Madam, primary care specialties such as paediatrics, general medicine, family and community medicine are losing their interest among Pakistani medical students. Although there has been an increased awareness of community based curriculum in local medical colleges, medical students of today prefer specialty training programmes over primary care specialties.¹ Multiple factors including social, cultural, economical and personal interest of the medical student are responsible for such a phenomenon.¹ These observations are consistent with the western world where an overall decline has been observed in primary care careers.²
It has been observed that the medical students associate prestige with the specialty careers i.e. the more competitive and advanced a specialty is, the more successful they are considered among their colleagues. In such an environment, students do not prefer to take up primary care careers when their colleagues are becoming surgeons and cardiologists. This indicates a lack of awareness of our medical students and graduates about specialty training in primary care careers. Medical students of today consistently demonstrate that financial rewards are much less in primary care careers in comparison to specialty careers, which to an extent, is true.
Several forces such as demands and rewards, lifestyle issues, uncertainty in health care environments and impact of faculty role models influence medical student career choices. Students who are inclined for primary care careers, consider an interest in underserved populations, variety of medical problems seen and relationships with patients as positive influences. For most of them salary and competitiveness are not significant.³
A study focused to determine career preferences of 232 final year Pakistani medical students in a private institution in Karachi showed internal medicine, surgery, paediatrics, family medicine, and community medicine chosen by 37%, 21%, 18%, 5%, and 4%, respectively. Overall students stated that personal interest was the most significant factor while selecting a career. More than one-third of the students strongly considered commitment to community, burden of disease and opportunities for contribution to society as influential factors for their career choices. Only 2.2% of all students preferred to practice in community based health centers while most of them (32.8%) preferred to work in private university teaching hospitals.¹
Areas of improvement at medical college level:
i. Family medicine interest groups can be initiated that links medical students to primary care physicians. These groups will increase awareness of challenging and rewarding career of family medicine.
ii. Students shall be made to understand that family medicine is a sub-specialty in which a doctor is trained to provide competent, cost effective, comprehensive care to all age group and gender (male, female, child, old age). Primary care physician shows a caring empathic and professional attitude maintain continuity of care apply age/gender appropriate screening, provide relevant health education and promote health and opportunistic care.
iii. An accelerated medical college curriculum designed specifically for primary-care can be established that reduces both the duration of training and expenses involved in obtaining medical education. Currently, medical colleges in Pakistan are moving towards a more problem based community oriented teaching curriculum.⁴ However, currently a few universities have such a curriculum in practice.⁵
iv. Community medicine is now also the part of most of the medical colleges in Pakistan. It is accepting popularity among medical students - relatively very little when compared to specialty medicine. Students must be encouraged about various career perspectives in community medicine in teaching, research and government organization sectors.
v. Rural clinical placements need to be encouraged to promote awareness of poor rural health status in Pakistan and health infrastructure comparing the urban phenomena. This will help increase recruitment of rural-interested students. These initiatives require greater support from the Government of Pakistan with some investment by the community, health and education developmental agencies.
An increasing number of recent graduates and physicians taking exams for Fellowship of the College of Physicians and Surgeons (FCPS) in Family Medicine has been seen. Additionally, the popularity of taking an exam for Membership of the Royal College of General Practitioners MRCGP (International) has been on a rise among our medical graduates⁶ But there is still a significant lack of knowledge among doctors about the primary care set up, primary care training programs.
An oversupply of specialists and a relative lack of primary care physicians is well-recognized in our country. There is a strong need to attend this issue in coming years because Pakistan immensely requires primary care health care providers at every level of its health care system. The perspective of our medical students towards primary care careers needs to be changed. And more importantly Pakistan Medical and Dental Council (PMDC) and College of Physicians and Surgeons of Pakistan (CPSP) needs to effectively address the nation\\\'s needs for primary care physicians.
 
Ranish Deedar-Ali-Khawaja,1 Firdous Jahan2
Medical College, Faculty of Health Sciences,1 Department of Family Medicine,2 Aga Khan University Hospital, Karachi, Pakistan.

1.Huda N, Yousuf S. Career preference of final year medical students of Ziauddin Medical University. Educ Health (Abingdon). 2006; 19: 345-53.
2.Pugno PA, McGaha AL, Schmittling GT, DeVilbiss AD, Ostergaard DJ. Results of the 2009 National Resident Matching Program: family medicine. Fam Med 2009; 41: 567-77.
3.Knox KE, Getzin A, Bergum A, McBride P, Rieselbach R, Friedsam D. Short report: factors that affect specialty choice and career plans of Wisconsin\\\'s medical students. WMJ 2008; 107: 369-73.
4.Jafarey NA. The changing shape of a medical college. J Pak Med Assoc 2005; 55:179-80.
5.Aga Khan University. PGME. Family Medicine Residency. (Online) (Cited 2011 Jul 28). Available from URL: http://www.aku.edu/pgme/pdfs/fammed.pdf.
6.Royal College of General Practitioners. MRCGP Int, Securing our future health: taking a long term view - The Walness report. (Online) (Cited 2011 Jul 28). Available from URL: http://www.rcgp.org.uk/default.aspx?page=2251.