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Research Article

CPIRD: A successful Thai programme to produce clinically competent medical graduates

[version 1; peer review: 3 approved]
PUBLISHED 18 Jun 2015
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Abstract

The programme titled “Collaborative Project to Increase Production of Rural Doctors” (CPIRD) is a rural medical education project launched in 1994 in Thailand. This study aimed to compare the academic performances in medical study over five years and the pass rates in national medical license examinations (MLE) between students enrolled in CPIRD and two other tracks.
Grade point average (GPA) over five years and results of MLEs for four cohorts of students enrolled from 2003 to 2006 in Prince of Songkla University were collected from the registration department. A longitudinal analysis was used to compare the GPA over time for medical students enrolled in CPIRD and those from the national and direct regional tracks through generalized estimating equation (GEE) models. The MLE pass rates were compared using chi-square and fisher's exact tests as appropriate.
Female students dominated the CPIRD group. GPAs in the first three years in the CPIRD group were significantly lower than those of the other two groups, this disparity narrowed in the fourth and fifth years. For step one of the MLE (basic sciences), cohorts 2003 and 2006 of the CPIRD group had a significantly lower pass rate than the other two groups but there was no significant difference in cohort 2004 and cohort 2005. The CPIRD step two and three MLE pass rates were not significantly different from the national track in all cohorts and lower than the direct track only for step two in cohort 2003 and step three in cohort 2006. The step three pass rate of the CPIRD group in cohort 2004 was significantly higher than the other two tracks.
Despite weaker competency in basic science, the CPIRD was successful in forming clinical competency.

Keywords

rural, grade point average (GPA), license examination, clinical competency, CPIRD

Introduction

In 2010, the World Health Organization (WHO) recommended sixteen interventions to improve health force retention in rural areas. These included education strategies to recruit students of rural origin, locating medical schools outside major cities, bringing students to rural communities and matching curricula with rural health needs1.

Thailand is well known for its emphasis on rural health development2. Since 1972, all medical graduates must spend at least three years of compulsory service in rural areas. In the same year, the medical school of Prince of Songkla University (PSU) was established in southern Thailand, the most remote part of the country, in order to strengthen the local capacity in medical services. From the initial establishment period, PSU had two kinds of enrollment methods. The first is a national entrance examination (hereafter abbreviated to national track), which allows students from all over Thailand to sit the examination for a chance to study3. For geographic and socio-cultural reasons, this medical school in the south has not been a popular choice for candidates from high schools in other regions of the country. The local medical school compensates for this by using a second method of recruitment called the direct admission programme (hereafter abbreviated to direct track). This method recruits students from the southern regional provinces exclusively based on an institution-specific examinations4, which take place a few months before the announcement of the national track examinations. This earlier announcement makes the programme popular to local candidates because they get admitted earlier and naturally have no difficulties acclimatizing to the different culture in the south of the country4. For decades, direct track students are known to have a better average academic performance than the national track students46.

To further ensure adequate supply of medical doctors to the rural region, especially the potential insurgent areas of southern Thailand, a third track was introduced in 2003. Under the “Collaborative Project to Increase Production of Rural Doctors” (CPIRD), rural students from the region were recruited with a longer period (six years) of obligatory service in specific areas where there were a shortage of doctors. Later, the “One District One Doctor (ODOD)” programme was brought in as the fourth track4. ODOD students were not included in this analysis as the programme was considered too new.

Students of all tracks complete the first three years of medical study together. The national track and direct track students take their following three years of clinical study in university hospitals and CPIRD students in accredited regional and provincial hospitals of the Ministry of Public Health (MOPH)4. Grade Point Average (GPA) was used to assess the student’s performance in all years and was based on the same standard set assessed by the regional medical university.

Since 2002, the Thai Medical Council has required all medical students who matriculated from the year of 2003 to pass all three parts of the Medical Licensing Examination (MLE) before getting their medical licenses7. The three steps of the MLE are taken at the end of the third, the fifth and sixth year, respectively. The first step of the MLE focuses on basic science knowledge, the second step on clinical science knowledge, and the third step on both knowledge and clinical skills evaluation. This is to standardize the basic competencies of graduate physicians and to assure health consumers have a standard health care service8.

While the idea of recruiting medical students from rural areas and training them at hospitals close to the rural population is highly advocated based on the findings that it had positive implication on rural retention912, but competency of graduates from such programmes have rarely been investigated.

The main objective of this study was therefore to compare the academic performance of the students recruited from different tracks as reflected by their GPA over five years and the pass rate at each step of the MLE.

Methods

Study site

Southern Thailand, where this study was conducted, is a region of the country with the highest levels of heterogeneity of the population and continuous ethnic unrest13.

Study design

A retrospective cohort study based on the records of the performance of all medical students enrolled in 2003 to 2006 was used.

Dataset and ethical clearance

The data was retrieved from the student registry of Faculty of Medicine, PSU. All personal identification was encrypted. The study protocol was approved by the Ethics Committee of the Faculty of Medicine, PSU (Permit No: 56-317-18-5).

Data analysis for academic performance of GPAs and MLE results

All data analyses were performed using R version 3.1.3 (http://www.r-project.org) and Epicalc package 2.15.1.0 (http://CRAN.R-project.org/package=epicalc). A longitudinal data analysis was used to compare the GPA over five years for medical students enrolled in three different programmes through generalized estimating equation (GEE) models. The results for the pass rates in MLE were analyzed using chi-square and fisher's exact test as appropriate. Statistical significance was set at 5%.

Results

No.GenderAdmissionNLE1NLE2NLE3yr1yr2yr3yr4yr5Cohort
1femaleCPIRDPPP3.043.133.333.393.282003
2femaleDirect TrackPPF3.433.373.453.43.432003
3maleNational TrackPPP3.713.613.643.373.442003
4maleDirect TrackPPF3.293.493.522.943.182003
5maleCPIRDFFP3.543.513.483.543.492003
6femaleNational TrackPPF3.053.143.253.143.212003
7maleDirect TrackPPF3.233.273.373.163.332003
8femaleNational TrackPPF3.443.373.483.493.512003
9femaleCPIRDFPP3.153.093.153.153.172003
10maleCPIRDPPP3.483.693.733.723.742003
11maleNational TrackPPP2.873.153.253.13.142003
12femaleDirect TrackPPP3.953.833.863.613.82003
13maleDirect TrackPPP3.453.273.343.293.362003
14maleDirect TrackPPP3.253.443.53.643.542003
15femaleDirect TrackPPP3.573.513.53.293.352003
16femaleCPIRDPPF3.043.033.213.183.282003
17maleDirect TrackPPP3.233.133.323.193.212003
18maleDirect TrackPPP3.373.363.443.163.182003
19maleNational TrackPPP3.022.933.143.033.012003
20femaleCPIRDPPF2.82.782.932.762.942003
21femaleNational TrackPPP3.73.663.693.473.452003
22femaleNational TrackFFP3.073.093.183.133.062003
23femaleDirect TrackPPP3.663.593.693.433.552003
24femaleNational TrackPPP3.113.313.53.23.292003
25maleNational TrackPPF3.163.253.222.943.072003
26maleNational TrackPPP2.72.833.143.493.252003
27maleDirect TrackPPP2.842.782.892.712.722003
28maleNational TrackPPF3.263.113.162.613.022003
29maleDirect TrackPPP3.613.653.683.313.372003
30maleNational TrackPPP3.613.553.673.313.432003
31femaleNational TrackPPP3.823.653.723.363.492003
32femaleNational TrackFPP3.333.383.383.293.362003
33maleDirect TrackPPP3.53.443.433.073.072003
34maleDirect TrackPPF3.333.273.272.933.12003
35maleDirect TrackPPP3.663.673.733.513.552003
36maleDirect TrackPPP43.933.953.593.722003
37maleNational TrackFPP2.983.013.132.62.912003
38maleCPIRDFFP2.572.672.872.772.682003
39maleDirect TrackPPP3.443.533.613.643.452003
40femaleNational TrackPPP2.882.953.053.23.012003
41maleDirect TrackPPP3.543.53.563.263.342003
42maleCPIRDPPP3.263.23.23.113.112003
43femaleDirect TrackPPP3.113.143.142.893.072003
44maleNational TrackPPP3.333.33.363.373.372003
45maleNational TrackPPP3.83.763.653.143.252003
46maleDirect TrackPPF3.563.463.53.163.152003
47femaleDirect TrackPPP3.753.73.73.293.492003
48femaleCPIRDPPP3.263.463.593.653.732003
49maleNational TrackPPP3.263.253.382.83.062003
50femaleDirect TrackPPP3.843.653.683.43.662003
51maleDirect TrackPPP3.032.993.152.992.952003
52femaleNational TrackPPF3.383.413.63.413.562003
53maleCPIRDFPF2.552.662.822.952.972003
54femaleNational TrackPPP3.363.123.182.962.972003
55maleDirect TrackPPP3.63.443.473.033.372003
56femaleDirect TrackPPP3.413.373.473.133.172003
57maleNational TrackPPP2.982.923.053.0332003
58femaleCPIRDFPP2.842.832.973.063.132003
59femaleCPIRDPPP3.133.173.293.123.262003
60maleDirect TrackPPP3.333.453.442.693.12003
61femaleNational TrackPPP3.553.453.483.443.462003
62maleDirect TrackPPP2.983.123.163.163.142003
63maleDirect TrackPPP3.273.293.393.263.362003
64femaleDirect TrackPPP3.33.383.483.373.492003
65femaleDirect TrackPPP3.363.23.353.13.222003
66femaleDirect TrackPPP3.853.823.823.763.832003
67femaleNational TrackPPP3.913.83.823.033.432003
68femaleCPIRDPPF2.92.973.13.243.272003
69femaleCPIRDPPP3.293.333.393.373.482003
70femaleNational TrackPPP3.273.273.322.973.132003
72maleDirect TrackPPP3.33.283.373.363.472003
73femaleNational TrackPPP3.333.243.372.973.282003
74femaleDirect TrackPPP3.653.513.573.013.252003
75femaleNational TrackPPP3.183.133.212.863.052003
76femaleNational TrackPPP3.333.233.263.213.232003
77femaleNational TrackPPF2.862.873.043.072.912003
78femaleNational TrackPPP3.043.223.3133.252003
79maleDirect TrackPPP2.9133.092.963.032003
80femaleDirect TrackPPP3.313.373.483.073.242003
81femaleNational TrackPPP3.443.373.433.243.432003
82femaleNational TrackPPP2.973.153.293.273.22003
83femaleDirect TrackPPP3.223.473.623.63.552003
84femaleDirect TrackPPP3.593.623.673.53.472003
85femaleDirect TrackPPP3.533.663.743.363.542003
86femaleDirect TrackPPP3.643.523.63.433.522003
87femaleDirect TrackPPP3.43.533.563.513.542003
88maleNational TrackPPP2.882.973.112.72.92003
89femaleDirect TrackPPP3.53.413.483.273.392003
90maleNational TrackPPP3.453.33.382.812.982003
91femaleCPIRDPPP3.673.513.553.523.632003
92maleNational TrackPPP2.923.053.142.843.092003
93maleDirect TrackPPP3.393.293.332.963.042003
94maleDirect TrackPPP3.343.223.312.873.052003
95femaleDirect TrackPPP3.693.633.723.53.62003
96maleDirect TrackPPP3.583.573.543.313.372003
97femaleNational TrackPPP3.313.293.413.133.372003
98maleDirect TrackPPP3.963.943.953.433.642003
99femaleNational TrackPPP3.222.943.052.742.892003
100maleDirect TrackPPP3.163.263.463.433.52003
This is a portion of the data; to view all the data, please download the file.
Dataset 1.Medical students academic performance and MLE results for four cohorts.
Admission indicates three different tracks including CPIRD, Direct track and National track; NLE indicates National License Examination; Yr1–Yr5 indicates First to Fifth year GPA.

Table 1 compares baseline characteristics of the students from the three tracks. Female students had a larger percentage in the CPIRD group compared with direct track and national track students. The number of students in the CPIRD increased from 19 in 2003 to 72 in 2006, whereas students from other two programmes remained stable.

Table 1. Student characteristics by the three enrollment programmes.

CharacteristicCPIRD
N=171
Direct Track
(N=208)
National Track
(N=252)
Total
(N=631)
Sex***
Female119 (69.6)98 (47.1)148 (58.7)365(57.8)
Male52 (30.4)110 (52.9)104 (41.3)266(42.2)
Year of Enrollment***
200319 (11.1)57 (27.4)48 (19.0)124(19.7)
200427 (15.8)48 (23.1)87 (34.5)162(25.7)
200553 (31.0)45 (21.6)66 (26.2)164(26.0)
200672 (42.1)58 (27.9)51 (20.2)181(28.6)

Numbers in bracket are percent unless otherwise stated. *** p-value <0.001, ** p-value <0.01, * p-value <0.05

CPIRD: Collaborative Project to Increase Production of Rural Doctors

Figure 1 shows how the GPA changed over five years of time. In the first three years, the mean GPA of students from three enrollment programmes was significantly different. Students from the direct track performed best. Followed by national track students. Students from CPIRD had lower GPAs than the others. However, the GPAs of the last two years from the three groups tended to converge. Table 2 summarizes results of the GEE with ‘year’ as a continuous variable and ‘track’ as a categorical variable. Their interaction was statistically significant; therefore the interaction terms were included in the final model. Non-significant positive coefficient for the main effect ‘year’ indicates that the tendency of increment of average performance scores of the reference group (CPIRD) was not significant. The other two main effects ‘direct track’ and ‘national track’ were both significantly higher than that of CPIRD in the reference year (first year). Both interaction coefficients are negative indicating that over the years, the difference between the two tracks and CPIRD was reduced significantly.

1edd650a-7112-4ed3-86f4-2baf50520493_figure1.gif

Figure 1. GPA over five years by three different programmes.

Table 2. Results of the generalized estimating equations analysis on the relationship between GPA and enrollment programmes.

Coef.SEp-Value
Year of study0.0090.0090.320
Enrollment programmes (ref: CPIRD)
    Direct Track0.4820.037<0.001
    National Track0.2720.036<0.001
Interaction terms
    Year: Direct Track
-0.0650.011<0.001
    Year: National Track-0.0490.010<0.001

Coef: Coefficient; SE: Standard error

Table 3 shows the association between enrollment programmes and results of the MLE for the four cohorts of students enrolled from 2003 to 2006. In step one of the MLE, CPIRD students were weaker than students in the other tracks for cohort 2003 and cohort 2006. In the remaining two MLE steps, CPIRD students’ pass rate was not statistically different from that of the national track students. Direct track students had a higher pass rate only in step two of the MLE in cohort 2003 and step three of the MLE in cohort 2006 compared with CPIRD students. In fact, CPIRD had the highest pass rate in step three of the MLE in cohort 2004.

Table 3. Association between enrollment programmes and results of medical license examinations stratified by cohorts.

Step 1Step 2Step 3
Fail
(N)
Pass
(N)
Fail
(N)
Pass
(N)
Fail
(N)
Pass
(N)
Cohort 2003P-valueP-valueP-value
CPIRD811316514
Direct Track057<0.01057<0.055520.12
National Track543<0.012460.269390.72
Cohort 2004
CPIRD522027225
Direct Track5430.5204811533<0.05
National Track22650.645820.463152<0.01
Cohort 2005
CPIRD1934350251
Direct Track8370.081440.732431
National Track18480.421650.4610560.08
Cohort 2006
CPIRD26463691652
Direct Track553<0.012561553<0.05
National Track744<0.0524917420.31

N: the number of students … indicates referent group

Discussion

CPIRD students had a lower GPA on average in pre-clinical years and lower pass rates of the MLE in basic science parts than students of the other two tracks. Their GPA tended to catch up with their peers in clinical years and the pass rate of the MLE in the clinical parts were more or less comparable with their peers.

The selection process of medical students in Thailand could explain the fact that CPIRD students had the lowest GPA in the first three years. Direct track students were those students in southern Thailand with good academic records who sat for the entrance examination at Prince of Songkla University. National track students selected Prince of Songkla University as an alternative choice because of its geographic distance from Bangkok. CPIRD students were those unable to get through by direct track examination and finally selected by the CPIRD route. As a result, direct track students had the highest academic performance in high school, followed by national track students, while CPIRD students were weakest4. The first three years was the pre-medical and pre-clinical study. It has been shown in other medical schools that the pre-clinical stage including second and third year, had a high correlation with the first year pre-medical stage3. The lower performance in these first three years for CPIRD students reflected their weaker background and performance in science and thus these students need support to reduce the dropout rate14,15.

A previous study suggested that CPIRD students had more opportunities to practice in regional hospitals and thus displayed more capable clinical skills in the fourth and fifth year3. In addition, the successful application of problem-based learning (PBL) in clinical study reduced the difference in academic performance and fostered a self-motivated study atmosphere among medical students16.

The findings that the CPIRD students could perform as good as those normal tracks of students in step two and step three MLE has important implications. Good clinical education does not need to be confined to a conventional teaching hospital. Decentralized medical education requires enhancement of existing hospitals. The byproducts of this strengthening include increasing service capacity and quality of health services to local populations, which reduces the inequality problems due to geographical barriers. Other studies also reported that Thai CPIRD doctors were more likely to stay longer in rural areas than their peers17,18. Most low and middle-income countries (LMICs) have a serious rural–urban disparity of health service and the clinical education is mostly based in university teaching hospitals in large cities19. The experience from the Thai CPIRD should therefore be carefully reviewed for potential adaptation to other low LMICs.

Limitations

This was a retrospective study; other factors influencing academic performance could not be determined and taken into account. Examination questions and behavioral performance of the students may differ with time and place. However, the MLE were rigorously standardized national examinations and comparisons across student groups were made mainly within the same cohort. Thus, this limitation has been minimized.

Conclusion

The CPIRD was successful in creating clinically competent doctors despite lower GPAs in the pre-clinical year.

Data availability

F1000Research: Dataset 1. Medical students academic performance and MLE results for four cohorts, 10.5256/f1000research.6638.d4993020

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Yanhua Y, Chongsuvivatwong V, Sriplung H and Rueanarong C. CPIRD: A successful Thai programme to produce clinically competent medical graduates [version 1; peer review: 3 approved]. F1000Research 2015, 4:158 (https://doi.org/10.12688/f1000research.6638.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
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PUBLISHED 18 Jun 2015
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Reviewer Report 20 Jul 2015
Shama Virani, Department of Environmental Health Sciences, University of Michigan, Ann Arbor, MI, USA 
Katie Rentschler, Department of Environmental Health Sciences, University of Michigan, Ann Arbor, MI, USA 
Approved
VIEWS 15
CPIRD: A successful Thai programme to produce clinically competent medical graduates
 
This research describes differences in GPA and MLE scores of medical students that enter the program through three different mechanisms. These mechanisms seem to have an impact on initial scores, ... Continue reading
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Virani S and Rentschler K. Reviewer Report For: CPIRD: A successful Thai programme to produce clinically competent medical graduates [version 1; peer review: 3 approved]. F1000Research 2015, 4:158 (https://doi.org/10.5256/f1000research.7131.r9407)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 09 Jul 2015
Weerasak Putthasri, International Health Policy Programme (IHPP), Ministry of Public Health, Nonthaburi, Thailand 
Approved
VIEWS 19
This manuscript generates concrete evidence to support the WHO 2010 recommendation focusing on the graduates' competencies. To disseminate this academic proof is important and useful for both national and global audiences. However, there are some minor points could be improved ... Continue reading
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Putthasri W. Reviewer Report For: CPIRD: A successful Thai programme to produce clinically competent medical graduates [version 1; peer review: 3 approved]. F1000Research 2015, 4:158 (https://doi.org/10.5256/f1000research.7131.r9408)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 01 Jul 2015
Supasit Pannarunothai, Centre for Health Equity Monitoring, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand 
Approved
VIEWS 23
The paper is concise and clear, providing evidence that medical students from Collaborative Project to Increase Production of Rural Doctors (CPIRD) tract finally watched up with medical students from local direct admission and national admission.

There are some points to improve ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Pannarunothai S. Reviewer Report For: CPIRD: A successful Thai programme to produce clinically competent medical graduates [version 1; peer review: 3 approved]. F1000Research 2015, 4:158 (https://doi.org/10.5256/f1000research.7131.r9104)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

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Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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