Size matters: what influences medical students’ choice of study site?

Abstract

Background: The University of British Columbia, Canada doubled its class intake in 2004, creating, in addition to its main metropolitan campus, 2 distributed campuses, one in a medium sized island city, and the other in a small geographically isolated northern city. Our admission process attempts to identify students more suitable for education in our northern, rural site. Students also indicate their preferred site. Little is known about what influences student choice when they have more than one campus to choose from at a single medical school.

Aim: To understand what influences students’ preference of study site in a single medical school with 3 separate campuses, one with a rural mission.

Methods: We used qualitative methodology to examine what influenced student choice of study site. Semi-structured interviews were conducted with students at all three sites (n = 37). Iterative and independent coding and analysis took place to corroborate research findings.

Results: The primary theme was size of class and community. Some students viewed a larger class size and larger study and practice community as advantages, others viewed a smaller class size and smaller study and practice community as important. Additional themes were perceptions of quality of education, relationships, and lifestyle. These were related to the larger theme of class and community size and overlapped. Students articulated advantages and disadvantages of each site, and dynamic tensions in their choice of sites. Close relationships and educational experiences were emphasized at the smaller regional sites. Greater access to medical and educational specialists and the diversity offered by a larger, more anonymous class, patient case-mix, and community were emphasized at the originating and largest site. Partner and family – trumps – could overrule preferred site choices.

Conclusion: Early and comprehensive descriptions of the differences between sites for students and their partners is needed to help truly informed choices.

Introduction

In Canada, as in many countries, physician shortages and maldistribution have led to efforts to expand places for undergraduate medical education. One method for medical schools to increase their capacity is to develop educational opportunities distant from the parent school, in geographically separate campuses. These are often either pre-clinical or clinical campuses (Mallon et al. 2003; Tesson et al. 2005). More recently some medical schools are developing distributed models where the majority of their curriculum is delivered at a regional site.

At the University of British Columbia (UBC) in Vancouver, Canada, the Faculty of Medicine expanded the undergraduate medical education program, increasing the class size from 128 to 224 over two years. The first expanded class was admitted in August 2004 (Snadden & Bates 2005). To achieve this expansion the Faculty of Medicine created two regional campuses that educate students for the full four-year program. The main campus is situated at a large, biomedical, research intense university located in the southern area of BC in a multi-cultural and multi-ethnic metropolitan area (regional population 2 million) where more than half of the residents speak English as a second language. One regional campus (island campus) was created in partnership with the University of Victoria, a well-established university located in a medium sized city (regional population 340,000) on Vancouver Island, four hours combined ferry and ground travel from the main campus. The second regional campus (rural campus) was created in partnership with the University of Northern British Columbia (UNBC), a small, ten year old university located in Prince George, a resource based town of 75,000 people in northern British Columbia, ten hours ground travel from Vancouver.

Table

Practice points
•The number of geographically separate medical campuses is expanding rapidly, particularly in N America.
•We know little about what influences students' preferred site of study when their medical school has more than one campus.
•This qualitative study explores what processes students go through in helping select their preferred site of study.
•This study shows that education, relationships and lifestyle are important, but that family and partner exert the greatest influence.
•Students need clear information on the factors they need to think about in expressing their study site preferences in order to make truly informed choices.

The regional campuses initially received 24 students each year, increasing to 32 in 2007. All students are graduate entry domestic students, and mirror the multi-ethnic nature of Vancouver. They are admitted through UBC admissions processes, are UBC students, follow the UBC curriculum, write common exams, and spend the first fourteen weeks together at the main campus. Lectures and lab demonstrations are video-conferenced across the three sites, while clinical education takes place in local health care settings.

Although the main aim of the expansion of medical student places is to increase overall physician capacity, the rural campus has a particular remit to recruit students who may be more likely to settle in northern and rural areas as recruitment and retention of physicians in rural BC is particularly challenging. Like other schools in Canada, the USA and Australia (Tesson et al. 2005), UBC considers rural suitability of prospective rural campus students and developed an instrument referred to as the Rural and Remote Suitability Score (RRSS) to identify students suitable for that campus and to assist with admission decisions (Bates et al. 2005). Students also indicate their preference for site of training. All interviewed students attend information sessions that describe offerings and resources of all three sites, and are asked to submit a form ranking their study site preferences. The admissions committee uses all academic and non-academic information including rural origin and suitability to make admission offers, which are site-specific, but is unaware of the student site preference at the time of decisions to admit. Student site preferences are used to finalize site placement. A high RRSS score has correlated with students more likely to choose the rural site (Bates et al. 2005).

We wondered what influenced students in their site preferences. What benefits might they be expecting in their educational program and personal lives, and what made their perceptions different from those of students who chose differently? Understanding why students prefer a specific campus is the primary aim of this study.

While there are published surveys on student site choices, there is little established theory in this area. We therefore chose a qualitative approach to address the question. The qualitative approach is a unique aspect of this study that allowed us to explore and understand what draws medical students to, or discourages them from studying in diverse geographic regions.

Methods

We used a stratified purposeful sampling technique (Patton 2002) to identify students to interview. This sampling method provided perspectives of students from two class cohorts, students from different cultural and ethnic backgrounds including aboriginal students, those who switched sites or returned from a previously admitted year, those located at a site including and other than their first choice, and variation in age, gender, ethnicity and rural origin and suitability across sites. As we were initially interested in why students chose the rural campus we sampled more students from this cohort. We specifically included students of rural origin who did not choose the rural site, and students of urban origin who did. This allowed us to seek disconfirming evidence. This is evidence that would be contrary to the themes emerging from analysis, and this enhances the trustworthiness of a qualitative study (Kuzel & Like 1991). Qualitative data collection and analysis is typically iterative. Early data is analysed which may inform the collection of future data and influence subsequent sampling. It became evident that the themes were not unique to our rural campus so sampling was extended to all sites. We also sampled until the data were saturated, or no new themes emerged. This determined the final sample size. The emergent themes were common to all the sites, and articulated by students at all sites irrespective of site preference.

Using a semi-structured guide (Table 1) (Mays & Pope 2000), we interviewed selected students who entered the program in September 2004 from January to April 2005. A small cohort of students entering in 2005 was also interviewed prior to the start of their first semester to compare baseline influencers of students not yet starting medical school with data of 2004 students who had been in medical school for 3 to 7 months at the time of data collection. This step also provided a method of triangulation using two or more data sources (Mays & Pope 2000).

Table 1.  Final semi-structured interview guide

1. What was your first choice of location for your medical studies?

2. Tell me about why you chose that location?

(Probe for 2005 cohort: was your choice influenced by what you  heard about the program from students, faculty, the orientation  session, other?)

3. If you think there are any advantages to this location what are they?

4. What do you think might be the drawbacks of this location?

5. What do you think you might miss that you might have experienced  at another location?

6. What are you expectations of this location, how will it be different?

7. Tell me about any experiences you have had in a similar location.

• How did those experiences affect your choice?

8. Tell me about how these things influenced your choice of  studying where you are studying?

• An outdoor and/or rural lifestyle

• Previous experience in a northern, rural, or aboriginal setting

• Your choice of settings where you have to depend on yourself    for decision-making

9. Is there anything else you would like to tell us?

Study participants were interviewed by one member of the research team (TM). Verbal and written consent was obtained. Interviews ranging from 30 to 60 minutes were audiotaped, transcribed and anonymized before their review and analysis by research team members. One member of the research team (TM) was a postdoctoral research associate with a background in medical nutrition education. Two members of the research team (DS and JB) are physician medical educators engaged in the design and implementation of the multi-campus expansion. One member (GW) is a physician clinician educator at the rural campus. One member (VF) was responsible for admissions across the program. One member (IS) is a family physician educator with a research background in student choice of discipline. The study was approved by the UBC Behavioural Research Ethics Board prior to conducting the research.

Data coding and analysis

Data were analysed using manual and open coding to create an analytic framework for organising and describing the data. The analysis of transcripts involved an iterative process, in which exploratory coding and analysis was followed by data immersion and reduction using content analysis (Weber 1990).

First, a rough coding framework was developed by two researchers (TM, IS) who independently coded 5 transcripts. The framework was then corroborated by other team members (DS, JB, VF, GW) by independent coding of at least one transcript each to achieve consensus. Once the coding framework was established, one researcher (TM) carried out data immersion, which involved manual, sentence-by-sentence analysis of all transcripts based on the established coding framework to develop common themes. Once the primary emergent theme was identified, all interview transcripts were re-analysed (TM), starting with students offered their first choice of study site, and followed by the other transcripts to confirm study findings. To enhance theoretical sensitivity (Strauss & Corbin 1990), five transcripts were independently coded and analysed by two research team members (JB, DS), and the coding and analytic framework modified until agreement was achieved. These themes were debated by all research team members.

Results

Thirty-seven students were interviewed. Based on students’ final location, the sample included 21 rural campus students, 5 island campus students and 11 main campus students, with 5, 2, and 1 of these respectively representing the 2005 cohort. Final location for eight of these students did not match their first choice of study site

The primary emergent theme was size of class and community, which was related to perceptions of education, lifestyle and relationships. These themes were dynamic and interdependent, and they directly influenced student site choice. Students were also influenced by partner and family, which could override (trump) any other considerations of the applicant.

These themes are presented as a model in Figure 1. Education, relationships and lifestyle are displayed as overlapping circles in the analytic framework as participants often commented on two or more of these themes concurrently when discussing their study site choice. Tensions were often apparent when participants discussed the advantages and disadvantages of the study sites and subsequently commented on the influence of these three overlapping themes on their own study site choice. It is important to think of the model as being dynamic with students weighing up advantages and disadvantages as they saw them and trying to make a decision that felt right for them. Irrespective of their own choice of site, students were able to articulate the potential advantages and disadvantages of each site, and related tensions in making their choice of study sites.

Figure 1. Analytic framework: Influencers of choice of study site. *Applicant experiences before medical school include location of upbringing, work and volunteer experiences, and the orientation session. ^†The primary emergent theme is size of class and community as an indicator of quality of education, relationships and lifestyle (overlapping circles or themes). Tensions in choices related to these themes were often observed. ^‡Trumps or external influencers that may override all others include partner and family. **Site choice and offered site may differ. 

Each of the main themes are described below with illustrative quotes taken from the data and tagged with source codes.

Education

Students placed major emphasis on academic over non-academic attributes of their study site choice. Students expected quality and equivalency in medical education experiences regardless of the study site chosen or offered. Students from all sites were aware of and acknowledged the differences in the sites in terms of patients, instructors, and class size, but anticipated and looked forward to the impact on quality of education generated by these differences differently. Access to medical and educational experts was considered an advantage of the main campus site, regardless of the study site selected. The more diverse student body, the larger number and diversity of patients, and the presence of large numbers of experts in their fields at the main site were seen as precursors for educational quality by main campus students, who valued this over the small and more intimate rural program setting.

I would say having a larger population gives me as a student the potential to see more of a variety of cases. (Main campus-ID#37)

I wanted the best education I could in this four years and so I saw that available in [the main campus] and there's a larger faculty size, there's more access to sort of tertiary care hospitals, more access to therapeutic types of physicians, more intercultural [patients] from Yugoslavians to Vietnamese, so diversity of experience and academic excellence … (Main campus-ID#24)

… we will probably in Vancouver get more exposure to specialty areas. We’ll be exposed to sort of maybe different patients, maybe more complicated patients …. But at the same time … I get the impression that maybe the people at the distributed sites will have a lot more hands-on experiences. (Main campus-ID#16)

Students across all sites acknowledged the likelihood of the educational benefit of the small class size, close relationships with instructors, mentorship by physicians, and access to clinical cases available in the distributed campuses. Students who selected the rural campus saw “one-on-one” or “hands on” experiences with faculty, other students, physicians and staff as precursors for educational quality, and valued this above the diversity available at other sites.

One of the biggest advantages I think is that I think I’ll have a better medical education. Not necessarily a better academic education as I won’t have as easy an accessibility to some professors as I might in Vancouver but I think my actual clinical experiences, the experiences that I have in my family practice, I think will be a lot better than I would have in Vancouver. (Rural campus-ID#30)

Well there are many advantages. I think that a smaller class I think is one of the leading advantages here, not just in number in a pool of students and that leads to I think more personal attention and actually people faculty and staff that actually care about your education. (Rural campus-ID#2)

The drawback [of smaller class size] would be that, because it's smaller, you’re exposed to few students. The diversity would be less …. I think even your patient pool is more polarized so you don’t get exposed to the diversity and variety and quantity. (Main campus-ID#31)

We have the ability here to, I think, be on a more personal level with our mentors, with our clinical skills tutors. (Rural campus-ID#30)

Relationships

Students at all sites discussed differences in relationships. They acknowledged the number, and diversity of patients and faculty available in clinical settings in the main campus, as well as the closer relationships possible in the smaller sites. Students choosing the main campus appeared to value the diversity over the intimacy possible in the smaller sites.

Students at the regional campuses anticipated a smaller, more intimate and less anonymous class and community leading to stronger relationships. These relationships included more close interactions with other students, staff, clinicians and faculty at the expense of access to numbers and diversity.

Small class size: you know, you definitely have a more intimate relationship with your classmates, with your instructors with the faculty, with the school. (Rural campus-ID#3)

While the students choosing the regional sites focused on the development of new long term and close relationships within medicine, the students who chose the main campus site focused on their existing relationships with friends, family, and other support networks.

… about [the main campus] the positive thing is that like I mentioned being connected to my family. (Main campus-ID#25)

Lifestyle

Many students discussed the importance of their present and future lifestyle, regardless of the study site chosen. Regional site students often commented on the diverse extracurricular, social and cultural activities afforded by the main campus and surrounding city while being cognizant of alternate benefits provided by the regional sites. These included reduced cost of living, stress and commute time.

… I mean there's so much more down there [main campus] that you can access, you know … everything from shopping to like I said, you know, arts community, the diversity of restaurants to, you know certain social and recreational things down there that you can’t do down here but there's a flip-side to that too. (Rural campus-ID#3)

Interplay: education, relationships & lifestyle

Students often mentioned the combined influence of two or more of education, lifestyle and relationships in choosing a study site. A student commented on the interplay between education, relationships and lifestyle in the following comment regarding reasons for choosing the island campus as a first choice.

It was a mixture of practical things because of school and also because of the lifestyle that I could have here. And with respect to the school that I liked it was going to be small. I would get to know people really well. I would have first-hand access to doctors in the community and to resources and to the administration I would be much closer and able to ask from them and communicate with them better than in a larger facility. As well, the building is new and the campus is smaller so I just, I work better in smaller more sort of intimate environments. And the lifestyle factors, I just like the island, it's much more laid-back and there's [outdoor sport] nearby which is what I like a lot, there's also a lot of outdoor activities. (Island campus-ID#18)

Other influences on student choice

While quality of education, value of relationships, and preferred lifestyle were dominant themes, location of upbringing, work or volunteer experiences, and plans for future practice location also influenced study site choice. Although some students also commented on informal information they received from others, this appeared to minimally influence study site choices.

Well I think the main reason is that I myself and my [partner] both grew up in a small community or several small communities and we have aspirations to raise a family and live in a small community where neither one of us are big city people. (Rural campus-ID#2)

I have prior experience with working in the north and I was captivated by the people and the environment there. (Rural campus-ID#11)

Personal trumps

Regardless of student values, perceptions and experiences, partner and family considerations disrupted the student's decision-making and were influential enough to override or trump all other considerations. A main campus student who grew up in a small town elaborated on the primary influence of partner on education site choice.

I am actually interested in doing rural practice after we graduate. And this is actually a really tough decision to make. My partner is doing [subspecialty postgraduate training] and since there isn’t many options in the smaller area for [subspecialists] that greatly influenced my choice. (Main campus-ID#34)

A rural campus student who ranked the main campus first commented on the importance of considering partner suitability for students who study and possibly practice in the north.

Well I think my number one reason for choosing that [main campus] and for probably going back down south will be my partner …. I’m certainly suitable for the North. My partner really isn’t. (Rural campus-ID#21)

Regarding family influencers, many main campus students noted the strong influence of family proximity in their choice of study site.

Proximity to family. I think the biggest was family factors. (Main campus-ID#35)

Discussion

This study shows that there is a complex set of variables that may influence students’ choice of study site. Although we initially were looking for what influenced students to choose our small rural site, it became apparent that the themes that emerged from this study were generic to all study locations. The most important finding was that size mattered to students in selecting their study location, but that size created opportunities that were valued differently by different students. In addition, there was a complex interplay of past experiences, future aspirations and perceptions that led students to finally decide on their preferences. It is not surprising that personal influencers such as partners and family trump all other influencers. This study provided confirmation that the commonly reported relationship between rural upbringing and eventual choice of rural practice location could be extended to choice of study location. However, the choice is not simplistically based on student experience and comfort in a rural environment: more complex experiences, perceptions and expectations are taken into account. Rural programs are focused on increasing the proportion of rural origin students in order to fill rural clinical training programs and create a rural physician workforce, but there is little in this model to incorporate and utilize the reasons why urban origin students might select a rural training site. The complexity we observed provides insight into the thinking of rural as well as urban origin students and may explain why admissions committees have not been able to accurately and consistently predict students’ choice of eventual practice location to date (Owen et al. 2002). Similar to our study findings, others have observed size of community and class as a quality indicator of their educational experiences (Crump et al. 2004). Students selecting an urban campus tend to value large city amenities, spousal opportunities and family proximity, whereas students selecting the rural campus valued one-on-one clinical training and small town life. A survey of over five thousand applicants to British medical schools found that both academic and non-academic program attributes, informal information and geographic location relative to home base influenced study site choice (McManus et al. 1993). The ability of the more rural clinical schools to attract students varies: surveys in Australia and the USA report that academic and personal barriers may influence students’ choice of regional sites (Brazeau et al. 1990; Worley et al. 2000; Ramsey et al. 2001; Crump et al. 2004; Jones et al. 2007). These barriers include concerns over distance from family and friends, educational quality, lack of academic resources and the worry of being disadvantaged in their subsequent careers. The evidence so far on student choices about where they may prefer to study is limited to survey data, and there is little understanding in the literature about the process of student choice. The influencers of student preference for education site become increasingly important as medical schools expand to 4 or 5 year regional campuses (Rackleff et al. 2007) but admit students through a common admissions process.

The study reported here is unique in its qualitative approach and in its illumination of the process of student choice. This study is limited to the experience of the development of regional campuses in British Columbia, but the finding of the strength of partner and family as ultimate influencers of choice of study site is important as is the complex interplay of these factors as student express site preferences. These findings have not been described in other studies and our research suggests that the unique features of sites and the influence particularly of partners and family need to be openly articulated to students and acknowledged by faculty in discussing decision making. Students need to understand how their educational styles and preferences for different relationships may make them a fit for a smaller regional campus irrespective of their rural or urban origins.

The differences in orientation to educational quality and relationships also has the potential to lead to the development of new admissions tools that can consider a body of applicants for allocating to different educational settings. The understanding of drivers of student education and career choices, and the tracking of student cohorts from admissions to practice can lead to an effective interaction between the academic institutions that educate future physicians, the regional campuses that provide new settings for medical education, and the policy makers with a mandate to address rural physician workforce shortages. While this is a long-term goal, a more immediate outcome of this research is the restructuring of our orientation session for interviewed applicants as we feel our current sessions are too superficial to support a truly informed choice and to help students understand the power of influencers that they may not have considered in their drive to enter medicine. Future tracking of this cohort of students will continue to shed light on their choices and the reasons behind them.

Contributions

All authors have reviewed the submitted manuscript and all have been involved in the research design, transcript analysis and final analytical model development.

Source of funding

We wish to thank the BC Medical Services Foundation Vancouver Foundation for funding the study.

Conflict of interest

None

Ethical approval

Received

Acknowledgements

We gratefully acknowledge Kerri Pandachuck, medical student, NMP class of 2008, for her review of the literature, the participating medical students for their time and insights and Sharon Brown Research Secretary.

Additional information

Notes on contributors

Tanis Mihalynuk

DR MIHALYNUK is Program Research Leader, Nutrition, Alberta Cancer Board. At the time the research was conducted, she was a postdoctoral research associate, Faculty of Medicine, Undergraduate Medical Education, University of British Columbia (UBC), Vancouver, Canada.

David Snadden

DR SNADDEN is Vice Provost Medicine and Professor, Northern Medical Program, University of Northern British Columbia (UNBC), Prince George, Canada and Associate Dean, Northern Medical Program and Affiliate Professor, Department of Family Practice, UBC.

Joanna Bates

DR BATES is Senior Associate Dean, Education, Faculty of Medicine, and Associate Professor in the Department of Family Practice, UBC.

Ian Scott

DR SCOTT is Director of Undergraduate Family Practice Programs, and Associate Professor in the Department of Family Practice, UBC.

Vera Frinton

DR FRINTON is a Clinical Professor in the Department of Obstetrics and Gynecology, UBC and.was Associate Dean, Admissions MD Undergraduate Program at the time this research was carried out.

Galt Wilson

DR WILSON is Year III/IV Clerkship Director, Northern Medical Program, UNBC and Clinical Professor in the Department of Family Practice, UBC.