Can medical residency keep young specialists in the place where they graduate? Cross-sectional and exploratory study of the first seven years after implementation of medical residency programs in the State of Tocantins, Brazil

ABSTRACT BACKGROUND: New medical schools and new medical residencies in Brazil, mainly in its interior, were opened under the justification of collaborating towards distribution of these healthcare professionals and specialist doctors across the national territory. However, this proposal did not guarantee that medical practitioners would become established in the place where they graduated and specialized. OBJECTIVE: To calculate, through interviews, how many specialists who graduated in the state of Tocantins stayed there after finishing their medical residency; and to analyze the factors that made them stay or leave the place. DESIGN AND SETTING: Cross-sectional exploratory study conducted at a Brazilian federal public higher education institution. METHODS: All graduates from medical residencies in Tocantins, who graduated between 2013 and 2019, were contacted by telephone and, after obtaining consent, an interview was conducted. The interviews took place between June 2020 and January 2021. RESULTS: The permanence of medical residency graduates in the state increased from 50% in an earlier study to 55.8% in the current study, thus showing a situation of stability. In addition, we detected some reasons for staying or not. In a multivariate analysis, only working in the state capital was related to staying in the state of Tocantins, showing a 5.6 times greater chance. CONCLUSIONS: The percentage of those who remained was just over 50%, even some years after implementation of the first programs. Most specialists remained working for the state health department, with a smaller proportion in municipal health departments, and were concentrated in the state capital.

New medical schools in Brazil, especially in its interior, were opened under the justification of collaborating with the distribution of these healthcare professionals and specialist doctors across the national territory. However, this proposal did not guarantee that medical practitioners would become established in the place where they graduated and specialized. 4 A pilot study conducted in the state of Tocantins that analyzed the prevalence of remaining in the state between 2013 and 2017 revealed that 65.9% of residents stayed in Tocantins. 5 Another complete survey considering only the years 2013 and 2014 revealed that 50% of graduating residents remained in the state. 3 These data demonstrated that medical residents' decisions on where to settle are based on numerous factors that go beyond the increase in vacancies, such as working conditions, sex, remuneration, city of origin, family and proximity to large urban and economic centers. 3 Therefore, there is a need to analyze the reasons that lead graduates to leave the state so that, in addition to expansion of opportunities, other aspects can be considered in order to increase the proportion of medical residents who stay.
Thus, the aim of the current study was to analyze how many residents who concluded their first medical residency between 2013 and 2019 remained in the state of Tocantins after finishing.
We tried to find factors that related to whether they stayed or not.

OBJECTIVE
Residents who graduated in the state of Tocantins were interviewed to ask them whether they had stayed in the state after finishing medical residency, with the aim of analyzing the factors that influenced their decision to stay or leave the state.

METHODS
This was an observational and exploratory cross-sectional study in which all graduates from medical residency in Tocantins, in the years 2013 to 2019, were evaluated. The subjects were contacted by telephone to obtain consent and then to answer the questions. Subjects were excluded if they did not agree to take part or could not be found. The period over which the interviews took place was from June 2020 to December 2020.
The variables (questions asked) were the following: year of graduation; residency program attended; age; date of birth; gender; marital status; whether before the residency they had worked in Tocantins or in any municipal network in this state; whether before the residency they worked in the public network of the state of Tocantins; whether after graduation they stayed in the state of Tocantins and the reason for staying or leaving; the current state where they were living; whether they were still working in the specialty in which they graduated; whether they were currently working in a public state network in another state or in Tocantins; whether they were currently working in a municipal network and in which city; whether they were currently working in the private network of Tocantins; whether their current income was higher than their residency income; hours worked weekly; whether the residency had improved their medical practice; and whether they had subsequently done another medical residency, and if so, in what specialty and where. The interviews took place via telephone. Out of the 265 graduates contacted, 240 agreed to take part and completed the survey.
Nine graduates were not found, fourteen were found but did not respond to the messages, and two refused to take part in the inter- with other variables as factors, using a general linear model with a logistic regression tool. In a multivariate analysis, we adjusted the significance using the Bonferroni correction for α ≤ 0.0008.

RESULTS
Details of the sample are presented in Table 1.
Regarding the institutions from which the subjects graduated, the number increased over the years. All of the 15   It is important to note that family and community medicine has increased greatly over the years, considering that in 2013 and 2015 no residents graduated in this field, and in 2014 only one.
However, in 2016 the numbers started to increase. The number of residents in general surgery did not change over the years studied, staying between four and six trained physicians, and this was also seen in relation to gynecology and obstetrics (between three and four) and pediatrics (between five and six).
Orthopedics and traumatology, dermatology, vascular surgery, infectiology, pediatric intensive care medicine and neonatology are more recent specialties in the state of Tocantins, and so the num-

DISCUSSION
In the literature, some data have suggested the possibility that doctors might remain in the places where they did their training. 6 However, these data vary and the values are not high in all locations. [7][8][9][10] In November 2020, Brazil reached a total of 500,000 doctors, The geographical distribution and career trajectory of medical graduates and the factors associated with their choice of practice location was evaluated in another study in which a total of 563 graduates completed a questionnaire. Among these, 4.3% reported that family medicine was their medical specialty, 19.9% reported other primary care specialties (internal medicine, pediatrics, surgery and obstetrics-gynecology) and the remainder chose subspecialties. Larger cities were more likely to be chosen for practice, particularly by newly graduated doctors. The job invitations received during medical residency training increased the likelihood of choosing highly populated cities.
In contrast, job invitations received during medical school increased the likelihood of choosing less populated cities. Among medical practitioners in cities with a lower population density, proximity to family members was an additional influencing factor, while those who chose more densely populated cities did so because of better infrastructure and recreational options. 12 In another study, the results showed that the employment attribute that most affected the respondents' choice was the location of the work, followed by working conditions, payment, access to medical residency, type of contract and workload. It was found that respondents who had attended private colleges, those with higher family income and females generally showed greater resistance to moving to unsafe urban regions and to remote areas of the interior.
The employment scenarios that proved to be the most plausible in terms of public intervention were those that combined intermediate wages, good working conditions and obtaining an additional 10 to 20 points in medical residency examinations. 13 Higher income, satisfaction with training decisions and board certification were also variables associated with a higher retention rate. 14

CONCLUSIONS
We see that medical residency led to insertion of new specialists in the state of Tocantins. However, the percentage of residents who remained had only increased by 5.8%, even years after implementation of the first programs. Most specialists are still working for the state health department, with a smaller proportion in municipal health departments, and concentration of specialists in the state capital. We presented reasons for staying in the state that corroborated data in the literature. In the current study, working in the state capital was the only significant factor. Therefore, the reasons that attract specialists to priority areas continue to be diverse and, hence, a variety of measures need to be adopted by public-sector management. The decisions of physicians to stay or leave showed a cost-benefit pattern once their basic needs had been met. 15