INTRODUCTION
The reorganization of health care since the creation of the Brazilian Unified Health System (SUS, Sistema Único de Saúde) has been guided by a proposal to expand and strengthen Primary Health Care (PHC). This process was a specific one in Brazil, with the implementation of multiprofessional health teams consisting of general practitioner, a nurse, a nursing technician and community health agents, who are responsible for the comprehensive care of a certain population, a model called the ‘Family Health Strategy’ ( FHS), which has been consolidated as the main organization strategy for the Brazilian PHC1.
The scarcity of physicians to work in the FHS teams is considered one of the main challenges for the consolidation of PHC in Brazil2)-(4. In addition to the scarcity of physicians, these professionals are often poorly geographically distributed, concentrated in cities with larger populations, located in more economically developed regions4. However, this is not a situation unique to Brazil, as other countries also have difficulties in providing physicians within the scope of PHC5)-(8.
Some countries have taken steps to increase training vacancies for general practitioners, such as Canada, which doubled training vacancies in family medicine between 2000 and 2013, as part of an effort to increase access to primary health care. However, in most countries of the Organization for Economic Cooperation and Development (OECD), specialist physicians earn more than general practitioners, thus financially encouraging medical doctors to become specialists9.
In Brazil, several intervention proposals for the training of human resources in health have been recognized as promoting a new social mission of medical schools in undergraduate and postgraduate courses10. In 2014, the Ministry of Education implemented the new National Curriculum Guidelines (NCG) for medical courses, which reinforce the need for training medical professionals aimed at the population’s needs and recommend the student’s inclusion in health service networks throughout the undergraduate course. Aiming at a more appropriate inclusion of students in PHC, it was necessary to establish a closer relationship between medical schools and health services11, and the federal government started to adopt, from that moment onward, policies that promoted the teaching-service integration, introducing programs to encourage curricular changes12.
Other important initiatives in relation to the training and provision of physicians for Brazil were the ‘More Doctors Program’ (PMM, Programa Mais Médicos) and the incentive to the increase of vacancies in the Family and Community Medicine Residency (FCMR) program. The PMM was created in 2013, aiming at increasing the density of physicians in Brazil based on three main actions: increase in the number of vacancies in undergraduate courses, increase in the number of vacancies in medical residency programs in the priority areas for the Unified Health System (SUS) and provision of physicians in Primary Care on the outskirts of large cities and in the countryside of the states13. A recent study that assessed the PMM impact recorded a substantial increase in the provision of physicians to work in PHC, which contributed to reducing the number of municipalities with a scarcity of these professionals14.
Despite the initiatives to provide human resources in priority areas for health systems, there is an inconsistency regarding the need for medical training and the individual career choices of medical professionals, not only in Brazil, but in several countries15, indicating that, while seeking to redirect health systems, some countries show a decline in the choice of careers linked to PHC16.
In recent years, the opening of new medical schools and the prominence achieved by the PMM defined a new scenario, with an appreciation of the space in primary care practices. In this sense, the present study aimed to identify the prevalence and factors associated with the interest of medical students in pursuing a professional career in Primary Health Care.
METHODS
This is a cross-sectional, analytical study, carried out with the participation of medical students attending the last two years of undergraduate medical school at four Higher Education Institutions (HEIs) in the state of Minas Gerais, Brazil. The state has 46 medical schools and, considering the logistical difficulty of a sampling approach to achieve the necessary representativeness among all institutions, a convenience sampling was chosen by selecting four HEIs, one in the capital and three in the countryside of the state, with interviews of all students regularly enrolled in the 5th or 6th years in these selected HEIs. The data collection instrument consisted of a self-administered questionnaire, created by the authors and based on the study objectives, with questions that included the sociodemographic and economic profile of the students, interaction with PHC throughout the course, career intention and intention to attend the FCMR program. After creating the instrument, face and content validation was carried out by six experts in the area, in addition to a pilot study with 5th-year students from another medical school in the state of Minas Gerais, not included in the study.
The questionnaire was applied as hard copy and in a virtual environment. The in-person contact with the students was carried out by scientific initiation (undergraduate) students, after the project was presented to the HEI by the researchers. The data collection team was specially trained and periodically visited the selected HEIs, identifying and approaching students attending the last years of the undergraduate course. Several visits were made to the HEIs, aiming to reach a larger number of students. After three visits to each class or sub-class, the students who did not agree to participate or who were not found were considered losses, regardless of the alleged reason.
Aiming to increase the number of participants, a list of the students’ electronic contacts was requested from the HEIs and the data collection instrument, in digital format, was sent by e-mail to the students, with a brief explanation about the research. All students aged 18 or over, regularly enrolled in the 5th or 6th years of the surveyed medical schools were considered eligible for the study. Exclusion criteria were not defined.
All data were submitted to statistical treatment using IBM SPSS software, version 22.0. A descriptive statistical analysis was performed by calculating the proportions and the bivariate analysis using Pearson’s chi-square test. The variables shown to be statistically associated with the assessed outcome (“interest in pursuing a professional career in PHC”) up to the level of 20% (p ≤0.20) were assessed jointly through logistic regression. A significance level of 5% (p <0.05) was considered for the final model, and the Odds Ratio (OR values) and their respective 95% Confidence Intervals (95% CI) were included.
The present study was approved by the Research Ethics Committee involving human beings at Universidade Estadual de Montes Claros/MG (Unimontes), in compliance with Resolution N. 466/2012 of the National Health Council, Ministry of Health. The anonymity of all information provided by the students was guaranteed and all participants signed the Free and Informed Consent Form. The research project was approved by the Research Ethics Committee of one of the institutions participating in the study under Opinion N. 2,426,972.
RESULTS
A total of 524 students participated in the study, which constitutes a response rate of 45% of the elective population for the study. Most respondents were females, aged between 21 and 25 years, single, with self-reported white ethnicity. More than half attended high school in private schools and informed the parents had attended HEIs. These and other characteristics of the group are shown in Table 1.
Variable | n | % |
---|---|---|
Age (years) | ||
≤ 25 | 349 | 66.7 |
> 25 | 174 | 33.3 |
Gender | ||
Female | 298 | 57.0 |
Male | 225 | 43.0 |
Marital status | ||
Single | 480 | 91.8 |
Married / Common-law marriage | 40 | 7.6 |
Skin color/ethnicity (self-reported) | ||
White | 277 | 54.7 |
Yellow | 8 | 1.6 |
Brown | 194 | 38.3 |
Black | 27 | 5.3 |
Type of high school attended | ||
Public | 108 | 20.7 |
Private | 415 | 79.3 |
Paternal level of schooling | ||
Illiterate | 1 | 0.2 |
Elementary School | 79 | 15.2 |
High School | 169 | 32.6 |
Higher Education or Postgraduate School | 270 | 52.0 |
Maternal level of schooling | ||
Elementary School | 32 | 6.1 |
High School | 121 | 23.1 |
Higher education or Postgraduate School | 370 | 70.8 |
Has a previous degree in another course | ||
Yes | 54 | 10.3 |
No | 469 | 89.7 |
Type of HEI* | ||
Public | 321 | 61.3 |
Private | 202 | 38.7 |
HEI located in the state countryside/capital | ||
Countryside | 355 | 67.9 |
Capital | 168 | 32.1 |
Admission modality in the HEI | ||
Prouni** | 35 | 6.7 |
ENEM***/ Entrance Exam | 476 | 91.5 |
Internal transfer | 9 | 1.7 |
(*) HEI: Higher Education Institution; (**) Prouni: Programa Universidade para Todos (University for All Program); (***) ENEM: Exame Nacional do Ensino Médio (National High School Exam).
There was a greater number of participants among the students attending the sixth year of the medical course, comprising the 11th and 12th course semesters. Just over half (55.5%) of the interviewees reported having already chosen the area they wanted to specialize in, after completing the course, and of these, 58.3% reported having greater aptitude for clinical specialties (Table 2). The majority (78.5%) of the interviewees reported having had a positive experience in PHC during the undergraduate course. More than half of the students participated in at least one academic league, with only 4.8% (n = 14) of these participating in academic leagues related to FCM. As for PHC being a work option after graduation, even if temporary, 79.3% of the participants reported that they intended to work in PHC after graduation, even without attending the FCMR program (Table 2).
Variable | n | % |
---|---|---|
Undergraduate course semester | ||
9th | 93 | 18,0 |
10th | 87 | 16,8 |
11th | 221 | 42,7 |
12th | 117 | 22,6 |
Have you chosen which specialty you want to study? | ||
Yes | 289 | 55,5 |
No | 232 | 44,5 |
Do you have a greater aptitude for clinical or surgical specialties? | ||
Clinical | 304 | 58,3 |
Surgical | 164 | 31,4 |
I do not know | 54 | 10,3 |
PHC** experience during undergraduate school | ||
Excellent/Good | 408 | 78,5 |
Regular | 92 | 17,7 |
Poor/Very Bad | 20 | 3,8 |
Do/Did you participate in academic leagues? | ||
Yes | 290 | 55,6 |
No | 232 | 44,4 |
Interest in FCMR* after graduation | ||
Yes | 52 | 10,0 |
No | 363 | 69,8 |
I do not know | 105 | 20,2 |
Interested in pursuing a career in PHC? | ||
Yes | 136 | 26,3 |
No | 382 | 73,7 |
Interest in working at PHC after graduation | ||
Yes | 402 | 79,3 |
No | 105 | 20,7 |
(*) FCMR: Family and Community Medicine Residency; (**) PHC: Primary Health Care.
The main determinant factor for working in PHC immediately after graduation was the fact that PHC was a temporary work option until they entered medical residency in another area (78.6%). This factor was followed by the availability of vacancies in the job market (47.3%) and having successful experiences in PHC during undergraduate school, with the latter showing less influential power, with 29.9% of respondents. Of the 20.7% that did not consider PHC as a career option after graduation, 66.7% reported that the main reason for this choice was the option of attending residency in a particular specialty without working in PHC before starting residency. The other most often mentioned determinant factors regarding the choice of not working in PHC after graduation were the lack of a career plan (39%) and poor remuneration (33.3%) (Table 3).
Determinant Factors related to the Choice | (n) | (%)* |
---|---|---|
To work in PHC** after graduation (n=402) | ||
Work option until approved in a medical residency in another area | 316 | 78.6 |
Job market has great availability of vacancies | 190 | 47.3 |
Successful experience in PHC in the curriculum | 120 | 29.9 |
Good remuneration | 107 | 26.6 |
Possibility of longitudinal care | 99 | 24.6 |
Possibility of being hired as public servant | 92 | 22.9 |
A good teacher/tutor during the PHC experience | 82 | 20.4 |
Commitment to SUS*** | 76 | 18.9 |
I had successful PHC experience outside the curriculum | 32 | 8.0 |
Others | 10 | 2.5 |
For NOT working in PHC after graduation (n=105) | ||
I intend to attend residency in a specific specialty without working in PHC before the residency | 70 | 66.7 |
Lack of a career plan | 41 | 39.0 |
Poor remuneration | 35 | 33.3 |
I had an unsuccessful PHC experience in the curriculum | 24 | 22.9 |
Workload and number of working hours (40 hours, 5 days a week) | 19 | 18.1 |
Preference for eventual and not longitudinal clinical care | 19 | 18.1 |
Little social acknowledgement | 12 | 11.4 |
Work overload | 11 | 10.4 |
Preference for not attending people from different age ranges | 9 | 8.6 |
Job market with few vacancies | 5 | 4.8 |
Others | 11 | 10.4 |
(*) The sum of the percentages is greater than 100% because respondents could give more than one answer; (**) PHC: Primary Health Care; (***) SUS: Sistema Único de Saúde (Unified Health System).
When asked about their intentions to attend residency in FCM, 10% of students reported that they intended to attend this residency after graduating and 20.2% reported that they still did not know whether they intended to attend this residency or not. About the intention of pursuing a professional career in PHC, 26.3% of the respondents answered affirmatively.
Table 4 shows the results of the bivariate analyses of the factors associated with the intention to pursue a career in PHC. After the multiple analysis, it was recorded that the variables female gender, having a previous university degree, entering the HEI through the Programa Universidade para Todos (University for All Program) (Prouni), greater aptitude for clinical specialties and positive experience in PHC during undergraduate school remained associated with a greater chance of pursuing a career in PHC. The variables age, marital status and maternal education were not significantly associated with pursuing a career in PHC.
Variable | Interest in PHC career | p value¹ | p value2 | OR (95%CI) * | |||
---|---|---|---|---|---|---|---|
Yes | No | ||||||
n | % | n | % | ||||
Gender | <0.001 | <0.001 | |||||
Female | 100 | 33.7 | 197 | 66.3 | 2.30 (1.45 - 3.65) | ||
Male | 36 | 16.3 | 185 | 83.7 | 1.00 | ||
Admission modality | 0.101 | 0.027 | |||||
Prouni | 13 | 37.1 | 22 | 62.9 | 2.40 (1.11 - 5.20) | ||
Enem/ Entrance Exam | 126 | 24.6 | 335 | 75.4 | 1.00 | ||
Has previous graduation | 0.003 | 0.010 | |||||
Yes | 23 | 43.4 | 30 | 56.6 | 2.51 (1.25 - 5.04) | ||
No | 113 | 24.3 | 352 | 75.7 | 1.00 | ||
Has greater aptitude for specialties: | <0.001 | <0.001 | |||||
Clinical | 109 | 36.1 | 193 | 63.9 | 2.95 (1.81 - 4.80) | ||
Surgical / I do not know | 27 | 12.5 | 189 | 87.5 | 1.00 | ||
PHC experience during graduation | 0.003 | 0.017 | |||||
Excellent/Good | 119 | 29.3 | 287 | 70.7 | 2.07 (1.14 - 3.77) | ||
Regular/Poor/Very bad | 17 | 15.2 | 95 | 84.8 | 1.00 | ||
Age (years) | 0.019 | 0.404 | |||||
> 25 | 56 | 32.7 | 115 | 67.3 | - | ||
≤ 25 | 80 | 23.1 | 266 | 76.9 | - | ||
Marital status | 0.092 | 0.919 | |||||
Married / Common-law marriage | 15 | 37.5 | 25 | 62.5 | - | ||
Not married | 121 | 25.3 | 357 | 74.7 | - | ||
Maternal schooling | 0.056 | 0.941 | |||||
Up to Elementary School | 13 | 40.6 | 19 | 59.4 | - | ||
High School or higher | 123 | 25.3 | 363 | 74.7 | - |
(1) Crude analysis (chi-square test); (2) Adjusted analysis (chi-square test); (*) OR: Odds Ratio; 95% CI: Confidence Interval.
DISCUSSION
The percentage of undergraduate students interested in pursuing a career in PHC observed in this study is close to that found in several countries, and in some, such as the United States (USA), Germany and France, the intention to work in PHC is even lower. A study carried out in 2019 in the USA showed that, in the country, only 14% of medical students entering the National Residency Program attend the residency in primary care17. In Germany, in 2015, 12% of the interviewed undergraduate students stated that they had chosen a career as General Practitioners (GP) in PHC18. In France, another study showed that about 20% of students chose a career in PHC after graduation19. In Pakistan, the result was similar to the present study: in a survey of 1,400 final-year medical students, in eight medical schools, it was verified that 24.1% of the respondents reported an interest in working in PHC20.
Although some countries, such as Canada, show an upward trend in the choice for FCMR, with an increase in demand that reached 38.5% of the students who selected Family Medicine as the first choice21, all of them show evidence of a lack of alignment between the needs of the health system and the students’ intentions22. In the United Kingdom, for instance, the Department of Health estimated that, in 2013, it would be necessary for 50% of graduates to become GPs when, in 2009, only 28% of undergraduate students said they intended to work in PHC23.
In Brazil, a 2016 study at Universidade de São Paulo showed that 47% of students in the sixth year of a medical course intended to work in the PHC of SUS12. These results have already been shown to be well above those found in another 2011 study, in which only 20% of the undergraduate students had the possibility of working with PHC after graduating24. A 2012 study of over 1,000 Brazilian medical students and physicians showed that 26% of the respondents chose specialties in the PHC group; however, only 1.2% chose family medicine as their first option for specialization25.
Although the challenge of achieving an adequate PHC workforce has been reported in several countries, the magnitude and complexity of SUS, which is the largest universal health system in the world, means that there are no internationally comparable data or countries similar to Brazil. Nevertheless, these international studies show a similarity with the result of this investigation, with similar percentages of professionals choosing PHC as a career, which is lower than what is needed by the health systems of each country. Several initiatives have been developed to address this problem. At the end of 2014, the Family Medicine for America’s Health (FMAHealth) Workforce Education and Development Tactic Team (WEDTT) was created in the United States, aiming at increasing the percentage of US medical students choosing family medicine from 12% to 25% by the year 2030, to meet the country’s needs. The WEDTT has developed a package of ideas for change based on its theory of what will direct the achievement of “25 x 2030”, which has led to specific projects completed by WEDTT and key collaborators. Among the WEDTT recommendations are policies to improve the social responsibility of medical schools in the USA, strategies focused on the wishes of the younger generations and early involvement of young individuals with their careers26.
In Brazil, several initiatives have been implemented to encourage medical training with a PHC profile, the most recent being the PMM which, in addition to the emergency provision of doctors, sought to stimulate the training of PHC professionals13. From 2013 to 2016, with the start of the PMM, an increase of more than 1,700 FCMR program vacancies was observed; however, unfilled vacancies remained at around 70%27. This unfilled vacancy rate has remained constant since 201128. Even among the professionals who work at the PMM, many are not interested in pursuing a career in PHC, as evidenced by a study carried out in 2015 at the four largest public universities in Minas Gerais, with newly admitted residents in all areas of medical residency. The aforementioned study identified that, of the residents who had already worked in PHC (most of them in PHC incentive programs such as PROVAB and PMM), only 3.7% had pursuing a career in PHC as motivation when entering these programs. The same study showed that 36% of the interviewed residents considered choosing some specialty in primary care during undergraduate school, and 61% of them chose this area after graduating29. The data show there is still a fragility in the mechanisms to encourage the choice and fixation of medical professionals in PHC. It may be necessary for these incentives to incorporate career planning strategies, adaptation of structures and distance support mechanisms for these professionals30),(31.
The association between the intention to pursue a career in PHC and the female gender is in line with other Brazilian and international studies18),(29),(32. A study carried out in Minas Gerais showed that women are 2.9 times more likely to choose a career in PHC29, a result very similar to that found by this investigation. Some studies also identified factors that interfere with the choice of specialty by women, among which the hours of work, quality of life and time to dedicate to the family are highlighted, in addition to focus on public health, doctor-patient relationship and personal satisfaction33),(34.
Admission to the university through Prouni, a federal government program that offers partial or full scholarships in private HEIs for low-income students, was also identified as an associated factor. No other studies that evaluated or identified the same association were found; however, some studies indicate that family income is associated with the choice of medical specialization34. A study carried out in 2016 at the Universidade Estadual de Campinas (Unicamp), shortly after changing the entrance exam process, with the implementation of a bonus policy for students from public schools and self-declared black ethnicity, points to a change in the choice of career and medical specialty, with an increase in the intention to work only in SUS after graduation35. The authors infer that this association may also be related to the perception of a debt that must be paid back to society, due to the fact that they attended graduation through a scholarship granted by the government. However, more specific studies are required for this association to be evaluated. Based on this association, it can also be inferred that policies for access to higher education, such as the Prouni, can also contribute to the training of professionals for the SUS demands.
Students with a previous degree showed greater interest in pursuing a career in PHC, but the reasons that lead graduates to start a new undergraduate course in medicine are little investigated. Among the factors that may influence the search for this new training, and which come close to the choice of pursuing a career in PHC, are the search for greater personal and professional appreciation, not achieved in the first course, in addition to better remuneration and employability. The remuneration and the job market in PHC, with the availability of vacancies, can justify this association36.
A self-reported aptitude for clinical specialties was another factor associated with the intention of having a career in PHC. An international study shows that students who report greater interest in clinical diagnostic reasoning tend to choose careers more often in PHC20. Although other studies with similar analyses have not been identified, the association with the interest in clinical areas seems to be obvious, considering the main activities developed in PHC. A previous study has already pointed out that interest in PHC during University increases the chance of choosing this career at the end of the course by more than 4 times29. Considering the possibility of a career in PHC since the moment of enrollment is also associated with this option after graduation18.
The association of a good experience in PHC during the curriculum with the preference for a career in PHC is in line with other studies, which demonstrated the importance of both a positive experience in PHC, as well as greater exposure to FCM during the curriculum, in addition to experiences with family doctors during undergraduate school, in encouraging the choice of careers in this área5),(12),(25),(37. In 2009, a literature review on medical students’ interest in pursuing a career as family doctors, indicated the little experience in PHC during undergraduate school, or even the experience in Family Medicine with an unmotivated and frustrated professional, as one of the reasons for the lack of interest in pursuing this career. The most recent NCGs of the undergraduate medical course, published in 2014, stimulated curricular changes that included the initial and more prolonged inclusion of the students into PHC practice38. Therefore, it corroborates the considerations made by Cavalcante Neto, Lira and Miranda (2009), that the successful experience in PHC, in fact, can be a motivating factor to lead young doctors to pursue a career in this área10.
Although the curricular changes, regarding the inclusion of students in PHC since the beginning of undergraduate school, reflect positively on the choice of doctors’ career in PHC, the organization of medical courses in traditional active learning methodologies does not seem to have an impact on choosing to work in PHC. A study carried out in Rio de Janeiro, which investigated the impact of curricular changes using active methodologies, in addition to the initial inclusion of students in PHC, associating it to the 5th-year students’ intention of choosing FCM as a specialty, showed that the changes in the course were well evaluated by students, but did not have an impact on the choice of careers in PHC, which remains poorly appreciated39.
Other factors not evaluated in this study have been described in the literature as positive influences on intention to pursue a career in PHC, such as: commitment and empathic atitudes25),(40, interactions with patients, with health professionals28),(41 and with the community20),(41),(42, financial issues41),(42, good balance between professional and personal life42),(43, appreciation of long-term doctor-patient relationships18),(28),(43, providing care at different stages of life18),(42, experience of providing care in rural áreas5),(18 and the possibility of working with preventive medicine20.
Authors have highlighted some factors as negative influences for choosing a career in PHC, such as the prejudice and stigma perceived in medical schools regarding work in PHC and the low remuneration10),(31),(42),(44, adverse working conditions, and low social and professional status10),(28),(31.
The results of this study must be considered in the light of some limitations. It was carried out with a convenience sample, which restricts the generalization of data. It is possible that the selected institutions do not adequately represent medical graduates from all over the country (either because of socioeconomic characteristics or job perspectives and opportunities, aspects that may interfere in the choice of the field of work after graduation). However, the number of respondents is significant, and the results are quite relevant and should not be disregarded. The fact that there is no standardized and valid instrument (nationally or internationally) may also limit the process of comparing the results with other studies. Still, the studies on the subject address a particular construct, which portrays the respondent’s interest, and indicates aspects that must be considered in the organization of public policies that contribute to the interest of medical professionals in working in priority areas for the health system.
Thus, it is understood that the results of this study should be considered by health and medical education managers, encouraging new proposals for professional training aimed at SUS, with greater incentive for teaching-service integration and with the inclusion of students into a strengthened PHC network throughout undergraduate school. Some strategies can be implemented aiming to increase the number of doctors who wish to work in PHC, including increasing the workload in PHC during undergraduate school, increasing the number of teachers who are FCM specialists and qualification of the health network in the municipalities where these HEIs are located. Furthermore, initiatives such as a career plan, investment in health network infrastructure and valuing the professionals who work in the area can contribute to increase this interest among medical school graduates. Programs such as the PMM have an impact on the emergency provision of doctors and on the increase in the number of undergraduate medical students; however, what shows the greatest impact on the training of professionals with a profile directed at SUS and the interest of students in working in PHC are positive experiences in this area during undergraduate school.
CONCLUSION
The results of this research show that more than a quarter of medical students from the assessed universities intend to work in PHC after finishing the course, a higher percentage than that recorded in previous studies, but still below what is required by SUS. Among the factors associated with the intention to work in PHC, a successful experience in PHC during undergraduate school is noteworthy, as it is a modifiable factor. Thus, strategies such as increasing the PHC workload during undergraduate school, increasing the number of teachers who are FCM specialists and the qualification of the health network in the municipalities where these HEIs are located, can be effective to increase the interest of medical graduates to work in PHC.
Entering the university through Prouni is also a factor associated with the intention to work in PHC that deserves to be highlighted, leading to the consideration that higher education access policies can contribute to the training of professionals to meet SUS needs. Considering that no studies were identified that evaluated the same association, it is suggested that further studies be carried out aiming to understand the factors that interfere with this result.
Although the study did not investigate the relationship between students’ choices and the social, political and economic context of the country, it is possible that the results reflect, at least in part, the students’ insecurity regarding their careers in PHC. Some international studies have investigated students’ motivations for career choices, but there are few Brazilian studies on this subject in the literature. Understanding that this choice is related, among other issues, to the country’s political and economic scenario, it is also suggested that studies be carried out looking for associations with career choices, aiming to contribute with the proposal of new strategies for the resolution of this problem.