As mentioned previously, this investigation is part of a larger international project, led by the third author, in which a qualitative case-based research strategy has been adopted.18 Our four cases are international medical academic centres in Canada, France, Spain, and the United Kingdom. Appropriate approvals by the Institutional Review Boards of the faculties of medicine involved in the study were obtained.

The cases were chosen purposefully and respond to both theoretical and practical concerns. The cases offer a variety of situational, organizational and societal contexts (maximum variation sampling18) regarding the topic under investigation. Practical concerns relate to the leader of the international research team, who holds a faculty position at a Canadian Department of Family Medicine, is of Spanish origin, and has established professional relationships with a number of family medicine researchers from the UK and France. In this paper, we report the results of the Spanish individual case of our international investigation.18

The Faculty of Medicine of this Spanish university graduates about 100 medical students every year, after 6 years of undergraduate medical training. By law, 80% of the curriculum content is shared with the rest of Spanish medical schools. Clerkships (rotations) start at the end of the 3rd academic year and take place in university hospitals. In contrast to Canada and France and similarly to UK, the Spanish Health Ministry is responsible for specialized training in medical residency programs. All graduate students must pass an annual national exam, i.e. Medical Internal Resident (MIR). According to their scores, graduate students will be able to choose their medical specialty. Family medicine offers the greatest number of residency positions – about 33–35% on average – and, in general, is a career path chosen by candidates with lower MIR scores. Indeed, family medicine comprises 4 years of residency, and training takes place in acute care hospitals, long-term care facilities, and community health centres.

The main method used for gathering appropriate data for the study was focus group interviewing. This technique is intended to obtain information regarding the attitudes, opinions, and behaviors of the participants around a particular topic of interest.19 Our intention was to engage medical students in in-depth discussions about their thoughts on the family medicine specialty (i.e. reputation) and the pros and cons of pursuing a career as a family physician (i.e. identification). In order to capture differences in thoughts, opinions, and attitudes related to the number of years of exposure to medical education centre discourses, focus groups were carried out with both 2nd and 6th year medical students. Their involvement in the study was requested through the Dean of the Faculty, who contacted student representatives and informed them about the study. The project was then publicised on the faculty students’ intranet. In addition, the first two authors introduced the project personally to students during lectures. Participation was on a voluntary basis. A total of 6 focus groups (i.e. 3 meetings per group of students) were conducted in May 2008 and May 2009. Focus groups consisted of 6–9 students. In total, 48 students participated in the discussions over the period, 27 out of a total of about 120 2nd year medical students and 21 out of a total of about 100 6th year medical students. Focus groups took place in university classrooms and lasted 2h on average. The first and second authors acted alternatively as group coordinator in all, and the third author participated in the last focus group. Notes about the discussion process and content were systematically written down by the authors during the sessions. Students signed a consent form prior to participation and, with their permission, all the focus groups were recorded and transcribed verbatim by research staff.

Data from focus groups were complemented by documentary analysis of a variety of documents pertinent to the purpose of the investigation, such as academic material, health ministry reports, and documents about family medicine residency.

Focus groups verbatim were subjected to discursive thematic analysis.20 First, researchers carefully read the corpus verbatim. Then, initial inductive coding, using the software package N-Vivo 7.0, was performed separately by the two first authors. The initial list of codes was discussed among the three authors and was followed by successive iterations until a definitive set of themes was created. These resulting themes, in combination with documentary analysis and field notes, supported further discussions among the three members of the research team, which ended up with the elaboration of interpretations on processes under examination.

We finally note that, in order to ensure maximum qualitative reliability and validity, a number of verification strategies21 were adopted while conducting the investigation. Thus, we first consider the congruence between the research question and our methodological decisions (methodological coherence). Then we carefully selected participants who could provide the best possible information regarding the topic of the study. Also data collection and analysis were iterative processes, emerging ideas being systematically confirmed with new data. Finally, the research team worked closely in developing the interpretations and concepts that best facilitate the understanding of the phenomenon under investigation.

Students describe the special patient–physician relationship established in family medicine as close, continuous in time, and focused on the whole person as distinctive of family medicine practice: “[family medicine] is the most holistic medicine; the physician knows people all their lives and follows them over time” (6th year medical student). Nevertheless, this emphasis on the human relationship is presented in opposition to medical technology. Even 2nd year medical students, for whom human relationships with patients are highly valued at the beginning of their medical training, suggest that over time, technological aspects of medical practice become more and more important. Indeed, for both 2nd and 6th year medical students, family medicine practice appears unattractive because of the absence of ‘technology’.

When students think of family physicians, they draw a very negative picture of the practice. For instance, they perceive that primary care facilities, at most, led to a ‘quasi-administrative’ medical practice, which mainly involves drug prescriptions and referrals to specialists. In addition, although students consider family medicine as a necessary medical field of practice, its content is superficial to them and is focused on issues perceived as simple and easy to diagnose or treat. Therefore, they view family medicine as a practice without intellectual challenges. Yet, 2nd year medical students stress that family medicine practice would be more appropriate as an end-of-career choice.

Another aspect that makes family medicine practice unattractive for medical students is that family physicians’ clientele mainly consists of the elderly. In particular, 2nd year medical students devalue the type of problems this sub-population present, as well as the associated overuse of medical resources. Although students also recognized that all medical specialties can become monotonous, they particularly come down on family medicine in this regard: “You know, for me, between seeing colds every day and seeing strokes every day, I prefer seeing strokes…” (2nd year medical student).

Family physicians represent, for medical students, the figure of the traditional doctor in terms of ‘broad’ practice—rather close to medical practice in rural settings. In addition, they highlight that, in our times, this figure is no longer present in other medical specialties: “[…] I think that what is missing nowadays in many specialties is the faith in a particular physician, that figure that, I think, certain family physicians still exhibit.” Having said this, they also think that family medicine has become more and more exceptional as the current conditions of practice have led family physicians to lose this role.

Students think that ‘personality’ is an important factor to take into account when selecting any medical specialty. Since the main feature of the practice of family medicine is the human relationship, a person choosing family medicine should be a tolerant, serene, and kind individual who enjoys human relationships. Most students understand these personal traits to be innate rather than learned; people without these qualities should not select this specialty as a career choice.

Students regard the family medicine discipline as encompassing more knowledge than other specialties. In fact, according to their views, a family physician has to acquire knowledge from all medical specialties, although shallower. Students are conscious that family medicine practice also involves knowledge about the community context within which a family physician operates, something that is particular to family medicine. However, particularly for some 6th year medical students, family medicine knowledge is viewed as opposite to specialty expertise: “It is true that in many specialties (family medicine, internal medicine, paediatrics), one has a larger knowledge base. Nevertheless, in our times the trend is towards specialization. You know about something, and you are the expert on that.” Sixth-year medical students perceive the current four-year residency program in family medicine, after six years of medical undergraduate studies as unnecessary.

Well-known roles of a family physician in the health care system are gatekeeper and care coordinator. All medical students acknowledge these functions, but while 2nd year students point out their importance, 6th year medical students attribute less value to them: “The specialty of family medicine mostly involves the distinction between serious and mild diseases, to decide whether or not it is necessary to urgently refer a patient to the hospital. This is the ability a family physician has to have: to be able to make the distinction between serious and mild problems” (6th year medical student).

Family medicine is viewed by students as less prestigious than other medical fields, surgery specialties being at the top: “There is a very clear hierarchy in medicine, and family medicine is at the bottom… Above lab but below medical specialties. Surgery has always had much prestige.” This low status is associated with lower salaries, less impressive facilities (community health centre vs. hospital), and a devalued type of knowledge needed to practice (general vs. specific medical knowledge). In addition, the technology used in current medical practice clearly places family medicine at the bottom of the heap: “One becomes a specialist when mastering techniques, apart from the specific theory in your field. The tools used by a family physician are, well, the stick, the stethoscope, and a lot of pens” (6th year medical student).

In addition, students believe that health care decision makers, as well as the population, fail to appreciate family medicine. For the former, this is associated with the high volume of administrative tasks that family physicians have to take on; for the latter, it is due both to family physician's accessibility outside hospital settings and the belief that it is not a specialty: “Only the fact that the family physician works in a community health centre, and one can go there for everything, it looks like family medicine practice is of less importance… People think that, when you finish your undergraduate studies, you can practice as a family physician; they are not aware it is a medical specialty” (2nd year medical student).

For 6th year medical students, the low professional prestige of family medicine practice appears to be concomitant with a lack of clear medical identity from an organicist point of view: “[…] Then, a lay person asks you ‘What type of physician are you? A family physician…? What do you cure?’ What you are going to answer…? A cardiologist treats heart diseases, a nephrologist treats kidney diseases… If you are a family physician, what do you treat…?” In contrast, for 2nd year medical students, the lack of professional recognition appears to be mostly related to the alleged limitations of family medicine practice in the specific Spanish context: “[Family physicians] in Spain are undervalued, but they play an important role in other countries… Here, they have no authority. From this everything goes down, because they do not have the social prestige they used to have…”.

When students are asked to explain the reasons underlying their career choice, they highlight the importance of family physicians as key players in the health care system while pointing out that family medicine is not an option for them. This happens either at the beginning or the end of their undergraduate training. Features discussed above become reasons for not choosing family medicine. Besides this, students’ experiences as health care system users have made them more conscious of professional problems experienced when practicing as a family physician.

Students recognize that they are not exposed to family medicine during their training, so they have little idea of what is really involved in being a family physician: “[…] Maybe this is one of the reasons why we are not attracted by family medicine: because actually we do not know what family medicine is. We finish our undergraduate studies and think that family medicine practice mostly consists of signing drug prescriptions, but this practice might have another content nobody has taught to us” (6th year medical student). In fact, it appears that few good experiences in later training years positively influence student attitudes with regard to family medicine practice: “[…] I always had that idea of the family physician… you arrive there, sit down, get a prescription, and leave. Now, I have known that there is another way, another manner to be a family physician. Yes, it is possible” (6th year medical student).

Quality of life appears to be critical when choosing a specialty, in particular for 6th year medical students. It concerns, for instance, the amount of tasks to be developed or the intensity and number of duties. Yet students consider quality of life specifically related to the city where they will pursue their residency, as well as the possibilities of work afterwards. Surprisingly, this quality of life criterion is considered only for specialties other than family medicine. In addition, it does not appear as a dimension that could support their choice for a family medicine career.

Related to this, one of the particular characteristics of the Spanish health care system is that physicians can work both in public and the private sectors. In this context, family physicians are not seen by the population as a specialty to consider when using private medicine because of the direct access to the rest of specialties available to them. Therefore, family medicine as a career choice appears unattractive to students because of the lower probability of generating additional income when practicing in the private sector.

Finally, all the students stress social pressure from family and relatives to become a specialist other than a family physician, which is viewed as a devalued ‘general’ practitioner: “Now people think that you will finish your studies and you will not be a family physician: you have to be a neurosurgeon and, if possible, in Barcelona… Less than that, you have spent six years of your life, and you have thrown them to the garbage” (2nd year medical student).

Indeed, such a negative influence also exists in the academic environment. According to the students, professors undermine family medicine when they give less importance to the clerkship in this field: “All of them say ‘You will have clerkships in gynecology, in psychiatry, and so on, and it will be great’. And in family medicine, they say it is not necessary; if you have that interest, you can go to a community health centre and ask a family physician if you can stay with him or her during the summer” (6th year medical student).