8
2007; 29: e227–e234 WEB PAPER Demographics and motives of medical school applicants in Croatia LIVIA PULJAK 1 , JASMINKA BRNJAS KRALJEVIC 2 , VESNA BARAC LATAS 3 & DAMIR SAPUNAR 4 1 University of Split Medical School, Croatia, 2 University of Zagreb Medical School, Croatia, 3 University of Rijeka School of Medicine, Croatia, 4 University of Split Medical School, Croatia Abstract Background: According to data regarding number of physicians per 100 000 inhabitants, Croatia is below the European average. Under those circumstances, more attention needs to be devoted to Croatian medical schools and their applicants. Aims: This study sought to investigate admission trends of applicants to Croatian medical schools, analyse their demographics and motives for medical school enrollment. Methods: We collected admissions data of applicants to Croatian medical schools from 1979 to 2006. Motives for and against medical school enrollment were assessed in a survey of 1146 applicants (response rate 84%, 966/1146) and 98 final-year medical students (response rate 82%, 80/98) during July 2006. Results: The number of applicants to Croatian medical schools had been declining until 1995, it was lowest during the 1991–1995 war in Croatia and it has been rising from 1996 onwards. Majority of applicants in 2006/07 were women (69%). Most of the applicants attended general high schools. The applicants profess choosing a certain medical school for its quality and reputation, but we showed that they actually chose the closest school. The main motives for medical school enrollment were humanitarian and scientific, while main reasons against were perceived difficulty and financial burden. We showed that final-year medical students profess significantly lower interest in science and that they are less interested in altruistic aspects of medicine. Instead, great number of them would reconsider choosing medical studies again because of the corruption in medicine, fear of mistakes and uncertainty of employment. Conclusions: Following the admission trends in medical schools on a national level gives insight into the prospects of health care. Analysis of motives for and against medical school enrollment can provide guidelines for their improvement. Unless Croatia and other countries in transition devote more attention to recruitment, education and retention of physicians, the prospects of our healthcare are poor. Introduction A high quality medical care and patient safety depends on the availability of a sufficient number of physicians. According to data regarding number of physicians per 100,000 inhabi- tants, Croatia is below the average for majority of European countries (Forgacs 2002; World Health Organization 2007). Taking into account that medical studies last six years and specialist training takes on average another four years, even with immediate actions at least ten years would be necessary to reach the desired standards (Rulebook on the specialization of healthcare providers 2003; Rulebook on minimum require- ments regarding premises; medical-technical equipment and staff for performance of healthcare activity 2004). Under the circumstances, special attention should be given to both recruitment and retention of physicians. Recruitment policies can only be effective when there is a pool of appropriately qualified candidates to recruit from (New Zealand Ministry of Health 2006). As for the retention, although a very low emigration rate has been recorded over the past few years, the possibility that emigration may increase after Croatia joins the EU is alarming (Kolcic et al. 2005). Therefore, Croatia and other countries where the cost of medical training for the majority of its medical students is sustained by government funds, should find more reliable ways of retaining their health professionals. Practice points . This is a 27-year retrospective study (1979-2006) of applicants to Croatian medical schools. . War negatively affects the medical school applicant pool. . Final-year medicals students in Croatia would not choose medical school again due to financial reasons and they are less motivated by science and altruistic motives when compared to medical school applicants. . Actions are needed to prevent loss of interest in science during medical school. . Promotional campaigns of medical schools in Croatia should be redesigned. Correspondence: Livia Puljak, MD, Department of Anatomy, Histology and Embryology, University of Split Medical School, Soltanska 2, 21 000 Split, Croatia. Tel: þ385-21-557-807; fax: þ385-21-557-811; email: [email protected] ISSN 0142–159X print/ISSN 1466–187X online/07/080227–8 ß 2007 Informa UK Ltd. e227 DOI: 10.1080/01421590701551714 Med Teach Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/28/14 For personal use only.

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Page 1: Demographics and motives of medical school applicants in Croatia

2007; 29: e227–e234

WEB PAPER

Demographics and motives of medical schoolapplicants in Croatia

LIVIA PULJAK1, JASMINKA BRNJAS KRALJEVIC2, VESNA BARAC LATAS3 & DAMIR SAPUNAR4

1University of Split Medical School, Croatia, 2University of Zagreb Medical School, Croatia, 3University of RijekaSchool of Medicine, Croatia, 4University of Split Medical School, Croatia

Abstract

Background: According to data regarding number of physicians per 100 000 inhabitants, Croatia is below the European average.

Under those circumstances, more attention needs to be devoted to Croatian medical schools and their applicants.

Aims: This study sought to investigate admission trends of applicants to Croatian medical schools, analyse their demographics

and motives for medical school enrollment.

Methods: We collected admissions data of applicants to Croatian medical schools from 1979 to 2006. Motives for and against

medical school enrollment were assessed in a survey of 1146 applicants (response rate 84%, 966/1146) and 98 final-year medical

students (response rate 82%, 80/98) during July 2006.

Results: The number of applicants to Croatian medical schools had been declining until 1995, it was lowest during the 1991–1995

war in Croatia and it has been rising from 1996 onwards. Majority of applicants in 2006/07 were women (69%).

Most of the applicants attended general high schools. The applicants profess choosing a certain medical school for its quality

and reputation, but we showed that they actually chose the closest school. The main motives for medical school enrollment were

humanitarian and scientific, while main reasons against were perceived difficulty and financial burden. We showed that final-year

medical students profess significantly lower interest in science and that they are less interested in altruistic aspects of medicine.

Instead, great number of them would reconsider choosing medical studies again because of the corruption in medicine,

fear of mistakes and uncertainty of employment.

Conclusions: Following the admission trends in medical schools on a national level gives insight into the prospects of health care.

Analysis of motives for and against medical school enrollment can provide guidelines for their improvement. Unless Croatia

and other countries in transition devote more attention to recruitment, education and retention of physicians, the prospects

of our healthcare are poor.

Introduction

A high quality medical care and patient safety depends on the

availability of a sufficient number of physicians. According

to data regarding number of physicians per 100,000 inhabi-

tants, Croatia is below the average for majority of European

countries (Forgacs 2002; World Health Organization 2007).

Taking into account that medical studies last six years and

specialist training takes on average another four years, even

with immediate actions at least ten years would be necessary

to reach the desired standards (Rulebook on the specialization

of healthcare providers 2003; Rulebook on minimum require-

ments regarding premises; medical-technical equipment and

staff for performance of healthcare activity 2004).

Under the circumstances, special attention should be

given to both recruitment and retention of physicians.

Recruitment policies can only be effective when there

is a pool of appropriately qualified candidates to recruit from

(New Zealand Ministry of Health 2006). As for the retention,

although a very low emigration rate has been recorded

over the past few years, the possibility that emigration

may increase after Croatia joins the EU is alarming

(Kolcic et al. 2005). Therefore, Croatia and other countries

where the cost of medical training for the majority

of its medical students is sustained by government funds,

should find more reliable ways of retaining their health

professionals.

Practice points

. This is a 27-year retrospective study (1979-2006)

of applicants to Croatian medical schools.

. War negatively affects the medical school applicant

pool.

. Final-year medicals students in Croatia would not

choose medical school again due to financial reasons

and they are less motivated by science and altruistic

motives when compared to medical school applicants.

. Actions are needed to prevent loss of interest in science

during medical school.

. Promotional campaigns of medical schools in Croatia

should be redesigned.

Correspondence: Livia Puljak, MD, Department of Anatomy, Histology and Embryology, University of Split Medical School, Soltanska 2, 21 000

Split, Croatia. Tel: þ385-21-557-807; fax: þ385-21-557-811; email: [email protected]

ISSN 0142–159X print/ISSN 1466–187X online/07/080227–8 � 2007 Informa UK Ltd. e227DOI: 10.1080/01421590701551714

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Page 2: Demographics and motives of medical school applicants in Croatia

Imminent lack of physicians invariably turns public

attention to medical schools, which are expected to produce

enough medical doctors. Students’ motives for and against

applying to medical schools become an important factor that

existing medical schools should be aware of when trying

to recruit the best possible candidates. Knowing these motives

may be important for attracting the best students that will

be the real participants and partners in a process

of revitalization of academic medicine (Clark 2005).

The purpose of this study was the analysis of admission

trends of applicants to Croatian medical schools, analysis

of their demographics and motives for and against studying

medicine.

There are no data published about the historical dynamics

of medical school applicants in Croatia. Knowing the trends

in the number of prospective students is necessary for

evidence-based discussion and planning future admissions.

Thus we searched archives of all four medical schools in

Croatia to generate insight into the admission trends over

the last 27 years, as there is no systematic follow-up of such

data. We also wanted to see whether 1991–1995 war in Croatia

had any effect on the applicant pool.

The archives of University of Split Medical School were

searched for high school grades and admission test scores

of all of its 4186 applicants in the period 1979–2006 in order

to investigate quality of applicants. This school was chosen

for detailed admissions’ analysis because it had these data

readily available.

Finally, a survey was administered to medical school

applicants in all four medical schools to find out their

demographics and motives for and against choosing a medical

school. The same questionnaire was administered to the final-

year medical students to examine their motives for and against

choosing a medical school in a hypothetical situation

of enrolling the medical school again.

Methods

Archival data

We searched archives of all four Croatian medical schools to

find out the number of applicants. Medical school in Zagreb

was founded in 1917, the one in Rijeka in 1955, while medical

schools in Osijek and Split began enrolling students in the first

year of studies in 1979. Our data search encompassed 27 years

during the 1979–2006 period. The archives of medical schools

in Zagreb and Osijek lack complete data on the number of

admission test candidates for the whole period of 1979–2006;

there is no legal requirement for them to safeguard these data

and that could be an explanation why their archives are

incomplete.

Archives of the medical school in Split were also searched

for high school grade averages and admission test results of all

the 4186 admission test candidates that the School has had

from 1979 to 2005. Since the schools changed the maximum

number of points a candidate can have at the admission test

several times, we calculated success percentage for each

candidate, depending on the scoring system that was used

for the respective admission year.

Survey

Design

We analysed applicants’ motives associated with their decision

to apply for medical school. Applicants in all four Croatian

medical schools were surveyed during admissions in July

of 2006. We also surveyed sixth-year medical students in the

University of Rijeka School of Medicine to see whether their

motives for or against medical school will be comparable

to those of the applicants.

Setting

Physicians’ education in Croatia is based on a six-year

undergraduate curriculum offered in four medical schools

at Universities of Osijek, Rijeka, Split and Zagreb. In the

academic year of 2006/2007 these schools enrolled a total

of 567 medical students in the first year of studies; 75 in Osijek,

135 in Rijeka, 75 in Split and 282 in Zagreb. The number

of applicants to Croatian medical schools exceeds the

number of available places for students; therefore a limited

number of students is admitted each year and this number

is decided by the government. The selection of medical

students is based on both high school grade averages and the

admission test score to yield final ranking and identify the best

candidates. All four Croatian medical schools were in full

operation during the 1991–1995 war in Croatia (Marusic 1994;

Marusic & Marusic 2004).

Subjects

Medical school applicants received questionnaire in the

Student Offices during the admissions in July of 2006.

Sixth-year medical students in Rijeka also received a

questionnaire in the Student Office in July of 2006.

A self-administered questionnaire for medical school

applicants consisted of 8 questions about city where they

live, gender, average grade in high school, reasons for

choosing a specific Croatian medical school, their motives

for and against enrollment to a medical school.

A self-administered questionnaire for sixth-year medical

students consisted of questions about motives for or

against studying medicine, if they had a chance to choose

again.

The questionnaire included 16 motives in favor of medical

school enrollment and 13 reasons against it; we chose motives

for which we believed might be important to prospective

students. Each of these motives was rated on a 5-point Likert

scale (agree strongly to disagree strongly). For data presenta-

tion we grouped ‘agree strongly’ and ‘agree somewhat’ into

‘agree’, while ‘disagree strongly and disagree somewhat’ were

grouped into ‘disagree’.

Grades: Croatian education system is using grades 1–5,

where 1 (insufficient) is not a passing grade, while 2

(sufficient), 3 (good), 4 (very good) and 5 (excellent) are

passing grades.

L. Puljak et al.

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Analysis

Every questionnaire was marked with a serial number

and responses entered in a spreadsheet (Excel 2004,

Microsoft, USA). Archives’ data were also entered in the

Excel spreadsheet. Data were analysed using Pivot

Table Reports. The internal consistency was examined using

Cronbach’s alpha.

Results

Archives’ results

The data of the Croatian medical school applicants from 1979

to 2006 showed a continuous downward trend towards an all-

time low in 1995 (Figure 1). From 1996 to 2006 the number

of students applying to Croatian medical schools has had

an upward swing, and in some schools it has reached its initial

levels (Figure 1). The lowest number of applicants was

observed during the 1991–1995 war in Croatia.

Survey results

In all four Croatian medical schools there were total of 1146

prospective students at the admissions in July of 2006.

The applicants’ survey response rate was 95% in Osijek

(141/148), 96% in Rijeka (171/179), 92% in Split (122/132)

and 77% in Zagreb (532/687). The overall response rate

among applicants was 84% (966/1146).

Among applicants who responded to our survey, women

were in majority (69% women vs. 31% men). The ratio

between women and men respondents was similar in all four

medical schools. The dominance of female respondents

ranged from 67.1% at Zagreb to 74.3% at Osijek medical

school (Table 1).

Most of the applicants came from two types of high schools:

general high schools or vocational high schools for education

of middle-level medical personnel (nurses, physiotherapy,

laboratory and pharmaceutical technicians).

When high school success was evaluated, medical school

in Zagreb had the highest number of applicants with excellent

grades (72%), and Rijeka the lowest (58%). Rijeka also had

the most applicants with grades below 4.

We also investigated which medical school was the most

popular. For this, medical school applicants were asked

to rank all four Croatian medical schools according to their

preferences. For majority (60.9%), the first choice was the

oldest medical school in Croatian capital of Zagreb, followed

by the medical school in Rijeka as a second (42.4%) school

of choice.

Choice of a medical school was mostly based on the quality

of the school (85%) and its reputation (38%) (Table 2).

Only 3.8% of respondents considered promotional campaigns

of the schools an important factor when making a choice in

which school to study.

Although quality and reputation of the medical school

were the most cited factors for choosing a certain

medical school, when we compared in which city they live

and what school they chose, it turned out that majority of our

respondents chose geographically closest school, i.e. the

school in the domicile or a neighboring county (Figure 2).

This, however, does not apply to Zagreb Medical School,

which had a number of applicants from all over Croatia

(Figure 2D).

Analysis of applicants’ reasons for entering medicine found

five main factors: ‘‘love for medical profession’’, ‘‘humanity of

medicine’’, ‘‘interest in human body structure and function’’,

‘‘interest in science’’ and ‘‘opportunity to work with people’’

(Table 3).

The greatest concerns of applicants regarding entering

medical school were: ‘‘life-long learning’’, it is difficult to enroll

in medical school’’, ‘‘medical studies are too long’’, ‘‘medical

studies are too expensive’’, and ‘‘need for residency after

finishing medical school’’ (Table 4). Cronbach’s alpha was 0.89

in the applicants’ survey of motives.

To investigate whether motives for and against medical

studies differ by the end of the medical school, we surveyed

sixth-year medical students in one of the Croatian medical

schools. The survey was performed in Rijeka and had a

response rate of 82% (80/98). Cronbach’s alpha was 0.88 in

this survey.

The main reasons of final-year medical students for

enrolling medicine again would be ‘‘love for medical profes-

sion’’, ‘‘humanity of medicine’’, ‘‘interest in human body and

structure’’, ‘‘always wanted to be a doctor’’, and ‘‘opportunity

to work with people’’ (Table 3). The main reasons for not

choosing medical school the second time around would be:

‘‘uncertainty of employment’’, ‘‘difficult financial situation in

healthcare’’, ‘‘medical studies are too expensive’’ and

Figure 1. Number of admission test candidates in all four

medical schools in Croatia, 1979–2006. Each line represents

one medical school, as indicated by a legend.

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

8n (%) 9n (%) Total n

Osijek 36 (25.7) 104 (74.3) 140

Rijeka 51 (29.8) 120 (70.2) 171

Split 33 (27.0) 89 (73.0) 122

Zagreb 175 (32.9) 357 (67.1) 532

Total 295 (30.6) 670 (69.4) 965

Medical school admission trends in Croatia

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Page 4: Demographics and motives of medical school applicants in Croatia

‘‘corruption in healthcare, residency placement and career

advancement’’ (Table 4).

Discussion

This study shows that the number of applications to Croatian

medical schools has been declining in the past, hitting the

bottom during the 1991–1995 war in Croatia. After the war,

however, the number of admission test candidates rose again.

To our best knowledge, this is the first study to analyse

the number of medical school applicants on a national level

in such a long period of time.

Challenging labor market conditions, difficulties in

obtaining desired specialization after graduation (Kolcic et al.

2005), institutional failings (Vrhovac 2002; Chalmers 2006)

and deeply embedded perception of Croatian medicine as

a corrupt (GFK Group 2006) close-knit community could have

contributed to declining interest in Croatian medical schools

among prospective students. These problems are not exclusive

for Croatia as other transitional countries are experiencing

the same (Albreht & Klazinga 2002; Balabanova & McKee

2002; Fister & McKee 2005; Jakusovaite et al. 2005).

Small applicant pool during 1991–1995 war in Croatia can

be noted as another important negative consequence of war.

Education is not the priority in times of war and even medical

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

Osijek Rijeka Split Zagreb Total

Quality of the studies 84.3 79.5 82.8 88.9 85.8

Reputation of a specific medical school 32.9 28.7 32.0 42.9 37.5

Cost of studying 22.1 19.3 17.2 5.1 11.6

Friends’ recommendations 16.4 21.6 6.6 8.0 11.5

Quality of the student life 8.6 11.1 9.8 8.8 9.3

Promotional campaign of the medical school 3.6 5.3 9.8 2.0 3.8

Figure 2. The counties are primary territorial and administrative subdivisions of Croatia. The maps depict the counties that were

the major source of 2006/07 applicants in the medical schools in (A) Osijek, (B) Rijeka, (C) Split and (D) Zagreb.

L. Puljak et al.

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Page 5: Demographics and motives of medical school applicants in Croatia

students that were studying during that time obtained

significantly lower grades in 5 major courses during the war

than before or after it (Bergovec et al. 2002).

Following the war not much has changed in the way

medical studies are performed, but the market conditions have

changed (Chen & Mastilica 1998) and now medical profes-

sionals are entitled to a private practice. One can assume that

the entrepreneurial promise of prosperity may be among the

reasons why high school students are choosing the medical

school in greater numbers again, but our survey results show

the opposite.

The motivations and other factors used by medical students

in making their career choices for specific medical specialties

have been looked in a number of studies (Mahoney et al. 2004;

Wright et al. 2004; Chang et al. 2006), but there are very few

studies that assess the generic factors which make the

medicine itself of interest to potential medical students

(McManus et al. 2006). Therefore, we assessed what would

be the pro and contra motives for medical school enrollment.

The most important motives for studying medicine turned out

to be idealistic and altruistic, while the least important were

those that could be associated with prestige, money and social

status of a physician.

Students are able to apply to Croatian universities after

graduating from the four-year high school, which is usually

at the age of 18. It could be that in this early age

prospective medical students are less interested in monetary

and ego-related benefits of medical profession. That is why

we did another survey of final-year medical students, which

showed that their motives to choose medical school again

would be the same as applicants’. However, when one

looks into these motives quantitatively, final-year students

choose these motives 20–30% less frequently. That would

mean that some of their noble motives fade away by the

end of the studies. This is in contrast to the report by Prka

et al. who found no evidence that medical students become

less altruistic and more materialistic over the course of their

medical education (Prka et al. 2002). Interest in science,

for example, is half less important motive for final-year

students than for the applicants. This is particularly

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

Medical school applicants Final-year medical students

Motives Agree Neutral Disagree Agree Neutral Disagree

Love for medical profession 95.2 3.8 1.0 92.4 6.3 1.3

Humanity of medicine 96.4 2.6 1.0 82.3 11.4 6.3

Interest in human body structure and function 94.1 4.5 1.5 84.2 7.9 7.9

Interest in science 93.3 4.7 2.0 63.1 19.7 17.1

An opportunity to work/interact with people 91.2 5.6 3.2 76.0 10.7 13.3

MD’s degree is valid in the whole world 87.9 6.7 5.4 45.5 11.7 42.9

I always wanted to be a physician 77.3 12.5 10.2 74.9 9.2 15.8

I want to test myself in a competitive field 70.8 17.0 12.3 43.4 35.5 21.1

Role models in medical profession 51.9 16.9 31.2 23.7 6.6 69.7

Personal or family experience with diseases 39.9 13.7 46.5 34.6 6.7 58.7

Possibility of high earnings 53.0 14.4 32.7 23.7 17.1 59.2

Power associated with physician’s social status 42.8 17.0 40.2 23.7 14.5 61.9

Privileged position in a society 37.1 16.6 46.3 26.3 13.2 60.5

Family tradition 22.7 4.8 72.6 15.4 7.7 76.9

Family or parents’ wish 17.7 6.2 76.1 5.2 5.3 89.4

Table 4. Reasons against entering medical school among medical school applicants and final-year medical students surveyed in July of2006 (in percent).

Medical school applicants Final-year medical students

Reasons Agree Neutral Disagree Agree Neutral Disagree

Life-long learning 51.1 13.6 35.3 52 13.3 34.7

It is difficult to enroll in medical school 65.3 13.0 21.6 31.1 9.5 59.4

Medical school is too long 61.9 12.4 25.7 65.3 6.7 28.0

Medical school is expensive 59.5 19.8 20.8 76.6 7.8 15.6

Need for residency after finishing school 50.1 14.7 35.2 57.5 10.9 31.5

Corruption in health care, residency placement and career advancement 41.2 24.7 34.2 69.7 13.2 17.1

Fear of mistakes and malpractice law suits 41.1 20.0 39.0 60.5 19.7 19.7

Difficult financial situation in health care 39.1 23.7 37.3 75.3 11.7 13

Uncertainty of employment 30.8 19.1 50.1 81.3 8 10.7

No time for family and private life 32.7 17.1 50.2 56.6 13.2 30.3

Fear of contracting an infection from patients 27.3 20.3 52.4 21.6 16.2 62.1

My grades are not good enough 24.9 11.1 63.9 9.3 6.7 84

Medical school admission trends in Croatia

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Page 6: Demographics and motives of medical school applicants in Croatia

disturbing and worrying regarding their prospects for later

academic involvement.

It is argued that altruistic motives are important for most

people, but there are also demand characteristics which make

respondents less likely to rate highly social desirable items

as ‘‘thought it would be glamorous/good life-style/status’’,

or ‘‘job security’’, and even less so for ‘‘becoming rich’’,

or ‘‘having power over people’’, however true they may be

(McManus et al. 2006). Self-administered questionnaires are

used with the assumption that they will be honestly answered

by the respondents because they are anonymous, and their

validity and reliability has been proven in numerous studies

(Alexiou et al. 1969; Shibata et al. 2002). Therefore, we have

no reason to doubt that the majority of our respondents indeed

embark on medical studies out of altruistic motives.

Some argue that becoming a physician today requires more

than altruism, it requires courage, managerial skills, adminis-

trative knowledge and no errors (Brase 2001), but that may

be a realization that comes later in life.

As for the reasons against choosing medical school, top

three applicants’ concerns are that it is too difficult, too long

and too expensive. Common doctors’ complaints about

malpractice lawsuits, uncertainty of employment and lack

of time for personal life (Chong et al. 2004; Bolanowski

2005; Katz et al. 2005) seem to be the last concerns of the

medical school applicants. Major reasons against choosing

medicine again, were pretty different for final-year students;

being in medicine for six years they are all too well aware

of difficult financial situation in Croatian healthcare

and hardships in obtaining a desired residency

(or internship). For final-year students, the most important

reasons against choosing again a medical school were

money-related.

Family wish apparently has little or no influence on

choosing medical school. Also, the applicants are less

concerned about the expensiveness of the studying, difficulty

of finding a job and mistakes, probably because they have

not been immersed in the healthcare prior to the admissions.

The professed expensiveness of a medical school in Croatia

is due to the several facts: (1) it lasts longer then any other

university studies, which postpones getting a job and earning,

(2) the tuition, although paid by only one third of students, is

more expensive than in other schools, and (3) the books for

medical students are expensive.

When we compared the ‘‘for and against motives’’

of enrollment of the applicants in the year 2006 versus those

of the final year medical students, the sample in the first case

is 1146 prospective students applying as candidates to all four

medical schools, whereas the sample of the final year students

is 98 students of only the Rijeka Medical School. It is unlikely

that the asymmetric samples in number and students’ origin

could affect the results, especially when these results are given

in percentages. However, one should have this asymmetry

in mind when analysing the results.

Our survey revealed additional information about Croatian

medical school applicants. The majority of applicants were

women, which is in line with multiple reports on so-called

feminization of medicine (Notzer & Brown 1995; Paik 2000;

Thomas 2000).

The majority of the respondents came from general high

schools, which provide broad general knowledge and good

preparation for university. Specialized high schools for

middle-level medical staff, the second most important source

of future physicians, educate their pupils to become

nurses or technicians that can start working right after

graduation.

The most popular medical school in Croatia turned out

to be the one in Zagreb, the capital of Croatia. With just under

one million inhabitants, Zagreb is home for about one fifth of

Croatian population and it is often viewed as a city with

the best career prospects and the most attractive social scene.

Zagreb medical school is also the biggest of four Croatian

medical schools and it is possible that for some students size

does matter.

Quality and reputation were cited as the most important

reasons for choosing a certain medical school, but when

we matched the city where our respondents live with their

choice of medical school it turned out that they chose

the closest one. This is easily explained with lower costs

of studying, as it is customary in Croatian society for adult

children to live with their families.

Only 3.8% of respondents considered promotional

campaigns of the medical schools to be important for their

decision to study medicine. Therefore, we can conclude that

promotional efforts of Croatian medical schools, introduced

several years ago, unfortunately did not achieve much to sway

undecided students towards medical studies.

Knowing all this, our medical schools should become

actively engaged in their students’ career after graduation.

One-year obligatory internship that all Croatian physicians

need to do before taking a licensing exam should be

guaranteed for every student as soon as they graduate,

in agreement with the hospitals. Currently, young physicians

can apply for these internships several times a year; they are

often without a proper mentor and more often than not unpaid

for the whole year.

After the internship is over, physicians can take state exam

and became licensed. The majority of them will then work for

years as temporary substitutes for family physicians.

Specialization of choice is hard to get as there are very few

openings available and selection criteria depend completely

upon the whim of an institution. Although it is not a

straightforward task and it includes numerous bureaucratic

obstacles, young physicians can pay the specialization

themselves, which means they will pay certain amount of

money to an institution to train them and they will not have

any salary during those training years. However, the institution

where they are specializing is not obliged to hire them

afterwards.

Because of the lack of doctors, there is a danger of trying

to fill the gap at the cost of quality of doctors. Introduction

of high quality state exam would prevent import of inappro-

priately qualified work power as it was proposed long ago

(Marusic & Sapunar 1996).

The motives of medical school applicants seem to be right,

but the reasons why final-year medical students wouldn’t

choose medical school again should be a warning to Croatian

medical institutions. In a system where meritocracy is still in its

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infancy, when years of studying and hard work cannot ensure

a decent job for physicians, their emigration sounds like

something we should realistically expect.

Conclusions

The applicant pool in Croatian medical schools was

affected the most by the 1991–1995 war in Croatia. In the

last ten years (1996–2006) the number of applicants

to Croatian medical schools has been increasing and

the applicants profess humanitarian and scientific motives

for choosing medical studies. The final-year medical students,

however, would reconsider enrolling the medical school

if they had a chance to do it again due to a difficulty in

finding a desired job, corruption and financial crisis in Croatian

health care.

Investment in health produced some of the richest

returns in not only social but also economic development

(Commission on Macroeconomics and Health 2001) and

therefore Croatia needs to address the imminent shortage

of physicians. An idealism of medical school applicants will

fade away and, if nothing changes soon, they will take their

knowledge and skills abroad as soon as they get a chance.

This may well be true for other countries in transition

that borne majority of costs of physicians’ education.

Therefore, Croatia and other countries in transition should

devote more attention to recruitment and retention of

physicians.

Acknowledgements

We appreciate help of Josip Baric, Boris Matutinovic, Nada

Kecman, Iva Kapovic, Josipa Rados and Katja Radonic, the

Student Office staff in Croatian medical schools, for adminis-

tering questionnaires to the admission test candidates and help

with the archives.

Thanks to Ana Marusic, Ivica Grkovic, Carlos David

Esteban Nieto, Katarina Vukojevic and Sanja Lovric Kojundzic

for critical reading of the manuscript.

Notes on contributors

LIVIA PULJAK, MD is a Researcher and Instructor at the Department

of Anatomy, Histology and Embryology, University of Split Medical School.

She is a published author of multiple articles and has editorial experiences

with electronic and print media. Her research interests include medical

education and neuropathic pain.

JASMINKA BRNJAS KRALJEVIC, BSC. Phys, PhD. Phys, is the Professor

at the Department of Physics and Biophysics, University of Zagreb

Medical School. She authored multiple textbooks and research

articles. Her research interests include magnetic resonance spectro-

scopy and imaging, spectroscopy of human lipoproteins and medical

education.

VESNA BARAC LATAS, MD, PhD is the Assistant Professor at the

Department of Physiology and Immunology, University of Rijeka

School of Medicine. She is a Vice Dean for Education for the School

and she authored multiple authors. Her research interests include

central nervous system demyelination in multiple sclerosis and medical

education.

DAMIR SAPUNAR, MD, PhD is the Professor at the Department

of Department of Anatomy, Histology and Embryology, University of

Split Medical School. He had been a Vice Dean for Education at the School.

He authored many articles on medical education. His research interests

include neuropathic pain and medical education.

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