Appendix 1: Previously Published Systematic Reviews on Medical Students Primary Care Career

Appendix 1: Previously Published Systematic Reviews on Medical Students’ Primary Care Career Choice

Author, YearRef No / Data sources / Study selection criteria / Countries / Year of publication / No. of included studies / Conclusions*
Bland et al, 19959 / MEDLINE, PsychInfo, Sociology Abstracts, ERIC, Dissertation Abstracts / Original research and reviews pertaining directly or indirectly to primary care specialty choice / United States, Canada / Between 1980 and 1993 / 73 /

Required family practice clerkships
Longitudinal primary care experiences

Meurer, 199511 / MEDLINE, ERIC, PsychInfo / Original articles describing studies comparing the presence of curricular programs or student characteristics with primary care career choices by medical school graduates / United States / From 1982 through April 1993 / 31 /

Required family medicine clerkships
Continuity experiences in primary care settings
Primary care tracks

Campos-Outcalt et al, 199512 / MEDLINE, PsychINFO, Current Contents, Expanded Academic Index / Original research pertinent to the effect of the following on generalist choices of students: Biomedical research funds,
medical school curricula, and faculty role models / United States / 1984 through 1993 / 85 /

Institutional reforms
Increasing the size of generalist faculty
Required clinical training in family practice

Senf et al, 200313 / MEDLINE, PsychInfo, HealthSTAR, Expanded Academic Index, the Health and Psychosocial Instruments / Original research related to choice of family medicine as a specialty / N/D / Since 1993 (no details on end point) / 36 /

Large-scale programs
Required family medicine time
Informal culture
Faculty role models

*Only conclusions related to interventions associated with students’ primary care career choice

Appendix 2: Recommendations Based on the Findings of a Systematic Review of the Literature Published Between 1980 and 1993, on Determinants of Primary Care Specialty Choice in the United States and Canada

Recommendations for medical schools for strategies to increase the proportion of primary care physicians (Bland, Meurer and Maldonado, 1995)9 / Recommendations for improving the quality of the research in the area of primary care specialty choice (Meurer, Bland and Maldonado, 1996)10

Develop academically credible departments of family practice, general internal medicine, and general pediatrics
Systematically attend to changing medical schools’ culture to value primary care
Change admission policies to favor students who are interested in primary care and to give weight to student characteristics likely to predict future primary care career choices
Change the composition of admission committees to include people who have track records of successfully selecting students who will ultimately pursue primary care careers
Use recruitment and selection processes that are most likely to attract students who will choose primary care careers
Have volunteer and clinical primary care faculty who have received teacher training – rather than regular full-time faculty – teach first- and second-year clinical courses
Establish required longitudinal primary care experiences
Establish required third-year family practice clerkships
Establish a course on the health care needs of society and the physician’s role
Establish a career counseling program, including formal education on key characteristics of specialties
Encourage medical schools to take an inquiry approach to education, continually assessing the impacts of their programs
Request the federal government, state governments, and health care organizations to allocate significant dollars for training and research in primary care and for the careful and continual study of medical education

Develop and/or identify reliable and valid instruments, specifically to assess variables that may influence specialty selection
Use consistent definitions of primary care and of specialty choice
Encourage researchers to use a model or theory to guide their work and to analyze and interpret results in relation to all hypothesized predictive variables. Researchers should include all the many variables they believe influence specialty choice in their studies
Use experimental designs whenever possible
When investigating non-demographic or interventional influences, use a longitudinal rather than a retrospective approach
Conduct further research on the Bland – Meurer model and alternative causal models

Appendix 3: Full MEDLINE Search Strategy used in a Systematic Review of the Literature Published between January 1, 1993 and February 20, 2015, on the Impact of Interventions to Increase the Proportion of Medical Students Choosing a Primary Care Career

(1)Students, Medical/Maj

(2)(“medical student$” OR “undergraduate”).ab,ti

(3)1 OR 2

(4)Education, Medical, Undergraduate/Maj OR exp Curriculum/Maj OR Clinical Clerkship/ OR Preceptorship/

(5)(“curriculum” OR “medical education” OR “competency based education” OR “competency based curriculum” OR “community based education” OR “community based curriculum” OR “practice based education” OR “practice based curriculum”).ab,ti

(6)(“clerkship$” OR “clinical placement$” OR “rural placement$” OR “rural program$” OR “tutorial$” OR “tutor$” OR “elective$” OR “clinical practice”).ab,ti

(7)(“role model$” OR “preceptor$” OR “preceptorship$”).ab,ti

(8)4 OR 5 OR 6 OR 7

(9)Career Choice/Maj OR Specialization/Maj OR Attitude of health personnel/ OR exp Professional Competence/

(10)(“career choice” OR “speciali#ation” OR “specialty choice” OR “career plan$” OR “specialty” OR “career preference” OR “residency choice” OR “physician retention” OR “physician workforce” OR “physician shortage” OR “recruitment”).ab,ti

(11)(“attitude” OR “opinion” OR “view”).ab,ti

(12)(“professional competence$” OR “clinical competence” OR “professional skill$” OR “clinical skill$”).ab,ti

(13)9 OR 10 OR 11 OR 12

(14)exp General Practice/Maj OR Primary Health Care/Maj OR Physicians, Family/Maj OR Physicians, Primary Care/Maj OR General Practitioners/Maj OR Community medicine/ OR Community Health Services/

(15)((“family” AND (“medicine” OR practice” OR “physician$” OR “doctor$” OR “health”)) OR “primary care” OR “primary health care” OR (“general” AND (“medicine” OR “practice” OR “practitioner$” OR “physician$” OR “doctor$”)) OR “generalist”).ab,ti

(16)14 OR 15

(17)3 AND 8 AND 13 AND 16

(18)Limit 17 to yr = 1993-2015

Appendix 4: Summary of Interventions and Main Findings of 72 Studies on the Impact of Interventions on Medical Students’ Primary Care Career Choice

Intervention type* / Author, yearRef no. / Country / Intervention setting / Duration
Timing† / Sample (n)‡ / Data source§ / Definition of primary care║ / Outcome and impact¶ / Quality score#
I / G / F
Compulsory clerkships (quantitative studies) / Maiorova, 200830 / The Netherlands / General practice clerkship / 12 weeks
Clin / S (184) / Q / GP / (+) / (0) / 4-4-4
Gazewood, 200231 / United States / Clerkship in a community practice / 1 month
Clin / S (464) / Q, DB / FM, GIM, GPed / (0) / 4-4-4
Takayashiki, 200732 / Japan / Clerkship in a community setting / 1 to 15 days
Clin / S (3199) / Q / “General medicine” / (0) / 4-4-4
Levy, 200129 / United States / Clerkship in an outpatient family practice / 3 weeks
Clin / S (969) / Q, RM / FM / (+) / (+) / 4-3-4
Maiorova, 200833 / The Netherlands / Clerkships in general practice, internal medicine and surgery / 12 weeks
Clin / S (168) / Q / GP / (+) / 3-4-4
Woloschuk, 200234 / Canada / Clerkship in a rural community / 4 weeks
Clin / S (254) / Q, RM / FM / (0) / (0) / 3-4-4
Williamson, 201236 / New Zealand / Clerkship and course in a rural general practice (ambulatory and hospital) / 7 weeks
Clin / P (36) / Q / GP / (0) / 3-4-3
Campos-Outcalt, 199938 / United States / Clerkship in family medicine / N/S
Clin / MS (121) / DB / FM / (+) / 4-3-3
Packer, 201039 / United States / Service learning program at homeless shelters / 5 days
Clin / S (53) / Q, RM / FM, IM, Ped, Med/Ped / (0) / (0) / 3-4-3
Henderson, 199635 / United States / General internal medicine clerkship (inpatient) / 12 weeks
Clin / S (194) / Q / FM, GIM, GPed / (+) / (+) / 4-3-3
Hunt, 199537 / United States / Physical diagnosis course and preceptorship / 4 days over 5 months
Preclin / S (204) / Q / FM, GIM, GPed / (0) / 3-3-3
Rabadán, 201045 / Spain / Primary care theoretical course and clerkship with a family physician / 4 months (total)
1 week (clerkship)
Preclin / S (81) / Q / FM / (+) / 3-3-3
Geske, 201146 / United States / Clerkship in family medicine / 8 weeks
Clin / S (1962) / Q, RM / FM / (+) / (+) / 3-3-3
Howe, 200141 / United Kingdom / General practice clerkship, seminars and small group sessions / 8 weeks
Clin / S (146) / Q / GP / (+) / 3-3-3
Williamson, 200342 / New Zealand / Clerkship in a rural community (general practice, hospital) / 7 weeks
Clin / S (87) / Q / GP / (+) / 3-3-3
Hogg, 200843 / United Kingdom / General practice module / 4 weeks
Clin / S (64) / Q, FG / GP / (+) / 3-3-3
Tani, 2014 / Japan / Clerkship and lecture in community-based medicine / 1 week
Preclin and clin / S (65) / Q / “Community medicine” / (+) / 3-2-2
Corbett, 200247 / United States / Clerkship with community-based generalist physicians / 1 week
Preclin / S (350) / Q, RM / FM, GIM, GPed / (+) / (+) / 3-2-3
Morrison, 199644 / United Kingdom / Clerkship in general practice / 4 weeks
Clin / S (200) / Q / GP / (+) / (0) / (0) / 3-3-2
Arora, 200649 / United States / General internal medicine clerkship (inpatient) / 4 weeks (average)
Clin / S (307) / Q, RM / GIM / (+) / (+) / 2-4-2
Dunker-Schmidt, 200948 / Germany / Clerkship in a family practice / 2 weeks
Clin / S (778) / Q / GP / (+) / 3-2-2
Senf, 199551 / United States / Clerkship in family medicine / 6 weeks
Clin / S (997) / Q, RM / FM / (0) / (0) / 2-2-2
Iqbal, 201052 / Pakistan / Clerkship in family medicine / 2 weeks
Clin / S (46) / Q / FM / (+) / 2-2-2
Davidson, 199353 / United States / Clerkship in ambulatory internal medicine (one half-day per week, as part of the inpatient medicine clerkship) / N/S
Clin / S (63) / Q / GIM / (0) / (0) / 2-2-1
Tai-Pong, 199754 / Hong Kong / General practice rotation (hospital general practice unit and community-based) / 2 weeks
Clin / P (88) / Q / GP / (+) / 1-2-1
Compulsory clerkships (qualitative studies) / Jordan, 200340 / Canada / Family medicine block (academic and community-based), including a rural week experience / 6 weeks
Clin / S (11) / I / FM / (+) / 3-3-3
Parker, 2014 / New Zealand / General practice module and rural clerkship / 8 weeks (module)
4 weeks (clerkship)
Clin / S (11) / FG / GP / (+) / 3-3-2
Dixon, 200050 / Hong Kong / General practice rotation (hospital general practice unit and community-based) / 2 weeks
Clin / S (110) / FG / GP / (+) / 2-2-2
Longitudinal programs (quantitative studies) / Zink, 201055 / United States / Special pre-clinical curriculum for rural primary care; clinical longitudinal preceptorship in a rural community / 2 years +
9 months
Preclin and clin / S (491) / DB / FM, IM, Ped, Med/Ped / (+) / (+) / 4-5-4
Phillips, 199957 / United States / Family physician pathway / 2 years
Clin / S (239) / DB / FM / (+) / (+) / 4-3-4
Grayson, 200159 / United States / Elective longitudinal primary care course (including clerkships, lectures and seminars) / 1 year
Preclin / S (925) / DB, RM / FM, IM, Ped, Med/Ped / (+) / (+) / 4-3-4
Haq, 201362 / United States / Program for training in urban health (including clerkships, seminars and project work) / 15 months
Clin / S, P (16) / Q, FG / FM, IM, Ped, Med/Ped / (+) / (+) / 3-5-3
Rabinowitz, 199960 / United States / Program for rural family medicine / 4 years
Preclin and clin / P (200) / Tr / FM / (+) / 4-3-3
Rabinowitz, 201161 / United States / Program for rural family medicine / 4 years
Preclin and clin / P (104) / Tr / FM / (+) / 4-3-3
Rabinowitz, 201263 / United States / Three different programs for rural practice / 9 months to 4 years
Preclin and clin / P (956) / DB / FM, GIM, GPed / (+) / 3-4-3
Crump, 2013 / United States / Regional medical school campus focused on rural medicine / 2 years
Clin / S (57) / RM / FM, IM, Ped, Med/Ped / (+) / 3-4-3
Halaas, 200864 / United States / Longitudinal clinical experience in a rural community, including an online curriculum and project work / 9 months
Clin / S (901) / DB, RM / FM, IM, Ped, Med/Ped / (+) / (+) / 4-3-3
Herold, 199365 / United States / Longitudinal clinical experience in a community-based clinic / 4 years
Preclin and clin / S (93) / DB, RM / FM, IM, Ped / (0) / 3-3-3
Stearns, 199372 / United States / Longitudinal clinical experience at a community health center / 2.5 years
Preclin and clin / P (349) / Q / FM, IM, Ped / (?) / 3-3-3
Florence, 200773 / United States / Longitudinal interdisciplinary program in rural community health / 3 years
Preclin and clin / P (24) / Q / “Primary care” (not defined) / (+) / 3-3-3
Stagg, 200968 / Australia / Longitudinal clerkship in a rural community / 1 year
Clin / P (46) / Q / GP / (?) / 3-3-3
Mennin, 199666 / United States / Special primary care curriculum / 2 years
Preclin / P (33) / Q / FM, GIM, GPed / (+) / 3-3-2
Sen Gupta, 201367 / Australia / Special medical school for rural practice / 6 years
Preclin and clin / S (292) / Q / GP / (+) / 3-3-2
Veitch, 200669 / Australia / Special medical school for rural practice / 6 years
Preclin and clin / S (58) / Q / GP / (-) / 3-3-2
Eley, 200976 / Australia / Clinical training in a rural community / 1 or 2 years
Clin / P (124) / Q / GP / (?) / (?) / 2-3-2
Glasser, 200874 / United States / Add-on curriculum for rural primary health care / 4 years
Preclin and clin / S (159) / DB / FM, GIM, Ped, Med/Ped / (+) / 3-1-2
Walker, 201278 / Australia / Clinical training in a rural community / 1 or 2 years
Clin / S (125) / Q / GP / (?) / 2-2-2
Wilkinson, 201079 / United States / Family medicine program / 1 to 4 years
Preclin and clin / S (38) / RM / FM / (+) / 2-2-2
Roman, 199471 / United States / Special preclinical medical school for primary care in underserved urban communities / 5 years
Preclin / S (1402) / DB / FM, IM, GPed / (+) / (+) / 2-2-1
Bland, 200070 / United States / Modified curriculum including multidisciplinary instruction and training in community-based health centers / 5 years
Preclin and clin / MS (7) / RM / FM, Primary care medicine, primary care pediatrics, Med/Ped / (+) / 2-2-1
Young, 201175 / Australia / Longitudinal clinical experience in rural communities / 4 years
Preclin and clin / S (1863) / DB / GP / (+) / (0) / (0) / 2-2-1
Eley, 201277 / Australia / Clinical training in a rural community / 1 or 2 years
Clin / P (115) / Q / GP / (?) / 2-2-1
Longitudinal programs (qualitative studies) / Kuzel, 199956 / United States / Longitudinal clinical skills course taught by community-based generalists / 2 years
Preclin / S (40) / FG / “Primary care” (not defined) / (-) / 4-5-4
Firth, 200758 / United Kingdom / Community-based curriculum, including several clerkships in general practice / 3 years
Clin / S (11) / I / GP / (+) / 4-3-4
Electives / Kane, 201380 / United States / Summer program in a rural community / 4 to 8 weeks
Preclin / S (253) / Q, RM / FM, GIM, Ped, Med/Ped / (+) / (+) / (+) / 4-4-3
Nieman, 200427 / United States / Elective clinical experience in family practice / 4 to 8 weeks
Preclin and clin / S (2517) / DB / FM, IM, Ped, Ob/Gyn / (+) / 3-3-3
Deutsch, 201326 / Germany / Family practice elective / 4 days
Preclin / S (133) / Q / FM / (+) / 3-3-3
Dobie, 199728 / United States / Elective clerkship in a rural or underserved community / 4 weeks
Preclin / S (86) / Q, RM / FM, IM, Ped, Med/Ped / (+) / (+) / 3-4-2
Davidson, 200225 / United States / Interdisciplinary course in community health, including project work and clinical exposure / 8 weeks
Preclin / S (51) / Q / “Primary care” (not defined, but includes Ob/Gyn and psychiatry) / (?) / 3-2-2
Seim, 199723 / United States / Weekend immersion in a rural family practice / 3 days
Preclin / S (N/S) / Q, RM / FM / (+) / (0) / 3-2-2
Farmer, 200324 / United Kingdom / Elective in rural general practice / 6 weeks
Clin / S (74) / Q / GP / (0) / 2-2-2
Talbot, 200022 / Australia / Weekend immersion in rural general practice (during the general practice term) / 4 days
Clin / S (103) / Q / GP / (+) / 2-2-2
Bruno, 2013 / United States / Global health elective / 6 to 8 weeks
Clin / S (164) / RM / FM, IM, GPed, Med/Ped, Ob/Gyn / (+) / 2-2-1
Crosson, 200321 / United States / Training program in patient education / 6 weeks
Preclin / S, P (23) / Q / FM / (+) / (+) / 2-2-1
Interest groups (quantitative studies) / Norris, 200319 / United States / Interprofessionalprimary care interest group / 4 years
Preclin and clin / S (216) / RM, DB / FM, GIM, Ped / (+) / 2-2-2
McKee, 200718 / Canada / Family medicine interest group / 4 years
Preclin and clin / S (18) / Q / FM / (?) / 2-2-1
Interest groups (qualitative study) / Kerr, 200820 / Canada / Family medicine interest group / 4 years
Preclin and clin / S (45) / FG / FM / (+) / 3-3-3
Student-run clinics / Tong, 201217 / United States / Medical school offering a student-run free clinic / N/S
N&S / MS (115) / Q, DB / GP, FM, GIM, GPed, Med/Ped, geriatrics / (0) / 4-3-3
Smith, 2014 / United States / Student-run free clinic and service-learning course / 9 months
Preclin / S (433) / Q / “Primary care” (not defined) / (+) / 2-4-3
Vaikunth, 2014 / United States / Student-run free clinic
for Hispanic populations / 4 years
Preclin and clin / S (141) / RM / FM, Medicine, Ped, Med/Ped, Ob/Gyn / (0) / 2-3-2
Others / Chang, 200416 / United States / Accelerated residency program in general internal medicine, combining the last year of medical school and the first year of residency / 1 year
Clin / P (11) / Q / GIM / (+) / 2-2-1
Jones, 200515 / United Kingdom / Intercalated research degree in primary care / 1 year
Preclin and clin / S (26) / I / GP / (+) / 4-5-4

*Definitions of intervention types: Compulsory clerkship: A student placement in a clinical setting (ambulatory or hospital) that is part of the curriculum. In the literature, various terms are used, such as rotation, attachment or preceptorship. Longitudinal program: A course lasting for at least one academic year, including one or several types of teaching, either as a part of the curriculum (for all students) or added to the conventional curriculum (for a subgroup of students), or a curriculum specifically focused on primary care. Elective: Optional clerkship or course outside the compulsory curriculum.

†Because of the variation in the duration of medical studies in different countries, we defined the timing of the intervention as either pre-clinical (preclin) or clinical (clin), depending on their occurrence in the curriculum.

‡Unit of measure for the study. S = students, P = physicians, MS = medical schools. N = sample size, not including control group.

§Abbreviations: Q = questionnaire, DB = database (includes medical school databases containing information on students, physician directories, and medical school directories), RM = residency match data (national residency matching programs), I = interviews, FG = focus groups, Tr = medical school tracking databases (medical schools tracking their graduates long-term and updating the information at regular intervals).

║Definition of primary care: Definition of the specialty considered for the outcome, as stated in the article. Abbreviations: GP = general practice, FM = family medicine, GIM = general internal medicine, GPed = general pediatrics, Ped = pediatrics, IM = internal medicine, Med/Ped = combined medicine/pediatrics, Ob/Gyn = obstetrics/gynecology.

¶Main outcome measures relevant for the present review. I = career intention before graduation, G = career choice at or around the time of graduation, F = final career choice. Impact of the intervention on relevant outcomes: (+) = positive impact (increase in numbers of students choosing a primary care career, or positive change of attitudes towards primary care); (0) = no impact; (-) = negative impact (decrease in numbers of students choosing a primary care career, or negative impact on attitudes towards primary care); ? = unknown impact (due to lack of control group or other control conditions).

#Quality scores were allocated on a scale from 1 to 5, and are reported in the following order: (1) methodological quality, (2) quality of information (3) strength of findings.

Appendix 5: Independent Variables, Detailed Outcomes and Major Threats to Validity Identified in 72 Studies Included in a Systematic Review of the Literature, Published between January 1, 1993 and February 20, 2015, on the Impact of Interventions to Increase the Proportion of Medical Students Choosing a Primary Care Career*

Author, yearRef No / Intervention type / Study design† / Independent variables included in analysis / Outcome: career intention‡ / Outcome: career choice (at graduation or later) / Major threats to validity
Maiorova, 200830 / Compulsory clinical clerkship / Pre, post and follow-up / Gender, previous work experience, other health care education, having considered allied profession, preferred work conditions, preferred patients category, assessment of the work of a general practitioner / Increase in the likelihood to become a general practitioner after the clerkship (increase in 38% for men, 22% for women, p<0.05).
Before the clerkship, work extrinsic factors were related to the likelihood of becoming a GP.
After the clerkship, work intrinsic factors had become significant. / At graduation, the likelihood to become a general practitioner decreased again to pre-clerkship levels. / 35% non-response at graduation
Self-constructed questionnaire
Gazewood, 200231 / Compulsory clinical clerkship (with family medicine or internal medicine preceptors) / Follow-up / Gender, ethnicity, rural residence, science major, exam scores, preceptor specialty, month of rotation / 37% of students selected a generalist career. No significant difference between the students assigned to preceptors of different specialties. There was no difference in the percentage of students choosing a generalist career in the 4 years preceding and the 4 years following the introduction of the clerkship. / No control group without the intervention
Outcome measure “generalist career” = construct of residency choice and the plan to pursue a primary care career
Takayashiki, 200732 / Compulsory clinical clerkship in community-based primary care at 62 medical schools / Follow-up / Gender, rural background, parents’ profession, academic background, profile of medical school / In multivariate analyses, a primary care clerkship increased students’ interest in primary care (OR 1.4), but not career preference (OR 1.0).