Corcoran, Kate

Kidd, Michael Richard

Leeder, Stephen R

Shaw, Tim

Thistlethwaite, Jill

Flinders Academic Commons

Archived at the Flinders Academic Commons:  http://dspace.flinders.edu.au/dspace/  This is the publisher’s copyrighted version of this article.  The original can be found at: http://www.racgp.org.au/afp/200811/200811thistlewaite.pdf © 2008 Australian Family Physician www.afp.org.au Copyright to Australian Family Physician. Reproduced with permission. Permission to reproduce must be sought from the publisher, The Royal Australian College of General Practitioners. research964  reprinted from australian Family Physician Vol. 37, No. 11, November 2008there is likely to be a shortage of general practitioners in australia well beyond 2012,1 when recent increases in medical student numbers will lead to an increase in the number of qualified doctors. however, the shortage will only be alleviated if a high proportion of these doctors choose to enter general practice. this is even more imperative as GPs increasingly choose to work fewer hours.2 additionally, the number of vacancies in rural and remote areas will not be filled by the current number of newcomers to the general practice workforce.3 The wide variation in the number of graduates from different medical schools choosing to enter general practice training suggests that undergraduate experience affects career choice.4 This article explores the factors that influence students and junior doctors to choose or reject a general practice career, and is the qualitative component of a literature synthesis on workforce choice among health professionals.5methodsThis qualitative study was developed to explore whether the findings of the literature review mirrored the opinions of current students and doctors in respect to factors affecting their choice of a career in general practice; therefore, a large sample was not sought, and interviews were restricted to 13 medical students (three male), five junior doctors (two male), five general practice registrars (three male) and 15 GPs (eight male). Three of the junior doctors had undertaken a Prevocational General Practice Placement Program (PGPPP) term.  The interviewees were recruited through:•	FridayFax (the weekly bulletin of The Royal Australian College of General Practitioners)•	the	University	of	Sydney	medical	student	electronic	notice	board•	emails	 to	GPs	with	University	of	Sydney	medical	 students	 in	 their	practices•	a	medical	 educator	 contact	 at	 James	 Cook	 University	Medical	School	who	 sought	 volunteers	 from	medical	 students	 and	 junior	doctors	at	Mackay	Base	Hospital	(Queensland)BackgroundThe shortage of general practitioners in Australia is likely to continue unless more doctors choose general practice as a career. The aim of this qualitative research was to explore the factors that influence students’ and junior doctors’ career choice, particularly in respect to choosing general practice.methodsMedical students, junior doctors, general practice registrars and GPs were recruited and interviewed. The interviews were semistructured, transcribed and analysed by theme.resultsThemes from the 38 interviews included the experience of general practice during training, the impact of the postgraduate general practice placements program, and factors that make general practice attractive or unattractive as a career choice.DiscussionThere are a number of factors that contribute to medical students’ and junior doctors’ career choice. Attention needs to be paid to the quality of the general practice learning experience and general practice posts in the early postgraduate years, and the attractions of general practice should be promoted.enhancing the choice of general practice as a careerstephen leederMD,	FRACP,	FRACGP,	is	Professor	of	Public	Health	and	Community	Medicine,	Menzies	Centre	for	Health	Policy,	University	of	Sydney,	New	South	Wales.michael r KiddMBBS,	MD,	FRACGP,	is	Professor	and	Head,	Discipline	of	General	Practice,	University	of	Sydney,	New	South	Wales.Jill thistlethwaiteMBBS,	PhD,	MMEd,	FRCGP,	FRACGP,	is	Associate	Professor,	Office	of	Postgraduate	Medical	Education,	University	of	Sydney,	New	South	Wales.	jthistle@med.usyd.edu.aureprinted from australian Family Physician Vol. 37, No. 11, November 2008  965•	a	 regional	 training	 provider	medical	 educator	 to	 recruit	 PGPPP	doctors.The semistructured phone interviews were audiotaped and transcribed, and the questions were based on the literature findings5 to explore their correlation with the views of a sample of Australian students and doctors. 	 Questions	 explored	 factors	 relating	 to	 career	 choice	 in	 general,	and general practice in particular, including positive and negative influences on choice. The questions were not piloted but were adapted and refined in each interview depending on the answers and experience of the interviewee. resultsThemes and subcodes which emerged from the interviews are shown in Table 1. Factors affecting career choice – role modelsRole models encountered during medical school and postqualification are important influences on career choice. This has important implications.‘I think the biggest influence is seeing good role models’. (Medical	student	1)General practice exposure Recent graduates and medical students have more exposure to general practice than doctors who graduated more than 5 years ago; some students felt that quality rather than quantity of exposure to general practice was important.‘I actually think my medical school has super saturated me with general practice, probably if I had less exposure and better quality exposure I’d feel more open to the idea of general	practice’.	(Junior	doctor	3)The interviewees also stressed the importance of early exposure to general	 practice.	While	 current	medical	 students	 believe	 they	 have	plenty of general practice experience, they want this experience to involve hands-on practice rather than observation. General practitioners should also have a high profile in medical school and be involved in teaching throughout the course.‘But	whereas	 you’ve	 never	 seen	 general	 practice	 and	 how	they actually operate...so I think people... are interested  in other specialties because of exposure to them, whereas we’re not exposed to general practice so if we were  maybe earlier on in the course it might be more attractive’. (Medical	student	5)There are often negative views of general practice expressed during hospital terms by hospital doctors, though not necessarily with specific reasons.‘I guess during my resident years I was steered away from really entering a career in general practice because general practice was somehow seen as... an inferior type of choice’. (Registrar 1)‘I feel like they don’t get a lot of respect from the rest of the medical profession especially from what I’ve seen in my clinical exposure in hospitals, certainly a lot of specialists don’t	have	a	lot	of	time	for	GPs’.	(Medical	student	7)Exposure	 to	 quality	 general	 practice	 experiences	 should	 give	students realistic expectations of the job. Conversely, a poorly rated general practice attachment is harmful to a student’s perception, particularly if the GP shows signs of burnout.‘I think overall... when I started med I wasn’t thinking that seriously about general practice, I was probably just thinking more of the glory... but my exposure to it has probably made it seem like a much more positive career choice with flexibility and variety and the chance to actually make a real difference	to	people’.	(Medical	student)	7The PGPPP gives postgraduate year 1 and 2 doctors opportunities to work in general practice for 3–4 months. The emerging evidence of the PGPPP’s effect on career choice was confirmed by those interviewees who had been through the program.‘I wasn’t very seriously considering general practice as a long term career but once I did it as an intern kind of it moved up my list of preferences if that makes sense’. (Junior	doctor	4)‘Well	 I	 think	 that	 for	 the	 ones	 that	 have	 come	 through	 the	program so far there’s been a definite shift toward choosing general practice as a career’. (GP 12)the attractions of general practice as a careerReasons given for considering choosing general practice included continuity of care, the range of patients and conditions, stimulating patient-doctor interactions, the skill mix (including procedural work), the	ability	to	practise	holistic	care,	lifestyle,	and	autonomy.	Flexible	working hours and career path are also important.‘It appeals mainly because of lifestyle issues, because I want	to	have	a	family’.	(Medical	student	3)‘If you are in an appropriate environment you’re able to be reasonably procedural as well... which appeals to me, I’m a kind	of	hands-on	person’.	(Medical	student	8)Kate corcoranBSc,	MPH,	is	a	project	officer	in	professional	health	education	and	research,	University	of	Sydney,	New	South	Wales.tim shawPhD,	is	Associate	Professor,	Office	of	Postgraduate	Medical	Education,	University	of	Sydney,	New	South	Wales.research966  reprinted from australian Family Physician Vol. 37, No. 11, November 2008enhancing the choice of general practice as a careerTable 1. Themes identified theme family subcodeFactors	affecting	career	choice	in	general	(medical	students	and junior doctors only) Medical	education	still	mainly	hospital	based	General practice seen as inferior choice during educationRole modelsGeneral practice exposure at medical school and for junior doctorsComparison of general practice with hospitalEffect	of	general	practice	attachmentsGeneralist versus specialistHaving	general	practice	exposure	earlier	during	trainingMore	stimulating	than	expectedNeeds	hands-on	experience	not	just	observationPerceptions of general practice while a studentSell	general	practice	as	a	great	jobPrevocational General Practice Placements ProgramThe attractions of general practice as a career Continuity of careFlexibility	and	hoursLifestyleStimulating	and	lots	of	varietyWorking	with	peopleAutonomyPrestigeSkill	mixSocial	statusHolistic	careMaking	general	practice	more	attractive	as	a	career	option Increase flexibilityReduce government interferenceBetter	communication	between	GPsPayPortray as enjoyable careerDoing	proceduresEnhanced	recognition	of	GPsMore	supportLess time pressureStudents	to	gain	better	understanding	of	roleIncrease availability of part time trainingWhat	makes	general	practice	unattractive? Lack of supportNot	intellectually	challengingLack of time with patientsNegative	media	coverageLack of prestigeGeneral practice teaching Enjoyable	to	have	students	in	practiceGeneral practitioners not trained to teachRemuneration factorsIncreases statusTeamwork and effects on choice Attractions of interprofessional teamsLack of training in teamworkTeam as supportTeamwork importantEffects	of	rural	attachments Compulsory rural termReasons for being rural GPHard	workresearchreprinted from australian Family Physician Vol. 37, No. 11, November 2008  967enhancing the choice of general practice as a careercity counterparts, so in part the appeal of the rural general practice term was possibly that it was rural but also I think I saw things about general practice that I hadn’t, that I hadn’t realised	were	part	of	it’.	(Medical	student	8)‘The suburban one really didn’t, didn’t really turn me on to general practice at all... there were a variety of reasons for that, but like I said, my rural experience was fantastic’. (Medical	student	8)DiscussionA common discussion point was the changing nature of general practice	 and	 the	 lifestyle	 aspirations	 of	GPs.	Many	GPs	 no	 longer	choose to work full time, and the flexibility of working hours is attractive for doctors and influences medical students’ choice.6 The potential to vary hours and the diversity of the workload should therefore be highlighted as major attractions of general practice.  One way to reduce doctors’ working hours is to enhance team based care, with an expanded role for practice nurses. This would require different funding models and additional training. General practice and rural attachments must be major features of medical school programs and intern years, but it is important to have students and junior doctors ‘do the job’ rather than simply observing.7 	 Quantity	should	not	be	delivered	at	the	expense	of	quality.	Being	able to experience working as a GP is an important feature of the PGPPP, and this type of junior doctor experience has been shown to influence	career	choice	in	the	United	Kingdom.8	Working	GPs	need	to	advertise the merits of their jobs and help dismiss the notion that they are ‘just a GP’.  Procedural work is important for potential male GPs, especially when considering a rural career,9 while flexibility is attractive for women in urban as well as rural areas.4,10 	 While	hospital	based	and	acute	care	may	seem	to	represent	the	exciting side of medical practice, and managing chronic disease in the community the less attractive option, the diversity and breadth of general practice should appeal to doctors wanting autonomy within patient care. The chance to build up longstanding and meaningful patient-doctor relationships is one of the hallmarks of general practice that students do not always appreciate in their short attachments.limitations of this studyThis study made no attempt to recruit a truly representative sample of interviewees, given that the purpose was to triangulate the findings of the literature review5 with the views of a selection of stakeholders. Their views were similar to the conclusions drawn from	the	198	papers	reviewed,	of	which	57	were	from	Australia.	 However,	 because	 these	 views	 are	 contemporaneous	 and	include more insight from the PGPPP perspective, we believe they add richness to the findings of the review; in particular, the fact that the interviewees cite similar negative factors to previous work suggests that change is still needed to rectify the workforce problem.making general practice even more attractiveInterviewees want less bureaucracy, better communication with other GPs and greater recognition of their role. Greater flexibility (including flexibility of the vocational training program), support, remuneration and the ability to perform procedures are also important.‘Setting	up	a	practice,	 assisting	with	administrative	 things	 if	there (are) these things in place where it wasn’t just me running a business or having to make sure everything is running, you know, where I was principally doing the job of a doctor and not an administrator and a small business owner, then I think there would	be	more	incentive’.	(Medical	student	1)‘If the training program was a lot simpler’. (Registrar 3)What makes general practice unattractive?Interviewees mentioned lack of support, lack of time with patients and the decreasing prestige of general practice as a career path as factors which reduced the attractiveness of general practice. Students	stated	that	general	practice	is	not	seen	as	a	specialty	or	as	intellectually	challenging.	Negative	 role	models	and	media	coverage	enhance the view of general practice as a poor choice.‘I know that... most specialties, the amount of time you can spend with a patient is restrictive, but I felt particularly in general practice often that the time really was limited and you often couldn’t spend as long with a patient as the patient really	 needed	or	 you	wanted	 to	 spend	with	 them’.	 (Medical	student 10)‘I think it could help if the profession talked publicly and privately about the positive aspects of the career instead of a relentless focus on the negative aspects of the job’. (GP 13)‘Whenever	 there	 is	 a	 discussion	 about	 health	matters	 the	image on television is usually of an operating theatre, as if it’s the only place that matters that important work gets done there. I think there is a public image aspect to this’. (GP 1)General practitioners as teachersGiven the obvious importance of good GP role models, there is a need for good GP teachers who involve students actively in patient interactions rather than placing the student as a passive observer. General practitioners are drawn to teaching because it is enjoyable and	 increases	 their	 status.	 However,	 the	 interviewees	 expressed	dissatisfaction about the level of remuneration.‘But	I	have	to	admit	it	[teaching]	is	very	onerous,	I’ve	actually	pulled out of some of the attachments that I’ve said I would do this year just because it is too onerous and the remuneration is appalling’. (GP 6)the effects of rural attachmentsThe students highlighted the importance of quality attachments and experiences as important factors in choice; this was also the case for rural attachments.‘Rural doctors and rural patients act differently than their research968  reprinted from australian Family Physician Vol. 37, No. 11, November 2008enhancing the choice of general practice as a careerConflict of interest: This research was funded by a grant from the Australian	Primary	Health	Care	Research	Institute.references1.	 Joyce	CM,	McNeil	JJ,	Stoelwinder	JU.	More	doctors,	but	not	enough:	Australian	medical	workforce	supply	2001–2012.	Med	J	Aust	2006;184:441–6.2.	 Charles	 J,	Britt	H,	Valenti	 L.	 The	evolution	 of	 the	 general	 practice	workforce	 in	Australia,	1991–2003.	Med	J	Aust	2004;181:85–90.3.	 Health	Workforce	 Queensland	 and	 Australian	 Rural	 and	 Remote	Workforce	Agencies	Group.	Doing	the	sums:	will	there	be	a	future	health	workforce	for	rural	and	remote	Australia.	Brisbane:	HWQ	&	ARRWAG,	2006.4.	 Australian	Medical	Workforce	Advisory	 Committee.	 Career	 decision	making	 by	doctors	 in	 vocational	 training	 –	AMWAC	medical	 careers	 survey,	 2002.	North	Sydney:	AMWAC,	2003.5.	 Thistlethwaite	 JE,	 Shaw	 T,	 Kidd	M,	 et	 al.	 	 Attracting	 health	 professionals	 in	primary health care: strategies for recruitment. Canberra: Australian Phimary Health	 Care	 Research	 Institute,	 2007.	 Available	 at	www.anu.edu.au/aphcri/Domain/Workforce/Thistlethwaite_25_FINAL.pdf.6.	 Tolhurst	H,	Stewart	M.	Becoming	a	GP:	a	qualitative	study	of	the	career	interests	of	medical	students.	Aust	Fam	Physician	2005;34:204–6.7.	 Laurence	C,	Elliott	T.	When,	what	and	how	South	Australian	pre-registration	junior	medical	officers’	career	choices	are	made.	Med	Educ	2007;41:467–75.8.	 Grant	 J,	 Southgate	 L.	 Pre-registration	 house	 officer	 placements	 in	 general	practice:	 final	 report.	Milton	 Keynes:	Open	University	 Centre	 for	 Education	 in	Medicine,	2000.9.	 Harris	MG,	Gavel	 PH,	 Young	 JR.	 Factors	 influencing	 the	 choice	 of	 specialty	 of	Australian	medical	graduates.	Med	J	Aust	2005;183:295–300.10.	 Wainer	J.	Work	of	female	rural	doctors.	Aust	J	Rural	Health	2004;12:49–53.CORRESPONDENCE afp@racgp.org.au

Enhancing the choice of general practice as a
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Enhancing the choice of general practice as a career

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