House Officers' Choice of Family Medicine Specialty amid the Implementation of the New Universal Health Insurance Law.

BACKGROUND: The new Egyptian Universal Health Insurance Law is introduced through family-oriented primary health care. Increasing the number of recent graduates who specialized in family medicine is considered a national need to overcome family physicians' shortage. AIM: To explore the factors affecting the house officers' choice of Family Medicine as a future career amid the implementation of the new Universal Health Insurance Law in Egypt.
METHODS: This is a cross-sectional study conducted on house officers during their training in Cairo university hospitals from the first of March 2020 to February 2021. The researchers offered an anonymous self-administered questionnaire to all house officers at the beginning of their 2-week family medicine training (1170 house officers).
RESULTS: A total of 1052 completed the questionnaire (response rate 90%). Family medicine as a specialty was considered by 53.6% (n = 564) of participants, while only 23.4% (n = 246) of participants had an obvious intention to choose family medicine. Multivariate (adjusted) logistic regression model revealed that factors significantly associated with intention to choose family medicine were marital status, knowledge about governmental advantages for family medicine offered to the specialized recent graduates, and previously encountered with family practice as customers.
CONCLUSIONS: The choice of family medicine specialty is increasing among house officers. This could be attributed to the growing interest in family medicine in Egypt, especially after implementing the new insurance law's first phase in several Egyptian governorates.

Introduction

Family medicine (FM) is a cornerstone for maintaining the health status of individuals and improving their quality of life.[1] Having well-qualified family physicians became widely acknowledged in health care systems to ensure health equity and guarantee to provide cost-effective health service in a comprehensive and patient-centered care manner.[2] In Egypt, Family medicine is considered a new specialty and is not well known to all Egyptians. Family medicine as an academic specialty was first established in The Faculty of Medicine, Suez Canal University (FOM, SCU). This was followed by the establishment of the family medicine department at Menoufia and Cairo universities.[3]

There is a growing interest in FM in Egypt. The new Universal Health Insurance Law is introduced through family-oriented primary health care, including family medicine units and centers.[4] The Egyptian Family Medicine Program aims to provide comprehensive and continuous health care to all the population. This is done by developing more than 2500 family medicine units and centers and offering technical and administrative training to family physicians.[5,6] Incentives were offered to them based on regular performance indicators, especially for those working in rural areas.[7]

The career choices of junior doctors are of great concern to ensure the right balance of physicians and covering the needs of the populations.[8] Choosing a future career in family medicine is a multifactorial and complex process. Several factors influence junior doctors and house officers’ decision in choosing family medicine as their future career, including the absence of social recognition and role models, pioneering personality, income, familiarity with the family medicine concept, short residency program, and lack of training systems. Those factors can have positive or negative influences on career choice.[9,10]

The shortage of Family physicians is considered a global problem in developed and developing countries.[11] In Egypt, it is also considered a significant problem for the health sector, as it represents an obstacle in implementing the new Universal Health Insurance Law. Therefore, it was crucial to determine the factors that affect the choice of family medicine as a future career in an attempt to bridge the gap and find a solution for the shortage of family physicians in Egypt.

This study aims to explore the factors affecting the house officers’ choice of Family Medicine as a future career amid the implementation of Universal Health Insurance Law on their choice. The research hypothesis was that the increased governmental interest in family medicine would affect the house officers’ choice of family medicine as a future career.

Methods

This was a cross-sectional study conducted on house officers during their training in Cairo university hospitals from the first of March 2020 to February 2021

Study Tool

All house officers trained in the family medicine department from the first of March 2020 to February 2021 were approached. An anonymous self-administered questionnaire was offered to all of them at the beginning of their 2-week family medicine training (1170 house officers). A total of 1052 completed the questionnaire with a response rate of 90%. The questionnaire was adapted from a study conducted by AlKot et al.[12] It consisted of 4 parts:

The first part included sociodemographic data (age, sex, residence, marital status, and history of traveling abroad).

The second part assessed the factors that affect their future career choice, including income, needed skills, career reputation, and intellectual challenge. Also, it evaluated whether they plan to choose FM as their future career. This included 2 questions; 1 inquired about if they ever considered choosing FM as their future career, and the other assessed their true intention in choosing FM.

The third part assessed their knowledge and attitude toward FM speciality, including the importance of implementation of FM to the health care system in Egypt and the advantages offered by the government to family physicians. They were asked to evaluate their knowledge regarding family medicine speciality, whether it was low, average, or high.

The fourth part inquired about their experience in visiting a family health center as a patient or having a family physician in his family and whether they plan to practice FM abroad.

Ethical Approval

Approval was obtained from the scientific council of the Family Medicine department. Ethical approval was obtained from the research ethics committee of the faculty of medicine. Participation in the study was voluntary, and written consent was obtained from all participants. The study followed the principles of the Declaration of Helsinki.

Statistical Analysis

This study was statistically analyzed using Stata statistical software version 16. The variables were presented in number and percent. Bivariate associations between the outcome variable (intension to specialize in Family medicine) and independent variables were done using the Chi-square test. Univariate and multivariate logistic regression (after controlling for marital status, having a family physician relative, knowledge of FM, Knowledge of governmental advantages for family physicians, and previously visiting a PHC or family physician) was done for identification outcome predictors.

Results

A total of 1052 completed the survey, and their responses were analyzed (response rate 90%). As shown in Table 1, the age ranged between 23 to 37 years, and the mean (±SD) was 25 (±1) years. Females were slightly greater in proportion compared to males (53%, n = 561). Most of the responders were living in greater Cairo (85.8%, n = 903), single (91%, n = 958), and graduated from Cairo University (91.9%, n = 967). More than half of the participants had an experience of traveling abroad (57.2%, n = 602), participated in regular volunteering activities (62.4%, n = 656), or had a relative who is a family doctor (24.8%, n = 261).

Table 1.

Socio-Demographic Characteristics of Study Participants (n = 1052).

		Intension to specialize in Family medicine
		No	Yes
	Total n (%)	n (%)	n (%)	P value*
Gender
Female	561 (53.33)	420 (74.87)	141 (25.13)	.152
Male	491 (46.67)	386 (78.62)	105 (21.38)
Residence
Greater Cairo	903 (85.84)	689 (76.30)	214 (23.70)	.838
City outside Cairo	102 (9.70)	80 (78.43)	22 (21.57)
Village outside Cairo	47 (4.47)	37 (78.72)	10 (21.28)
Marital status
Single	958 (91.06)	742 (77.45)	216 (22.55)	.041
Married	94 (8.94)	64 (68.09)	30 (31.91)
Training university
Cairo university	967 (91.92)	745 (77.04)	222 (22.96)	.270
6 October university	85 (8.08)	61 (71.76)	24 (28.24)
Previous traveling abroad
No	602 (57.22)	457 (75.91)	145 (24.09)	.534
Yes	450 (42.78)	349 (77.56)	101 (22.44)
Participation in regular volunteer work
No	656 (62.36)	515 (78.51)	141 (21.49)	.062
Yes	396 (37.64)	291 (73.48)	105 (26.52)
Having a family physician relative
No	791 (75.19)	619 (78.26)	172 (21.74)	.029
Yes	261 (24.81)	187 (71.65)	74 (28.35)

P value of Chi square test and is considered significant if <.05.

Regarding the factors that might influence the choice of medical speciality, the intellectual challenge of the speciality was important for 71.6% (n = 753) of responders, followed by the “type of patients dealt with” in 66.8% (n = 703). The greater proportion of responders (59.5%, n = 626) reported wages as a factor, while 61.6% (n = 648) consider the speciality based on prestige and reputation. Career lifestyle, progression, and learned skills were factors in 65.1% (n = 685), 50.5% (n = 531), and 45% (n = 474); respectively. Finally, 56.9% (n = 598) would choose the speciality that is perceived as “important” (Table 2).

Table 2.

Factors Influence Career Choice and Perception of Family Medicine (FM) (n = 1052).

		Intension to specialize in Family medicine
		No	Yes
	Total (%)	n (%)	n (%)	P value*
Factors influence career choice
Income
No	426 (40.49)	324 (76.06)	102 (23.94)	.724
Yes	626 (59.51)	482 (77.00)	144 (23.00)
Prestige and career reputation
No	648 (61.60)	485 (74.85)	163 (25.15)	.086
Yes	404 (38.40)	321 (79.46)	83 (20.54)
Career progression
No	521 (49.52)	399 (76.58)	122 (23.42)	.980
Yes	531 (50.48)	407 (76.65)	124 (23.35)
Intellectual challenge
No	753 (71.58)	577 (76.63)	176 (23.37)	.989
Yes	299 (28.42)	229 (76.59)	70 (23.41)
Lifestyle
No	367 (34.89)	290 (79.02)	77 (20.98)	.178
Yes	685 (65.11)	516 (75.33)	169 (24.67)
Needed skills
No	578 (54.94)	437 (75.61)	141 (24.39)	.393
Yes	474 (45.06)	369 (77.85)	105 (22.15)
Type of the patients dealing with
No	703 (66.83)	542 (77.10)	161 (22.90)	.600
Yes	349 (33.17)	264 (75.64)	85 (24.36)
Importance of the speciality
No	454 (43.16)	343 (75.55)	111 (24.45)	.477
Yes	598 (56.84)	463 (77.42)	135 (22.58)
Knowledge and perception of FM speciality
FM importance in foreign countries
No	163 (15.49)	131 (80.37)	32 (19.63)	.218
Yes	889 (84.51)	675 (75.93)	214 (24.07)
Beneficence of FM to healthcare system in Egypt
No	75 (7.13)	63 (84.00)	12 (16.00)	.117
Yes	977 (92.87)	743 (76.05)	234 (23.95)
Governmental advantages for FM specialized fresh graduates
No	776 (73.76)	615 (79.25)	161 (20.75)	.001
Yes	276 (26.24)	191 (69.20)	85 (30.80)
Knowledge about FM
No	148 (14.07)	123 (83.11)	25 (16.89)	.044
Yes	904 (85.93)	683 (75.55)	221 (24.45)
FM knowledge scale
Low	226 (21.48)	183 (80.97)	43 (19.03)	.215
Average	537 (51.05)	406 (75.61)	131 (24.39)
High	289 (27.47)	217 (75.09	72 (24.91)
Visited family physician or PHC as a consumer
No	665 (63.21)	531 (79.85)	134 (20.15)	.001
Yes	387 (36.79)	275 (71.06)	112 (28.94)
Planning to practice FM abroad
No	322 (30.61)	248 (77.02)	74 (22.98)	.838
Yes	730 (69.39)	558 (76.44)	172 (23.56)

P value of Chi square test and is considered significant if <.05.

Figure 1 shows that family medicine as a speciality was considered by 53.6% (n = 564) of participants, but only 23.4% (n = 246) of participants say they have an obvious intention to choose family medicine. Figure 2 shows the perceived knowledge of family medicine specialty, where 27% of participants perceived themselves as having a high knowledge of family medicine.

Figure 1.

Percentage of participants intending and considering family medicine as a speciality.

Figure 2.

House officers’ perceived knowledge of family medicine speciality.

The bivariate association between demographic, career choice, knowledge of family medicine, planning to practice abroad, and being a customer to family medicine variables and the outcome variable of considering family medicine as a speciality are shown in Tables 1 and 2. The chi-square test shows a significant association between aspiring family medicine and marital status, having a family doctor relative, knowledge about FM, and the governmental advantages for FM specialized recent graduates.

Factors that were significantly associated with intention to choose family medicine in the test of association were entered into univariate and multivariate (adjusted) logistic regression models to explore significant predictors for FM speciality choice. Table 3 shows that: of these factors, the odds (OR, 95%CI) for choosing FM were less in non-married house-officers (0.62, 0.38-0.98) compared to married. Participants with knowledge about governmental advantages for FM specialized recent graduates, and past utilization of family health center as customers had higher odds of (OR 1.52, CI 1.11-2.10) and (OR 1.42 CI: 1.06-1.92); respectively, to choose family medicine.

Table 3.

Logistic Regression Analysis.

	Unadjusted regression		Adjusted regression
	OR (95% CI)[^]	P value*	OR (95% CI)	P value
Marital status
Single	0.62 (0.39-0.98)	.042	0.61 (0.38-0.98)	.041
Having a family physician relative
Yes	1.42 (1.04-1.96)	.029	1.31 (0.95-1.82)	.101
Governmental advantages for FM specialized fresh graduates
Yes	1.70 (1.25-2.31)	.001	1.52 (1.11-2.10)	.010
Knowledge about FM
Yes	1.59 (1.01-2.51)	.046	1.37 (0.86-2.18)	.181
Visited family physician or PHC as a consumer
Yes	1.61 (1.21-2.16)	.001	1.42 (1.06-1.92)	.020

OR odds ratio, 95% CI, 95% confidence interval.

P value is considered significant if <.05.

Discussion

This is a cross-sectional study conducted in Cairo university hospitals from the first of March 2020 till February 2021 to explore the factors affecting the house officers’ choice of Family Medicine as a future career amid the implementation of the new Universal Health Insurance Law. In the faculty of medicine, Cairo University, family medicine was introduced in the undergraduate curriculum in the academic year 2018/2019. Unfortunately, house officers who graduated in 2019 were not exposed to family medicine during their undergraduate studies. They recognized the importance of implementing family medicine while studying public health in their fourth year in medical school. But this was not enough to understand and differentiate Family Physicians’ roles in providing a preventive and curative service.

The new Universal Health Insurance Law is introduced through primary health care, resulting in a growing interest in FM in Egypt. The universal health insurance system aims to cover all the Egyptian governorates by the year 2032. It was crucial to strengthen the Egyptian health system focusing on core components including financing, health workforce, and service delivery in primary health care.[4]

Therefore, it was crucial to assess the factors that affect house officers’ choice of family medicine as their future career and detect whether the growing governmental interest in family medicine has influenced their choice. The current study found that 23.4% of the house officers reported having an intention to choose FM as their future career, and more than half of them considered FM as their future career choice. This is regarded as a promising result compared to another Egyptian study conducted in 2015 by AlKot et al,[12] where only 4.7% of the house officers intended to pursue a career in Family medicine. This is because of the growing interest in FM in Egypt after implementing the first phase of the new insurance law in several Egyptian governorates, which positively impacted the attitude of house officers toward the family medicine specialty. This was also clear in our study, as 92.9% of the house officers have perceived family medicine as an essential specialty to Egypt’s health system, even though they were not introduced to family medicine in their undergraduate studies.

In our study, factors that influence medical specialty choice included the intellectual challenge of the specialty, type of patients, income, prestige, and reputation. While in a study conducted in Egypt in 2015, the nature of the speciality and its perceived importance was the most critical factors. This was different from a study conducted in Pakistan in 2021, where the most reported factors for choosing any specialty were interest in the subject, peer pressure, high income, and flexible working hours.[13] There was no statistical difference regarding the factors that influence a career choice between house officers who intend to choose family medicine as their future career and those with no intention. This differs from a study conducted by Gill et al,[14] where students who prefer family medicine as a future career were influenced by prestige and income, and research. The difference may be attributed to the difference in the study sample being medical students.

A study conducted in Sinclair et al[15] concluded that the reasons stated for choosing to practice family medicine were the continuity of care, doctor-patient solid relationship, dealing with all age groups, and the diversity of the encountered medical conditions. This was not the case in our study, where marital status, knowledge about governmental advantages for FM offered to the specialized fresh graduates, and previously encountered with family practice as customers were considered predictors for choosing family medicine as a future career. Other studies concluded that exposure to FM role models in undergraduate studies, the scope of practice, and lifestyle are the most critical factors for choosing a career in family medicine.[16,17] This is also different from a study conducted in Egypt in 2015 by Elkhawaga et al,[18] where rural residence and low grades in public health were independent predictors of choosing FM as a career. The difference is related to the fact that the house officers enrolled in our study didn’t study family medicine in their undergraduate years and are not acquainted with the different components of family practice.

The current study has shown that married house officers were more likely to select family medicine as a career choice. This may be since they had more obligations and need more time to care for their own families. In contrast to what was commonly believed, there was no statistical difference between male and female house officers regarding their intention to choose family medicine as a future career. This is in concordance with a study done in Morocco in 2020.[19] Another study conducted in 2004 by Ward et al[20] concluded that male participants were less likely to become family physicians.

There is no doubt that a robust primary health care system is the cornerstone for the implementation of the health insurance system. Developing the family health centers’ infrastructure and improving the delivered services were crucial to accomplish the comprehensive health insurance system and effectively improve health outcomes. This was reflected in our study, where house officers with past utilization of family medicine as consumers were more likely to have FM as the intended career choice. This is similar to a study conducted by AlKot et al[12] and reflects the good medical experience encountered as a patient in primary health care.

The human component was given the utmost importance during the implementation of the universal health insurance system. The Egyptian government had provided financial and academic incentives to encourage junior physicians to pursue a career in family medicine. This was obvious in our study, where knowledge about governmental advantages for family physicians was one of the predictors for choosing family medicine as a future career. In addition to all these incentives, it is of utmost importance to expose undergraduate students in all Egyptian medical schools to Family Medicine early besides providing obligatory family medicine clinical training to house officers.

Conclusion

The growing interest in FM in Egypt had a positive impact on house officers’ attitude toward the family medicine specialty, especially after implementing the first phase of the new insurance law in several Egyptian governorates. Governmental advantages offered to family physicians positively impact the house officers’ intention in choosing family medicine as a future career. Also, the comprehensive care provided in family practice in Egypt and the development of the health care units had made the past utilization of family health centers as customers an essential factor for choosing family medicine as a future specialty.