Rescuing the profession we love: general practice training sector recommendations for improving the attractiveness of general practice training. A qualitative analysis

The inadequate numbers and inequitable distribution of general practitioners have long been problems in Australian primary health care,1 particularly in rural areas, but they have become increasingly prominent in the past few years. It is projected that the general practitioner workforce will not meet the growing demand in either rural or urban Australia,1,2,3,4 as relatively few Australian medical students express interest in general practice careers.5

Research in Australia and overseas has explored factors that encourage medical students and junior doctors to choose and pursue careers in general practice. Perceptions of better work–life balance,6,7 greater autonomy and continuity of care,8 and closer relationships with patients6 favour general practice, whereas higher income and status6,7,9,10 and opportunities for procedural and academic work6,8 favour hospital‐based specialties. Perceptions of innately interesting and satisfying work6,7,9,10 and personal fit with specialty norms11 and workplaces12 are also important.

Evidence for the effectiveness of strategies for increasing recruitment to general practice training is weak, with the arguable exceptions of undergraduate placements in rural areas, postgraduate placements in areas with fewer medical services, and selective recruitment of medical students with rural backgrounds.13 The educational quality of government‐funded, twelve‐week general practice placements for Australian junior doctors (postgraduate years 1 to 3) as part of their pre‐vocational, predominantly hospital‐based training has been reported,14,15 but this program (known as PGPPP or PGYPPP) was largely discontinued in 2014.

We therefore investigated the views of the general practice training sector about responding to recruitment challenges, with the aim of identifying effective initiatives and other solutions. We undertook this study during a period of return to medical college‐led training, a transition that brings both opportunities to refresh training and risks of losing expertise and knowledge from the sector.

Methods

Our qualitative study was undertaken in two stages: an initial online workshop for medical educators was followed by focus group discussions seeking views from a broader selection of people involved in general practitioner training. The investigator team included an experienced general practitioner and university‐based medical educator and academic (NS), a recent Royal Australian College of General Practitioners (RACGP) fellow commencing a doctoral investigation of transitions in general practice training (MT), and an experienced research assistant with no previous exposure to general practitioner training (SV).

The workshop was facilitated by three professional facilitators who used an appreciative enquiry approach;16 this method focuses on best practice and future possibilities, and is highly interactive.17 Invitations to express interest in participation were distributed online during March–May 2022 by regional training organisations and RACGP medical educator networks as brief notices in regular newsletters and other group emails.

The 4.5‐hour workshop on 20 May 2022 explored participant experiences of general practitioner training, particularly trainee recruitment. The workshop included Zoom whole group and breakout room discussions, as well as individual and small group written tasks, including summarising discussions and commenting on others’ posts. Written work was captured on a mural board, in Google Docs documents, and in the Zoom chat. The authors circulated among the groups during the workshop as observers and made written notes. All discussions were recorded and transcribed, and all written work was collected. A summary of workshop discussions, compiled by authors NS and SV, was subsequently emailed to all participants for further comments (none were received).

After the workshop, strategies generated during the workshop were aggregated by the authors into key topics to be used as focus group prompts. Focus group discussions (FGDs) were held via Zoom during 29 August – 2 December 2022. Invitations to express interest in participation were distributed in the same manner as for the workshop by RACGP recent fellow groups, the RACGP National Faculty for GPs in Training, General Practice Supervision Australia, and General Practice Registrars Australia. Medical educators who had expressed interest but had been unable to attend the workshop were individually invited. The discussions were audio‐recorded and professionally transcribed, and read by authors NS and SV, who descriptively and iteratively coded the transcripts by proposed strategy (including any barriers or caveats) using qualitative descriptive analysis.18 The focus group guide was modified iteratively as analysis progressed and data saturation was reached. Broad strategies with widespread consensus were identified as key recommendations. Author NS conducted a subsequent reflexive thematic analysis19 of the transcripts from a constructivist realist perspective20 in ATLAS.ti (https://atlasti.com).

The authors constantly compared their analytical ideas with the participants’ comments to ensure that participant voices were heard21 and that the four key recommendations had broad support. NS, in particular, reflected on her own professional and personal commitment to general practice throughout this process.

Ethics approval

The study was approved by the RACGP National Research and Evaluation Ethics Committee (project 22‐133). All participants provided written, informed consent to participation.

Results

The half‐day online workshop was attended by 26 medical educators from regional training organisations, universities, and the RACGP. The authors facilitated thirteen semi‐structured, online focus group discussions (two to four participants per group; 60 minutes’ duration) that included a total of 34 participants (Box 1).

The workshop recommendations

The workshop participants generated four major recommendations:

• increase the number of student and junior doctor clinical placements in general practice;
• increase exposure of students and junior doctors to general practitioner teachers and educators;
• improve general practitioner trainee pay and entitlements; and
• improve the integration of general practice and hospital patient care and professional relationships.

The focus groups broadly supported these recommendations, with a strong consensus in favour of the first two. Positive exposure to a range of general practices and general practitioners (as clinicians and as teachers) and opportunities to experience general practice before committing to a specialty training program were seen as important for attracting the most suitable students and junior doctors to general practitioner training, and increasing the understanding of general practice among other medical professionals:

I know my own choices were heavily influenced by having really good exposure in pre‐hospital training to really wonderful and inspiring GPs, and having mentors throughout… having that established relationship can just break down barriers to asking more questions or exploring the idea of a career in general practice. (recent fellow, FGD308)

[Junior doctor placements in general practice] would be a really good way of getting a bit of an idea of what general practice is like because it's so, so different. And you have to really at the moment make quite a big decision to leave hospital medicine and start general practice without really knowing. It feels like a bit of a gamble in some ways… It's one of the few specialties where you don't get to be able to trial it.(recent fellow, FGD258)

Many focus groups discussed the PGPPP program, generally agreeing that it had positively influenced general practice career choices, and that a similar program should be piloted again as an option for junior doctors. Making such postgraduate placements mandatory was suggested by some participants, but the burden on practices and patients of junior doctors who “really [do] not want to be there” was generally considered too high. Several participants had had positive personal experiences of the old program:

I did the PGYPPP as an intern… It was an amazing practice, and the general practitioners were inspiring and had lots of different skills, and I just had a fantastic experience. So I think it would definitely help get more junior doctors thinking about it as a career. (recent fellow, FGD298)

Clinical supervisor roles were regarded as both rewarding and onerous, and primarily motivated by a desire to develop a high quality, healthy general practitioner workforce and retain the best trainees as general practice colleagues after they became fellows. Participants also discussed the risk of exposure to general practitioner supervisors who were exhausted, burned out, or not interested in teaching, which has a negative impact on prospective trainees. To reduce this risk, participants emphasised the need for adequate structural and financial support for any intervention that had an impact on training practice and supervisor workload, workflow, income, or patient satisfaction and care. These impacts were frequently discussed in the context of junior doctor placements in general practice (Box 2).

There was a clear consensus that poorer income and employment conditions for trainees than in other medical specialties, particularly the lack of parental and study leave and the non‐transferability of accumulated leave between hospitals and general practices, were strong incentives for not entering general practitioner training:

Participant 1: I do think that the drop in pay puts off people probably the most out of anything to go into general practitioner training.

Participant 2: It's a really hard decision to make to say, “Okay, I'm going to give up maternity leave to do this speciality.” (recent fellows, FGD308)

The third recommendation caused considerable debate, especially with respect to single employer models — in which general practitioner trainee salaries are paid by another employer, such as a government or college, rather than their training practice — and general practice funding models other than fee‐for‐service models. Practice managers and supervisors emphasised the potential risks of trainees receiving better pay and conditions than established general practitioners, or completing training unprepared for the financial realities of general practice after receiving their fellowship, a concern also expressed by recent fellows. They also cautioned against undermining current high performing general practitioner training practices when introducing new funding models, and emphasised the importance of flexibility and choice in any restructuring of general practice training (including proposals to retain supervisors on government salaries). There was a strong consensus that many general practitioners preferred the increased autonomy and incentives to work harder in the current small business model, although some participants personally preferred a salary‐based model. The predicament of general practitioners in the United Kingdom, thought to be working harder for less financial and professional reward as a result of accepting government salaries, was raised in many focus groups:

I think that system is broken… that's why we have a lot of UK doctors come here because that system just leads to burnout and very poor remuneration compared to other specialities. (recent fellow, FGD308)

The fourth recommendation was strongly supported in principle, as a core element of quality patient care, and as a way to increase the visibility of general practice and general practitioners to potential trainees. Participants approved of general practitioner liaison roles in hospital settings, and valued opportunities to connect with general practitioners and other specialist colleagues, but considered proposals that general practitioners regularly attend hospital‐based case conferences or other events impractical.

Overarching themes

We determined two overarching themes that infused the participants’ comments using reflexive thematic analysis (Box 3). “Rescuing the profession we love” reflected participants’ loyalty to and passion for general practice. This passion underpinned their recommendation to attract suitable trainees by increasing exposure to general practice.

However, there was also a strong sense of current threat to the flourishing of the profession, one practice manager describing “a litany of issues facing general practice at the moment” (FGD101), and the consensus was that morale among general practitioners was low. A medical educator reflected that it was important but challenging to communicate passion and enthusiasm to potential trainees while also advocating change:

… general practitioners are not happy at the moment and they're calling loudly for change… [but] put yourself in the position of a medical student or a junior doctor, do you want to go and join a group of people who are saying “we're really unhappy”? No, that's not very attractive. It's this difficult tightrope to navigate, of still really being passionate and enthusiastic about the profession we love, but also making it better, and kind of rescuing it. (medical educator, FGD299)

The second theme, “No idea what general practitioners do”, captured participants’ sense of general practice being poorly understood by hospital‐based medical and allied health practitioners: “Other specialist colleagues often have no idea what GPs do” (recent fellow, FGD308). Several participants mentioned that lower quality general practice tended to be more conspicuous in hospital contexts, which, combined with a lack of appreciation of the constraints and challenges of general practice, compounded the lack of understanding and led to damaging misrepresentations:

I think a lot of the responsibility for putting people off general practice rests with the people who teach into the medical school and run the placements in the hospitals, because certainly my experience was that the hospital culture is quite disparaging of general practice. (recent fellow, FGD298)

This situation was resented and considered difficult to rectify:

I think GPs are more appreciated and respected by the general population than by the hospital. So if you can work some miracles, that would be great. (recent fellow, FGD258)

Discussion

We have reported the views of a broad range of people involved in general practitioner training, including practice managers, supervisors, recent fellows, and both general practitioner training and university medical educators. Practice managers and supervisors were particularly rich informants regarding the potential impact of proposals on patients and practice viability.

The four workshop recommendations for attracting and recruiting people to general practitioner training are not new, although proposals for single employer models are relatively recent. However, they offer a direction of travel for implementation and evaluation. Participants strongly supported increasing the visibility of positive general practitioner role models for medical students and junior doctors, and increasing the number of high quality clinical placements in general practices for both, provided that the practices are adequately compensated for lost income. Participants agreed that poorer income and employment conditions were major disincentives for considering general practice, and that more integrated patient care, while difficult to achieve, would strengthen professional relationships.

Our findings lend support to Australian medical school initiatives that offer longitudinal and extended general practice placements in urban and rural areas, and for ensuring that general practitioners contribute strongly to student teaching and mentoring. Our findings also support the reinstatement of junior doctor placements in general practice more broadly, while being alert to the potential impacts on training practices and patients, as well as the careful evaluation of trials of single employer models of trainee employment, with attention to reservations raised by our participants and others.21

Limitations

The participants in our workshops and focus groups were motivated to participate, and most were involved in general practitioner medical education or training. There were few migrant doctors among our participants. The participants’ views may not reflect those of the broader general practice community. We did not separately assess views by remoteness of participant location, and may have missed some location‐related differences.

Conclusion

The passion for general practice that infused many of the participants’ comments suggests that morale in the profession is reasonably healthy, although many practitioners see substantial challenges, the solutions for which are largely outside the control of the profession. The intensity of perceptions of being misunderstood and not respected by hospital‐based colleagues was striking. This suggests that there is some urgency for clinicians and educators from both sectors to work together to improve recruitment to general practice and reduce frustration in the profession. Support from several levels of government is also required to implement and evaluate many of the recommendations.