structure”, “always wanted to be a doctor”, and “opportunity to work with people” (Table 3). The main reasons for not choosing medical school the second time around would be: “uncertainty of employment”, “difficult financial situation in healthcare”, “medical studies are too expensive” and “corruption in healthcare, residency placement and career advancement” (Table 4).

Discussion

This study shows that the number of applications to Croatian medical schools has been declining in the past, hitting the bottom during the 1991–1995 war in Croatia. After the war, however, the number of admission test candidates rose again. To our best knowledge, this is the first study to analyse the number of medical school applicants on a national level in such a long period of time.

Challenging labor market conditions, difficulties in obtaining desired specialization after graduation (Kolcic et al. 2005), institutional failings (Vrhovac 2002; Chalmers 2006) and deeply embedded perception of Croatian medicine as a corrupt (GFK Group 2006) close-knit community could have contributed to declining interest in Croatian medical schools among prospective students. These problems are not exclusive for Croatia as other transitional countries are experiencing the same (Albreht & Klazinga 2002; Balabanova & McKee 2002; Fister & McKee 2005; Jakusovaite et al. 2005).

Small applicant pool during 1991–1995 war in Croatia can be noted as another important negative consequence of war. Education is not the priority in times of war and even medical students that were studying during that time obtained significantly lower grades in 5 major courses during the war than before or after it (Bergovec et al. 2002).

Following the war not much has changed in the way medical studies are performed, but the market conditions have changed (Chen & Mastilica 1998) and now medical professionals are entitled to a private practice. One can assume that the entrepreneurial promise of prosperity may be among the reasons why high school students are choosing the medical school in greater numbers again, but our survey results show the opposite.

The motivations and other factors used by medical students in making their career choices for specific medical specialties have been looked in a number of studies (Mahoney et al. 2004; Wright et al. 2004; Chang et al. 2006), but there are very few studies that assess the generic factors which make the medicine itself of interest to potential medical students (McManus et al. 2006). Therefore, we assessed what would be the pro and contra motives for medical school enrollment. The most important motives for studying medicine turned out to be idealistic and altruistic, while the least important were those that could be associated with prestige, money and social status of a physician.

Students are able to apply to Croatian universities after graduating from the four-year high school, which is usually at the age of 18. It could be that in this early age prospective medical students are less interested in monetary and ego-related benefits of medical profession. That is why we did another survey of final-year medical students, which showed that their motives to choose medical school again would be the same as applicants’. However, when one looks into these motives quantitatively, final-year students choose these motives 20–30% less frequently. That would mean that some of their noble motives fade away by the end of the studies. This is in contrast to the report by Prka et al. who found no evidence that medical students become less altruistic and more materialistic over the course of their medical education (Prka et al. 2002). Interest in science, for example, is half less important motive for final-year students than for the applicants. This is particularly disturbing and worrying regarding their prospects for later academic involvement.

It is argued that altruistic motives are important for most people, but there are also demand characteristics which make respondents less likely to rate highly social desirable items as “thought it would be glamorous/good life-style/status”, or “job security”, and even less so for “becoming rich”, or “having power over people”, however true they may be (McManus et al. 2006). Self-administered questionnaires are used with the assumption that they will be honestly answered by the respondents because they are anonymous, and their validity and reliability has been proven in numerous studies (Alexiou et al. 1969; Shibata et al. 2002). Therefore, we have no reason to doubt that the majority of our respondents indeed embark on medical studies out of altruistic motives. Some argue that becoming a physician today requires more than altruism, it requires courage, managerial skills, administrative knowledge and no errors (Brase 2001), but that may be a realization that comes later in life.

As for the reasons against choosing medical school, top three applicants’ concerns are that it is too difficult, too long and too expensive. Common doctors’ complaints about malpractice lawsuits, uncertainty of employment and lack of time for personal life (Chong et al. 2004; Bolanowski 2005; Katz et al. 2005) seem to be the last concerns of the medical school applicants. Major reasons against choosing medicine again, were pretty different for final-year students; being in medicine for six years they are all too well aware of difficult financial situation in Croatian healthcare and hardships in obtaining a desired residency (or internship). For final-year students, the most important reasons against choosing again a medical school were money-related.

Family wish apparently has little or no influence on choosing medical school. Also, the applicants are less concerned about the expensiveness of the studying, difficulty of finding a job and mistakes, probably because they have not been immersed in the healthcare prior to the admissions.

The professed expensiveness of a medical school in Croatia is due to the several facts: (1) it lasts longer then any other university studies, which postpones getting a job and earning, (2) the tuition, although paid by only one third of students, is more expensive than in other schools, and (3) the books for medical students are expensive.

When we compared the “for and against motives” of enrollment of the applicants in the year 2006 versus those of the final year medical students, the sample in the first case is 1146 prospective students applying as candidates to all four medical schools, whereas the sample of the final year students is 98 students of only the Rijeka Medical School. It is unlikely that the asymmetric samples in number and students' origin could affect the results, especially when these results are given in percentages. However, one should have this asymmetry in mind when analysing the results.

Our survey revealed additional information about Croatian medical school applicants. The majority of applicants were women, which is in line with multiple reports on so-called feminization of medicine (Notzer & Brown 1995; Paik 2000; Thomas 2000).

The majority of the respondents came from general high schools, which provide broad general knowledge and good preparation for university. Specialized high schools for middle-level medical staff, the second most important source of future physicians, educate their pupils to become nurses or technicians that can start working right after graduation.

The most popular medical school in Croatia turned out to be the one in Zagreb, the capital of Croatia. With just under one million inhabitants, Zagreb is home for about one fifth of Croatian population and it is often viewed as a city with the best career prospects and the most attractive social scene. Zagreb medical school is also the biggest of four Croatian medical schools and it is possible that for some students size does matter.

Quality and reputation were cited as the most important reasons for choosing a certain medical school, but when we matched the city where our respondents live with their choice of medical school it turned out that they chose the closest one. This is easily explained with lower costs of studying, as it is customary in Croatian society for adult children to live with their families.

Only 3.8% of respondents considered promotional campaigns of the medical schools to be important for their decision to study medicine. Therefore, we can conclude that promotional efforts of Croatian medical schools, introduced several years ago, unfortunately did not achieve much to sway undecided students towards medical studies.

Knowing all this, our medical schools should become actively engaged in their students’ career after graduation. One-year obligatory internship that all Croatian physicians need to do before taking a licensing exam should be guaranteed for every student as soon as they graduate, in agreement with the hospitals. Currently, young physicians can apply for these internships several times a year; they are often without a proper mentor and more often than not unpaid for the whole year.

After the internship is over, physicians can take state exam and became licensed. The majority of them will then work for years as temporary substitutes for family physicians. Specialization of choice is hard to get as there are very few openings available and selection criteria depend completely upon the whim of an institution. Although it is not a straightforward task and it includes numerous bureaucratic obstacles, young physicians can pay the specialization themselves, which means they will pay certain amount of money to an institution to train them and they will not have any salary during those training years. However, the institution where they are specializing is not obliged to hire them afterwards.

Because of the lack of doctors, there is a danger of trying to fill the gap at the cost of quality of doctors. Introduction of high quality state exam would prevent import of inappropriately qualified work power as it was proposed long ago (Marusic & Sapunar 1996).

The motives of medical school applicants seem to be right, but the reasons why final-year medical students wouldn’t choose medical school again should be a warning to Croatian medical institutions. In a system where meritocracy is still in its infancy, when years of studying and hard work cannot ensure a decent job for physicians, their emigration sounds like something we should realistically expect.

Conclusions

The applicant pool in Croatian medical schools was affected the most by the 1991–1995 war in Croatia. In the last ten years (1996–2006) the number of applicants to Croatian medical schools has been increasing and the applicants profess humanitarian and scientific motives for choosing medical studies. The final-year medical students, however, would reconsider enrolling the medical school if they had a chance to do it again due to a difficulty in finding a desired job, corruption and financial crisis in Croatian health care.

Investment in health produced some of the richest returns in not only social but also economic development (Commission on Macroeconomics and Health 2001) and therefore Croatia needs to address the imminent shortage of physicians. An idealism of medical school applicants will fade away and, if nothing changes soon, they will take their knowledge and skills abroad as soon as they get a chance. This may well be true for other countries in transition that borne majority of costs of physicians' education. Therefore, Croatia and other countries in transition should devote more attention to recruitment and retention of physicians.

Additional information

Notes on contributors

Livia Puljak

LIVIA PULJAK, MD is a Researcher and Instructor at the Department of Anatomy, Histology and Embryology, University of Split Medical School. She is a published author of multiple articles and has editorial experiences with electronic and print media. Her research interests include medical education and neuropathic pain.

Jasminka Brnjas Kraljevic

JASMINKA BRNJAS KRALJEVIC, BSC. Phys, PhD. Phys, is the Professor at the Department of Physics and Biophysics, University of Zagreb Medical School. She authored multiple textbooks and research articles. Her research interests include magnetic resonance spectroscopy and imaging, spectroscopy of human lipoproteins and medical education.

Vesna Barac Latas

VESNA BARAC LATAS, MD, PhD is the Assistant Professor at the Department of Physiology and Immunology, University of Rijeka School of Medicine. She is a Vice Dean for Education for the School and she authored multiple authors. Her research interests include central nervous system demyelination in multiple sclerosis and medical education.

Damir Sapunar

DAMIR SAPUNAR, MD, PhD is the Professor at the Department of Department of Anatomy, Histology and Embryology, University of Split Medical School. He had been a Vice Dean for Education at the School. He authored many articles on medical education. His research interests include neuropathic pain and medical education.