According to the World Organization of National Colleges, Academies and Academic Associations of General Practitioners and Family Physicians (WONCA), Family Medicine (FM) physicians, also called family physicians, are expert doctors who are trained to provide comprehensive and ongoing primary healthcare to patients within the broader contexts of family, community and culture irrespective of age, gender or health condition.¹ Since 1978, when PHC was defined,² many countries have endeavoured to integrate primary healthcare (PHC) into their healthcare systems,³ helping to ensure the provision of holistic^4,5 and cost-effective patient care.⁶ Ideally, family physicians lead the PHC teams within healthcare facilities.^7,8 Over the years, FM training has been enhanced in several countries, including Kenya, where postgraduate training in FM commenced in 2005. Two years later, a nationwide FM strategy was released, augmenting the recognition and importance of this speciality for healthcare provision to individuals and communities.^8,9,10

However, several challenges hinder the progress of FM as a specialty in Kenya. Among these is that FM remains ill-defined and poorly understood in the community and among other medical specialists and health policymakers.^7,8 Furthermore, as PHC is generally under-resourced, funding is mostly allocated to curative care rather than preventive services.^7,8,11 In addition, some family physicians find themselves addressing human resource shortages within the healthcare system rather than practising in the roles for which they were specifically trained.⁷ The summation of these challenges means that the training and production of family physicians are slow and their numbers few,^3,12,13 leading to a limited pool of FM specialists available to practice and teach undergraduate and postgraduate medical trainees on the core FM concepts.^9,11 Overall, the low number of practising FM specialists curtails the contact time and role modelling for medical trainees despite the consensus that early exposure to the concepts of FM and PHC in medical school is beneficial.^7,11

Some African countries, including South Africa^14,15,16 and Nigeria,¹⁷ have integrated FM into the curricula of undergraduate medical education. In Kenya, only one out of thirteen medical training schools has clinical FM exposure at the undergraduate level.¹¹ In addition, there is a notable lack of research about the practice of FM and how it is perceived in Kenya.

In 2023, the Aga Khan University (AKU) in Nairobi, Kenya, launched an innovative 6-year, trimester model, Bachelor of Medicine and Bachelor of Surgery (MBChB) curriculum to train undergraduate students. This is structured into two phases, a 3-year preclinical phase followed by a 3-year clinical phase. Here, FM is not taught as a stand-alone course but is integrated in the curriculum through courses facilitated by FM physicians who serve as key educators across the programme. They teach consultation skills and emergency medicine in the early years of training and instruct on leadership, clinical governance and entrepreneurship during the clinical phase. This is done in tutoring small groups, leading interdisciplinary course modules and through mentorship. Medical students therefore receive early, albeit indirect, exposure to key FM concepts such as person-centred care, continuity of care and interprofessional teamwork.

There is a need to evaluate the effect of early exposure to FM among the undergraduate students, and the findings used to inform medical school curricula development and ultimately shape the landscape of PHC in Kenya. This study, therefore, set out to understand the perceptions among first-year medical students at AKU towards FM and assess the influence of the first-year curriculum on the choice of FM as a future career.

Despite many of the first-year students surveyed recognising the importance of FM, most did not fully understand its scope or the specific duties of the family physician. This echoes an observation from a previous study in Kenya, which showed a significant lack of clarity on how FM should be implemented in practice, despite FM having been defined by the Kenyan Ministry of Health.⁸ This study showed that at least 37% of respondents would not choose FM as a career in the future. This could be because of an overall paucity of understanding about this speciality and its practice in Kenya. Such low interest has also been reported in other studies in Africa. For instance, a study that reviewed career choices among final-year medical students from six sub-Saharan African countries showed that only 4.5% of the participants were interested in FM.¹⁸ Similarly, a study in South Africa observed that only 9% to 23% of students were interested in pursuing FM as a career,^14,15 and another showed that FM was ranked as the sixth most preferred specialisation choice¹⁶ among final-year medical students. In Ghana, one study indicated that despite 88% of undergraduate medical students being aware of FM as a speciality, only 2.4% considered pursuing FM for postgraduate training, mainly because of inadequate understanding of the speciality.¹² In contrast, a study conducted in Nigeria among medical students in their clinical years showed that FM was the second most popular speciality after surgery.¹⁷ All respondents felt that FM was relevant, 68.9% understood FM well, and 57.3% perceived it positively as a career speciality. It is worth noting that FM training in Nigeria started more than 50 years ago, a factor that would lead to the high interest indicated in that study.

Compared to these findings, our study focused uniquely on first-year students – a group for whom early perceptions may be more malleable. However, data on first-year medical students’ attitudes towards FM in Africa remains scarce. Most existing studies, as observed, focus on final-year cohorts, whose views are likely influenced by cumulative clinical experiences and prevailing institutional cultures. This gap underscores the value of our study in capturing baseline perceptions at the beginning of medical training.

Interaction with practising FM physicians is one potential avenue to augment the understanding of FM as a speciality. Here, we showed that the first-year students had multiple interactions with family physicians through lectures, tutorials and mentorship programmes. However, there was still a general lack of understanding of what FM entails. This could in part explain why very few students are interested in pursuing a career in this speciality. It has previously been shown that informal one-on-one career guidance, such as with personal tutors or seniors during placements, is more effective than formal career advice.¹⁹ Such an approach for guiding undergraduate medical students would help to bridge the gap in the knowledge, training and practice of FM in Kenya and the region.

This survey showed some negative sentiments from participants towards the FM physicians they had previously interacted with; at least two participants mentioned that family physicians seemed “inauthentic”. Career decisions are often honed over multiple experiences and potentially numerous years; one negative experience can lead to ruling out a career path.¹⁹ As such, negative experiences could be another contributing factor to a low number of respondents indicating interest in pursuing a career in FM. In our study’s context, the first-year students surveyed had not yet been attached to FM clinics but had interacted with FM physicians in other settings, for instance as patients. Curricula changes could address this gap by introducing early longitudinal exposure to FM practice and clinics. Indeed, longer placements in a specific field have been shown to increase the authenticity of an experience.¹⁹ It is also shown that having a role model can significantly impact a student’s career path.^19,20,21 Taken together, increased contact time between medical students and practising family physicians may help to create additional avenues for role-modelling and mentorship.

Given that FM is a relatively new speciality in Kenya, there is a paucity of robust support systems for its training and practice despite some indicated growth.^9,10 Our study suggests that this is an area of concern among students, some of whom feel that there are no systems in place to support FM, and that a career in this area would be less rewarding. The limited exposure to family physicians in the preclinical years of undergraduate medical programmes largely impacts student’s interest, an aspect also found in Canadian medical schools.²¹

Interestingly, 69% of our cohort were unsure whether a career in FM would offer fulfilment. Although limited research exists on what brings fulfilment in a FM career, studies in broader healthcare contexts have identified factors such as independence,²² new skills²³ and altruism,²⁴ as influencers of a healthcare professional’s sense of satisfaction. These attributes could feasibly be incorporated into a career in FM. Furthermore, some personal aspects of quality of life known to increase the happiness of healthcare professionals, such as taking breaks away from work, undertaking recreational activities, spending quality time with family and friends and getting good quality sleep,^{22,25,26,27,28} might be challenging to realise especially in the absence of adequate support. This is a point of concern among medical students and an area for further research to evaluate indicators of fulfilment in a career as a family physician in our context

Arguably, career preferences may not remain stable throughout one’s medical school training.^29,30 Therefore, research involving the same cohort of students later in their undergraduate medical training would be insightful, given that 55% of the cohort reported not seriously considering their career path yet. In addition, research among students across different medical schools in our region would provide a wholesome and generalisable picture of the perception of FM among undergraduates.

A minority of first-year medical students surveyed were interested in pursuing FM as a career, with many respondents disagreeing that the curriculum advanced their understanding of the speciality. We recommend that medical schools better integrate FM training into their undergraduate medical curricula, as well as offer longitudinal exposure to FM, therefore foster understanding and a sense of authenticity among students. Furthermore, the inclusion of medical educators’ perspectives would provide insight into any curriculum gaps and offer opportunities to strengthen FM student exposure and practice. In a wider context, advocacy to increase awareness and scope of FM will be beneficial in attracting the necessary support for its training and practice in our region.