Introduction
The need to attract and retain physicians in rural and medically underserved areas is a worldwide issue1,2. WHO has issued guidelines for national policies, yet most recommended initiatives require funding and are therefore implemented in high-income countries only1. In France, the most medically underserved region in the country is the Centre-Val de Loire (CVDL) region: in 2023, there were only 2.56 physicians for every 1000 inhabitants, as compared with a national average of 3.393,4. In the CVDL region, the county of Indre is particularly underserved, with 1.97 physicians for every 1000 inhabitants4. At the same time, Indre had a higher proportion of older residents (>75 years) than the comparable national average: 14% versus 9%, respectively, in 20205,6. This population has more healthcare needs, thereby increasing the need for physicians in the county.
The Global Consensus for Social Accountability of Medical Schools was launched in 20097,8. Medical faculties, in addition to their usual missions, were urged to fulfil their social responsibility in their respective geographical regions7,9. One area identified in the consensus document was the importance of anticipating societal healthcare needs based on medical demographics: medical faculties should be able to meet the healthcare needs and challenges of the people they serve7.
Various initiatives have been implemented to encourage young physicians to practise in underserved areas2,10. An Australian study reported the beneficial effect of a medical curriculum focusing on primary care and the needs of these communities9. The US and Canada have successfully attracted physicians to underserved areas by proposing financial incentives10. A recent systematic review concluded that physicians from rural areas and those with rural experience during their medical training were more likely to establish their practices in underserved areas2. Yet numerous reports have also indicated that, once licensed, physicians tend to remain in the region in which they studied9,10.
In France, students enrol in medical studies directly from secondary school, through a selective first year. Once they pass this first year, undergraduate medical students must do their professional training in the region of the medical faculty that they attend. The only medical faculty in the CVDL region is located in the city of Tours. Consequently, the only students eligible to complete their training in the underserved county of Indre are those who attend the faculty in Tours. As Indre borders the adjacent Nouvelle Aquitaine region, however, many students from this county prefer to enrol at the medical faculties in the nearby cities of Limoges and Poitiers (in Nouvelle Aquitaine) rather than at the faculty in Tours (CVDL); yet while the Limoges and Poitiers faculties are closer to Indre, attending these schools also precludes subsequent training in the students’ home county.
At the medical faculty in Tours, students from Indre are scarce: in 2018, they represented only 22 of 1250 students from second to sixth year. Are these students less successful than others? Do students from Indre tend to decide against attending medical school? The extent of and reasons for students’ choices remain unclear.
We hypothesised that this relocation of potential future physicians from Indre to the neighbouring region of Nouvelle Aquitaine exacerbates the lack of physicians practising in the rural and medically underserved CVDL region.
The primary objective of this research was to assess the number of students from a medically underserved county in France enrolled at the regional and the closest medical faculties, and to compare first-year pass rates between these and other students. The secondary objective was to identify factors that may hinder or facilitate students’ choice of medical faculty.
Methods
We conducted a mixed-methods study with simultaneous quantitative and qualitative analyses11. The quantitative analysis assessed the number of students from Indre registered at three different medical faculties (Tours, Limoges and Poitiers). We compared the pass rates of Indre students in each of these three faculties with those of other students. The qualitative analysis investigated the factors that hindered or facilitated choice of medical faculty.
Quantitative analysis
We performed a retrospective, observational study to assess Indre students’ access to medical education at the faculties of Tours, Limoges and Poitiers. The study population consisted of students originating from Indre and registered in their first year of medical school at these three faculties from academic years 2014–2017. The French national student management software was used to extract student data and provide anonymised listings. Data collected were number of students registered, number of students who successfully completed their first year of medical school, and students’ previous county of residence.
For each medical faculty, we compared the number of students from Indre registered over the three academic years to the total number of students. The success rates of the first-year students from Indre were calculated for each faculty and compared with those of all registered students. Data were compared by χ2 test, with a Yates correction when applicable, except in cases of small sample sizes, when Fisher’s test was used. The significance level was set at 5% (p<0.05). Statistical analyses were performed with BiostaTGV software (Pierre Louis d'Epidémiologie et de Santé Publique; https://biostatgv.sentiweb.fr).
Qualitative analysis
We also performed a qualitative study, using a general inductive analysis approach, to identify factors that may hinder or facilitate the choice of a medical faculty12. The study population comprised students originating from Indre who were registered at the medical faculty in Tours during the academic year 2017–2018. Students were invited by email to participate in the study. Participation was voluntary. Data were collected using semi-guided interviews, conducted individually by telephone or during in-person focus groups. The interviews were constructed around three themes: the students’ desire to study medicine, factors/events that affected the choice to study medicine and difficulties encountered. The interviews were recorded, transcribed and pseudonymised. The audio recordings were destroyed after transcription.
Data were analysed using a general inductive approach. The data were coded independently by two researchers (BL and IE), then pooled, with arbitration by a third researcher (CR) if needed, to constitute the codebook. Axial and thematic coding were then performed with the same process.
Ethics approval
Both parts of this study were approved by the regional ethics committee in Tours, France (no. 2018-096 and no. 2018-052). All aspects of the research were carried out in accordance with the Declaration of Helsinki. All participants provided written informed consent for the study.
Results
From 2014 to 2017, a total of 296 students from Indre registered for the first-year medical examination. Significantly more students from Indre were registered at the medical faculty in Limoges than at the faculties in Poitiers and Tours (5.7% v 1.2% and 2.0%, respectively; p<0.01) (Table 1). The first-year pass rate, combined for the three faculties, was 15.5% (46/296) for students from Indre, as compared with 16.1% (1754/10,864; p=0.84) for all students (Table 2).
Table 1: Cumulative first-year enrolment of students in the medical faculties of Limoges, Poitiers and Tours from academic years 2014–2017
| Faculty | All registered students | Registered students from Indre† | |
|---|---|---|---|
|
(n) |
n | % | |
| Tours | 4576 | 93 | 2.0 |
| Limoges | 2820 | 160 | 5.7 |
| Poitiers | 3468 | 43 | 1.2 |
| Total | 10,864 | 296 | 2.7 |
† Comparison by faculty, p<0.01.
Table 2: First-year success rate for students from Indre versus all students in the medical faculties of Tours, Limoges and Poitiers from academic years 2014–2017
| Faculty | All students | Students from Indre | p-value† | ||||
|---|---|---|---|---|---|---|---|
| Registered | Passed | Registered | Passed | ||||
|
n |
n | % | n | n | % | ||
| Tours | 4576 | 745 | 16.3 | 93 | 12 | 12.9 | 0.46 |
| Limoges | 2820 | 410 | 14.5 | 160 | 26 | 16.3 | 0.63 |
| Poitiers | 3468 | 599 | 17.3 | 43 | 8 | 18.6 | 0.98 |
| Total | 10,864 | 1754 | 16.1 | 296 | 46 | 15.5 | 0.84 |
| Comparison by faculty | p=0.01 | p=0.65 | |||||
† Comparing students from Indre with all students.
Factors that hinder and facilitate the choice of faculty
Of the 22 students from Indre who were registered at the medical faculty in Tours during the academic year 2017–2018, 21 (95%) agreed to participate in the qualitative study. A further student from Indre initially enrolled in the first year of medical school was also interviewed, but this student changed their area of study during the second quarter of the year. Overall, 22 students were interviewed: 12 in two in-person focus groups of five and seven students each, and 10 individually by telephone. The students cited various factors that influenced their decision-making process, as reported below.
Obligation to leave the county of Indre
The county of Indre does not have a medical faculty, a reality that constitutes a central factor in students’ choice of school. Indeed, most of the students interviewed were aware that they would have to leave their county of origin for their studies, as these students from two towns in Indre reported:
Anyway, being in Châteauroux, we knew we would have to leave. (interview 18)
For example, where I live in La Châtre, there’s nothing at all after high school. You just don’t have a choice. Whatever you want to do, you’re gonna have to leave your parents’ house … Some people manage to stay, but … as long as you have a bit of ambition … you have to leave anyway, there’s no teaching pool, there aren’t enough things [to do]. (focus group 2)
Consequently, students from rural areas are forced to travel long distances daily or find accommodation close to the faculty. As this student observed:
[There aren’t] too many people who make the morning and evening round trip from La Châtre; it’s still 1–2 hours ... They’re in boarding school or something ... even during high school. (focus group 2)
Prior impressions of the city
Students’ overall impressions regarding a given city also influenced their choice of medical faculty. Prior knowledge and a pleasant experience in the city of study reinforced their desire to pursue their education there, as was the case for these students:
It was much more beautiful in Tours. (focus group 2)
We went out the night before ..., and the will to come to Tours was very much confirmed by the evening we spent. (focus group 2)
Reputation of the faculty
The reputation of the faculty and the ease of access constituted further criteria influencing school choice. One student recalled:
My father looked at the figures and odds and told me, ‘In Tours, you have a better chance of success.’ (focus group 2)
Some found that the information provided by faculty professors seemed different from the reality experienced by students:
Whatever they say, I think they don’t know what … the competitive first year is, unless they have lived it. (focus group 1)
Conversely, hearing directly from former students about their experiences appeared to be more appreciated as prospective students weighed their choices:
He kept telling us his story to motivate us. (interview 2)
There is no better person to explain … experience than a student. (interview 9)
Availability of community support
For students who already had community in a particular city, like a family member or friend, it was easier to imagine themselves relocating to that city for their studies:
I had family members in Tours and that helped me decide, too. (focus group 1)
What motivated me, in particular, was that my best friend was also coming ... to Tours. (focus group 2)
Some students cited logistical support from their community as important for helping them focus on their studies, leading them to choose a faculty in a city where a family member lived:
I was ... at my mother’s, so ... it’s nice, you don’t have to do the housework, you don’t have to iron, you don’t have to cook ... (focus group 1)
They [my parents] save me as much time as possible: they pick me up in Tours, take me back, do my grocery shopping … They help me with the cleaning while I am attending classes. (interview 4)
Without community support, some students found it difficult to continue their studies:
I kind of stopped my first year of medicine because … being far from my family, unconsciously, also played a role. (focus group 1)
Financial considerations
The cost of housing in the city of study also played a role in students’ decisions, as did the cost and duration of travel between the city and their family home. As one student noted:
Limoges has only one advantage: it is that you can go there by freeway. It is free [to study] ... and much faster. (focus group 1)
One student suggested that a faster transport network could make a difference:
As long as there is not a Tours–Châteauroux train line ..., there will not be more doctors in Châteauroux, that’s for sure. (focus group 2)
Discussion
Students from the rural county of Indre were as successful as other students in passing the first year of medical school, but they did not seem to be aware of this. To feel confident enough to apply to medical school, prospective students need reliable information, preferably from undergraduates to whom they feel close. Belonging to a community helped students from Indre succeed by providing them with access to mutual moral and logistical support. Students were therefore more likely to apply to medical school in a town where they had friends or family. To attract and retain students, medical faculties can help re-create these sorts of communities.
Dismantling the misconception surrounding pass rates
Students cited pass rates as one criterion in choosing a medical faculty. However, our quantitative results do not indicate that pass rates differed between first-year medical students from Indre and their peers, pointing to a discrepancy between perception and data. Over three academic years, nearly 300 students from Indre registered for the first year of medicine at the faculties in Tours, Limoges and Poitiers; in all three schools, their first-year pass rates were comparable to those of the larger student body. Furthermore, first-year pass rates for students from Indre were similar in each of the three medical faculties, and compared well with the national rate. These results indicate that students from Indre were as successful as their peers, across faculties.
Contrary to what students say, passing rates appear to have no real bearing on the choice of medical faculty. The perception that students have regarding pass rates, and by extension the perception of those around them, would seem to be based more on rumour and misconception than on concrete data. This finding suggests that awareness of and access to raw data on pass rates could influence rural students’ choice of medical faculty. Similarly, an Australian study indicated that the lack of accurate information regarding admissions processes, and the difficulty in obtaining this complex information, may constitute key obstacles that prevent rural students from enrolling in medical studies13. More detailed and accurate information on these processes could be more widely shared in secondary schools to help students feel more comfortable enrolling.
Keeping medical students in their region of origin
Logistical support
Several factors influencing medical students’ decisions to stay in their region of origin or relocate concern all students, not just those from underserved areas. However, certain factors took on an outsized importance for students from Indre and were central considerations in their choice of medical faculty. The greater distance to the faculty in Tours and the lack of transport infrastructure contributed to increased costs and wasted time, both of which were important elements to consider. Likewise, the need for logistical help and a nearby family support system also weighed heavily in the balance. While universities and regional stakeholders cannot provide familial support, they could organise special transportation and housing assistance for these students14. For instance, officials could offer a regular weekend shuttle or dedicated on-campus residences with restaurants, cleaning services, etc. These services would meet the logistical needs of students from Indre, develop conviviality and help build a community of mutual support15.
Appeal of the medical faculty
What can a medical faculty, like that in Tours, do to attract students? Several factors identified in this study concerned career orientation. Students indicated that their choice of medical faculty was influenced by secondary school visits from physicians and/or medical students from the region or medical faculty, aimed at discussing the medical profession16. Students also indicated that career orientation forums helped them make their choice. As such, the medical faculty in Tours could further develop its communication strategy at forums and in school visits in order to increase its appeal to prospective students. Furthermore, coordinating university students from different majors to speak at local secondary schools could help prospective students form diverse friend groups and build community early on, increasing the draw of the city and medical faculty. Finally, students indicated that secondary school staff members who advised them were not well informed17. To help address this information gap, medical faculties could develop documents to promote medicine, while sharing the benefits of staying in the local region, including increased quality of life and the possibility to practise medicine with a more person-centred approach.
Measures to encourage students to return to their home region
Some students who relocate to neighbouring regions for school may later return to their region of origin to practise medicine – but not all. Once licensed, physicians tend to remain in the region in which they studied9,10. In 2018, 54.5% of those who had completed their medical residency between 2007 and 2016 were practising medicine in the same geographical area as that of their earlier schooling10. Moreover, a recent Swiss study found that, overall, only 13.7% of the medical students surveyed intended to practise in underserved areas, even though a higher proportion had studied at the semi-rural medical school in Lausanne than at the urban medical schools in Zurich and Geneva9. In France, medical students must do their practical training in the region in which their faculty is located. Consequently, when students move away from rural, underserved areas to attend medical school, that initial relocation ultimately leads to fewer physicians choosing to practise medicine in such areas. To address this issue and increase the probability that potential future physicians elect to establish their practices in such areas, medical students from Indre enrolled in the faculties in Limoges and Poitiers could be authorised to do their medical training in the underserved CVDL region.
Study limitations
Our quantitative study only used official academic data, analysed by two researchers. We limited the study to the medical faculties closest to Indre. We did not expand the study to all French medical schools because the number of Indre students attending more-distant faculties was expected to be extremely low, limiting statistical power and reducing the relevance to the regional policy context. Moreover, the small number of study participants reduced the significance of certain results.
Our qualitative study included all students from Indre studying medicine in Tours. For accessibility (and ethical reasons), we included only one student who had not passed their first year. Therefore, we do not know whether this student’s motivations for choosing their city of study were the same as those who passed. Additionally, we limited the qualitative study to students from Tours only, and therefore did not take into account factors that may have hindered or facilitated the choice of other faculties.
The triangulation increased the validity of the study results. In addition, the main investigator was from Indre, which facilitated exchanges with the students interviewed. Supplementing in-person focus groups with individual interviews also added to the strength of our findings. The focus groups allowed group participants to build off one another and delve deeper into perceptions, while the individual interviews enabled us to look more closely at personal and intimate factors.
Both quantitative and qualitative scientific criteria were met in the study.
Conclusion
A large proportion of potential future physicians from the rural and medically underserved county of Indre study in their home region at the medical faculty in Tours, rather than at faculties closer to Indre that are located in the neighbouring region. This relocation of students in turn contributes to the paucity of physicians in rural and underserved regions, like the CVDL region. Several factors associated with the choice of faculty were identified, including greater distances to a given faculty and lack of a transport network, both of which often result in increased costs and time wastage for rural students. The study also identified, however, mitigating factors that could encourage medical students from rural areas to remain in their home region for their studies: medical faculties could, for example, implement broader communication strategies at the secondary school level, and provide improved informational documents. Furthermore, many misconceptions seem to influence students’ choice of medical school. From secondary school onwards, informing prospective students and their communities about the realities of rural students’ success and courses of study can help combat misrepresentations and build confidence in aspiring medical students.
Acknowledgements
This article was supported by the French network of University Hospitals, HUGO (Hôpitaux Universitaires du Grand Ouest). We thank Clara Siegmund for the revision of the English version of the manuscript.
Funding
No funding was received for this study.
Conflicts of interest
The author reports there are no competing interests to declare.