In our study we found that expected salary plays an important role for medical students in their career choice. Most of them have already thought about it and report that the expected salary could highly influence their choice of specialisation. On the other hand, only less than half of the students have exact information in this area. Students’ information is mostly acquired from informal channels, such as doctors, other medical students or friends, and the media has a big impact as well. The university lectures provide an excellent opportunity for high quality professional training but do not create sufficient opportunities to get to know the working and living conditions associated with each speciality. Despite the information acquired through many different channels, or, rather due to that, most of the students are uncertain about the expected salaries. The importance of expected salary and uncertainty in the estimation in our study are in line with other international studies. In a recent German study, more than half of the students stated that earning opportunities are important in career choice and approximately 90% were uncertain in salary estimation. Naimer et al. in 2018 found that Israeli medical students do not have appropriate information about general practitioners’ salaries either [13, 15].

In all three categories (resident, family physician and other specialist), the estimated salaries are close to reality; however, for residents, the estimated salary is higher than the actual one. The cause of this result could be that in Hungary there are many scholarships for residents and young doctors, which could mean an extra income of €270–550 above the official salary every month. Nevertheless, this result was surprising compared to our previous study where 84% of the students underestimated the expected salaries [16]. In another one of our previous studies, most family medicine residents also underestimated expected salaries [14]. Based on these findings, we can state that Hungarian medical students are becoming more and more informed about their future earning opportunities. German medical students also significantly underestimated earning opportunities [13]. We did not find significant differences between urban and rural estimated or ideal incomes. Ideal salaries significantly exceed the estimated ones in every category. The fact that the students reported that the ideal income of a non-family physician specialist should be significantly higher than that of a family doctor may be in line with the lower prestige of family medicine among medical students [17].

Every year, women are increasingly represented in medicine, so gender differences are important to address in human resources. Eith et al. (2006) found that in Hungary fifth year women medical students want to be engaged in their medical profession but family plans are at least as important to them [18]. In our study, gender seems to play an important role in salary estimation. Men estimated higher salaries in almost every category and they were more confident in their estimates. Our findings are in line with a study carried out among surgery residents where women expected lower starting and ideal salaries [19]. A previous study in Hungary stated that among first year medical students “lifestyle and income” is more important in speciality choice for men [20]. According to international surveys, these expectations are close to reality because male physicians usually have higher salaries than their female colleagues [21, 22]. Students from the University of Debrecen estimated the highest income in all categories. This correlation was a novel finding because we know that undergraduate education has a significant role in career choice but its effect on salary expectations is not yet well-known [23,24,25]. Preferred speciality and motivation to work in rural settings or abroad did not influence the estimations significantly.

Attitudes of doctors and medical students towards informal payment is a key question if we want to shed light on this phenomenon of the healthcare system. In our study, we found it to be somewhat controversial. In theory, more than eight out of ten students reject it. However, two thirds of the students will accept it if the system will not change, although with different motivations. What it means is that about half of the students are influenceable by rules or circumstances. In our previous study, we found that in 2014–2015 19.7% of family physicians and 38.3% of family medicine residents were absolutely rejective of informal payment, 47 and 37.8% reported that their acceptance depends on the situation; mostly on the financial status of the patient [14]. Szinapszis Market Research and Consulting Ltd. regularly provides representative data about informal payment in Hungary. In their research in 2009 10%, in 2013 19%, in 2017 33% were absolutely rejective of informal payment. In 2009 81%, in 2013 78%, in 2017 61% accepted it in their daily work depending on the circumstances [26,27,28]. Based on these results we can see a positive tendency in doctors’ attitudes, but it is not enough to stop this harmful practice. Patients’ attitudes are at least as important. Baji et al. (2013) found that 47.3% of the respondents thought “Informal CASH payments to physicians and medical staff are similar to corruption.” and 54% answered that” Cash or gifts in kind, given informally to physicians and medical staff, should be eradicated.” 51.7% stated “If I have serious problems with my health, I will be ready to pay as much as I have in order to get better medical services.” From these results it can be seen, that patients do not like informal payment; however, it is a very deeply rooted phenomenon in Hungarian society [11]. We found significant correlations between acceptance of informal payment and aspects in connection with the importance of income. This finding indirectly confirm our hypothesis that if physicians would have higher income the problem of informal payments would be solved. Gender is also an influencing factor; males more often accept informal payment. The reason for this difference is ambiguous, the role of the hidden curriculum and other factors outside education, like social gender roles, may be considered [29]. Human resource recruitment in the healthcare system and informal payment are not only medical questions but affect society as a whole. Therefore it is crucial to handle them a scientific basis without any political or emotional influence.

Strengths and limitations

This is the first study, which examined the effect of estimated future income on career choice among medical students at all of the four Hungarian medical universities. It provides current and relevant data in the topic of informal payment, which is a burning problem of the Hungarian healthcare system. The sample size and acceptable response rate allowed us to draw general conclusions. As a limitation, we have to mention that participants involved in our study included medical students from different stages of their medical education. Fourth and fifth year students may have different experiences and perceptions. The reason for this selection criteria was that we involved medical students, who were having family medicine lecture courses and the universities have different curricula. Due to the COVID-19 pandemic Hungarian universities transitioned to online education; therefore, we reached a lower response rate at the University of Pécs, which can limit the comparison of results from different universities. The cross-sectional study as study design is also a limiting factor. Cross-sectional data cannot be used to infer causality and we are not able to evaluate whether the perceptions and motivations persist in graduates. Only few of the medical students are interested in family medicine as a future specialty, so we could not describe the special characteristics of this group.

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