Factors that affect general practice as a choice of medical speciality: implications for policy development
Amit Vohra A D , Richard Ladyshewsky B and Stephen Trumble C
+ Author Affiliations
- Author Affiliations
A Sonic Clinical Services Pty Ltd, Level 32, 60 Margaret Street, Sydney, NSW 2000, Australia.
B Curtin Business School, Curtin Graduate School of Business, Curtin University, GPO Box U1987, Perth, WA 6845, Australia. Email: rick.ladyshewsky@gsb.curtin.edu.au
C Department of Medical Education, Level 7 East Melbourne Medical School, University of Melbourne, VIC 3010, Australia. Email: s.trumble@unimelb.edu.au
D Corresponding author. Email: amit.vohra@outlook.com
Australian Health Review 43(2) 230-237 https://doi.org/10.1071/AH17015
Submitted: 20 February 2017 Accepted: 4 October 2017 Published: 28 November 2017
Abstract
Objective This article critically appraises the range of personal, professional and social factors that affect the choice of speciality across medical students, prevocational doctors, general practice registrars and general practitioners.
Methods This qualitative study applied constructs from the fields of decision theory and career theory to better understand the complex nature of choosing a speciality. In all, 47 in-depth interviews were conducted with participants at different stages of their career cycle. The data was codified and analysed using NVivo to identify key factors that influenced speciality choice.
Results The research identified 77 individual findings influencing general practice as a choice of medical speciality. These were distilled into a matrix to show that factors such as money, prestige and peer interaction did not have a compelling effect, whereas clinical and academic role models, flexibility, work–life balance, scope of practice, connection with patients, training environment and practical opportunities did.
Conclusion The findings indicate that the decision in relation to the choice of medical speciality is a complex cognitive process that is undertaken within a personal, social and professional context particular to each individual.
What is known about the topic? Current literature aims to quantify changes in attitudes towards choice of speciality or the effect of particular variables in isolation while ignoring the complexity of this decision process and how the numerous variables compare with each other.
What does this paper add? The present study is the first intergenerational research on this topic in the Australian context and the paper dismisses the role of prestige and remuneration as key drivers of choice in picking general practice as a speciality, noting that money is merely a ‘hygiene factor’.
What are the implications for policy makers? A policy framework outlining 10 key principles is presented to assist policy makers seeking to affect workforce outcomes by applying policy levers to influence doctors’ choice of speciality.
References
[1] Daley J, McGannon C, Hunter A. Budget pressures on Australian governments 2014 edition. Melbourne: Grattan Institute; 2014. Available at: https://grattan.edu.au/wp-content/uploads/2014/05/812-budget-presures.pdf [verified 6 November 2017].[2] Moyniham M, Birrell B. GP oversupply – ignoring the evidence. Melbourne: The Australian Population Research Institute, Monash University; 2016. Available at: http://tapri.org.au/wp-content/uploads/2016/04/GP-oversupply-ignoring-the-evidence-12-Dec-2016.pdf [verified 6 November 2017].
[3] Australian Bureau of Statistics (ABS). 3101.0 Australian Demographic Statistics. Canberra: ABS; 2013.
[4] Weston R, Qu L, Soriano G. Ageing yet diverse: the changing shape of Australia’s population. Australian Family Briefing No. 10. Canberra: Australian Institute of Family Studies, Commonwealth Government of Australia; 2001. Available at: https://aifs.gov.au/publications/ageing-yet-diverse [verified 6 November 2017].
[5] Goss J. Projection of Australian health care expenditure by disease, 2003–2033. Canberra: Australian Institute of Health and Welfare; 2008. Available at: https://www.aihw.gov.au/reports/health-welfare-expenditure/projection-of-australian-health-care-expenditure-b/contents/table-of-contents [verified 6 November 2017].
[6] Health Workforce Australia. Health workforce 2025: medical specialties. Vol. 3. Adelaide: Health Workforce Australia; 2012.
[7] Mason J. Review of Australian Government health workforce programs. Canberra: Department of Health; 2013. Available at: http://www.health.gov.au/internet/main/publishing.nsf/content/review-australian-government-health-workforce-programs [verified 6 November 2017].
[8] Health Workforce Australia. Health workforce 2025: doctors, nurses and midwives. Vol. 1. Adelaide: Health Workforce Australia; 2012.
[9] Australian Government. Rebuilding general practice education and training to deliver more GPs. Canberra: General Practice Education and Training Limited; 2014.
[10] Birrell, B. Too many GPs. Melbourne: Centre for Population and Urban Research; 2013. Available at: http://tapri.org.au/wp-content/uploads/2016/02/birrell-too-many-gps-2013.pdf [verified 6 November 2017].
[11] General Practice Education and Training Limited (GPET). GPET Annual Reports 2001–2013. Canberra: GPET; 2013.
[12] Woods M. , Overview of Australian Health Workforce, Canberra: Commonwealth of Australia, 2007.
[13] RACGP. Media release: UGPA leaders insist on immediate training reforms to increase Australia’s GP workforce. 2013. Available at: https://www.racgp.org.au/yourracgp/news/media-releases/ugpa-training-reforms/ [verified 6 November 2017].
[14] Skinner C. Re-inventing medical work and training: a view from Generation X. Med J Aust 2006; 185 35–6.
[15] Kamien M, Cameron WI. Solving the shortage of general practitioners in remote and rural Australia: a Sisyphean task? Med J Aust 2006; 185 652–3.
[16] Joyce CM, McNeil JJ, Stoelwinder JU. Australian medical workforce supply 2001–2012. Med J Aust 2006; 184 441–6.
[17] Gati I, Landman S, Davidovitch S, Asulin-Peretz L, Gadassi R. From career decision-making styles to career decision-making profiles: a multidimensional approach. J Vocat Behav 2010; 76 277–91.
| From career decision-making styles to career decision-making profiles: a multidimensional approach.Crossref | GoogleScholarGoogle Scholar |
[18] General Practice Education and Training Limited (GPET). If the job fits…the complexity of medical career decision making: a review. Canberra: GPET; 2007.
[19] Brooks PM, Lapsley HM, Butt DB. Medical workforce issues in Australia: ‘tomorrow’s doctors –too few, too far’. Med J Aust 2003; 179 206–8.
[20] Kamien M. The viability of general practice in rural Australia. Med J Aust 2004; 180 318–19.
[21] Charles J. The evolution of the general practice workforce in Australia, 1991–2003. Med J Aust 2004; 181 85–90.
[22] Hansson SO. Decision theory: a brief introduction. Royal Institute of Technology, Stockholm 1994. Available at: http://home.abe.kth.se/~soh/decisiontheory.pdf [verified 6 November 2017].
[23] Tennyson RD, Schott F, Seel RM, Dijkstra S. Instructional design: international perspectives: theory research and models. Vol 1, NJ: Lawrence Earlbaum Associates; 1997.
[24] Joslyn C. Decision theory. 2000. Available at: http://pespmc1.vub.ac.be/ASC/DECISI_THEOR.html [verified 6 November 2017].
[25] Peterson M. An Introduction to decision theory. New York: Cambridge University Press; 2009.
[26] Scott J. Rational choice theory. In: Browning G, Halcli A, Webster F, editors. Understanding contemporary society: theories of the present. London Sage Publications; 2000; pp. 126–130.
[27] Oppenheimer JA. Rational choice theory. In: Bevir M, editor. The Sage Encyclopedia of Political Theory. London Sage Publications; 2008.
[28] Dewey J. How we think. Boston: D.C. Heath & Co. Publishers; 1978 (original work published 1910).
[29] Mintzberg H, Raisinghani D, Théorêt A. The structure of ‘unstructured’ decision processes. Adm Sci Q 1976; 21 246–75.
| The structure of ‘unstructured’ decision processes.Crossref | GoogleScholarGoogle Scholar |
[30] Wason PC, Johnson-Laird PN. Psychology of reasoning: structure and content. Cambridge, MA: Harvard University Press; 1972.
[31] Johnson-Laird PN, Byrne RMJ. Conditionals: a theory of meaning, pragmatics, and inference. Psychol Rev 2002; 109 646–78.
| Conditionals: a theory of meaning, pragmatics, and inference.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD38nhslWhsQ%3D%3D&md5=70c895e0c0905f2224e13e0bf61e2116CAS |
[32] Kahneman D, Tversky A. Choices, values and frames. Am Psychol 1984; 39 341–50.
| Choices, values and frames.Crossref | GoogleScholarGoogle Scholar |
[33] Doya K, Shadlen MN. Decision making. Curr Opin Neurobiol 2012; 22 911–3.
| Decision making.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BC38XhslWqu7%2FM&md5=c8bf45ed007b18aabc64d1d13aa899faCAS |
[34] Parsons F. Choosing a vocation. New York: Houghton Mifflin Company; 1909.
[35] Ginzberg E, Ginsburg SW, Axelron S, Herma JL. Occupational choice: an approach to a general theory. New York: Columbia University Press; 1951.
[36] Holland J.L. Some explorations of theory of vocational choice. I. One- and two-year longitudinal studies. Psychological Monographs: General and Applied 1962; 76 1–49.
[37] Super DE. Vocational development theory: persons, positions, and processes. Couns Psychol 1969; 1 2–9.
| Vocational development theory: persons, positions, and processes.Crossref | GoogleScholarGoogle Scholar |
[38] Krumboltz JD. A social learning theory of career selection. Couns Psychol 1976; 6 71–80.
| A social learning theory of career selection.Crossref | GoogleScholarGoogle Scholar |
[39] Dawis RV, Lofquist LH. Research on work adjustment and satisfaction: implications for career counseling. In: Brown SD, Lent RW, editors. Handbook of counseling psychology. New York: Wiley; 1984. pp. 216–217.
[40] Bandura A. Social cognitive theory: an agentic perspective. Asian J Soc Psychol 1999; 2 21–41.
| Social cognitive theory: an agentic perspective.Crossref | GoogleScholarGoogle Scholar |
[41] Krumboltz JD. The happenstance learning theory. J Career Assess 2009; 17 135–54.
| The happenstance learning theory.Crossref | GoogleScholarGoogle Scholar |
[42] Gottfredson LS. Circumscription and compromise: a developmental theory of occupational aspiriations. J Couns Psychol 1981; 28 545–79.
| Circumscription and compromise: a developmental theory of occupational aspiriations.Crossref | GoogleScholarGoogle Scholar |
[43] Phillips SD, Strohmer DC. Decision-making style and vocational maturity. J Vocat Behav 1982; 20 215–22.
| Decision-making style and vocational maturity.Crossref | GoogleScholarGoogle Scholar |
[44] Harren VA. A model of career decision-making for college students. J Vocat Behav 1979; 14 119–33.
| A model of career decision-making for college students.Crossref | GoogleScholarGoogle Scholar |
[45] Gati I, Asher I. Prescreening, in-depth exploration, and choice: from decision theory to career counseling practice. Career Dev Q 2001; 50 140–57.
| Prescreening, in-depth exploration, and choice: from decision theory to career counseling practice.Crossref | GoogleScholarGoogle Scholar |
[46] Zemke R, Raines C, Filipczak B. Generations at work. New York: American Management Association; 2000.
[47] Gursoy D, Maier T, Chi C. Generational differences: an examination of work values and generational gaps in the hospitality workforce. Int J Hospit Manag 2008; 27 448–58.
| Generational differences: an examination of work values and generational gaps in the hospitality workforce.Crossref | GoogleScholarGoogle Scholar |
[48] Cennamo L, Gardner D. Generational differences in work values, outcomes and person-organisation values fit. J Manag Psychol 2008; 23 891–906.
| Generational differences in work values, outcomes and person-organisation values fit.Crossref | GoogleScholarGoogle Scholar |
[49] Chang KM. Influence of non-cognitive factors on complex dynamic decision-making using computer-based simulations. Ann Arbor: University of Minnesota; 2000.
[50] Creswell JW. Research design: qualitative, quantitative and mixed methods approaches. 2nd edn. Thousand Oaks, CA: Sage Publications; 2003.
[51] Creswell JW. Qualitative inquiry and research design: choosing among five traditions. Thousand Oaks, CA: Sage Publications; 1998.
[52] Denzin NK, Lincoln YS. The landscape of qualitative research: theories and issues. 2nd edn. London: Sage Publications; 2003.
[53] Whiteley A, Whiteley J. The familiarisation study in qualitative research: from theory to practice. Qual Res J 2006; 6 69–85.
| The familiarisation study in qualitative research: from theory to practice.Crossref | GoogleScholarGoogle Scholar |
[54] Moustakas C. Phenomenological research methods. Thousand Oaks, CA: Sage Publications; 1994.
[55] Fontana A, Frey JH. The interview from neutral stance to political involvement. In: Denzin NK, Lincoln YS, editors. Handbook of qualitative research. Thousand Oaks, CA: Sage Publications; 2000. pp. 695–727.
[56] Stokes D, Bergin R. Methodology or “methodolatry”? An evaluation of focus groups and depth interviews. Qual Market Res Int J 2006; 9 26–36.
| Methodology or “methodolatry”? An evaluation of focus groups and depth interviews.Crossref | GoogleScholarGoogle Scholar |
[57] Saunders M. Choosing research participants. In: Symon G, Cassell C, editors. Qualitative organizational research – core methods and current challenges. London: Sage Publications; 2012. pp. 35–52.
[58] Banister P, Burman E, Parker I, Taylor M, Tindall C. Qualitative research in psychology: a research guide. Buckingham: Open University Press; 1994.
[59] Lincoln YS, Guba EG. Naturalistic inquiry. Newbury Park: Sage Publications; 1985.
[60] Herschell RM. Some principles for ‘quality control’ in qualitative research: a phenomenographic treatise. Association for Qualitative Research, Cambridgeshire, 1999.
[61] Thistlewaite JE, Shaw T, Kidd MR, Leeder S, Burke C, Corcoran K. Attracting health professionals into primary care: strategies for recruitment. Canberra: Australian Primary Health Care Research Institute; 2008. Available at: http://rsph.anu.edu.au/research/projects/attracting-health-professionals-primary-care-strategies-recruitment [verified 6 November 2017].
[62] Watmough S, Taylor D, Ryland I. Using questionnaires to determine whether medical graduates’ career choice is determined by undergraduate or postgraduate experiences. Med Teach 2007; 29 830–2.
| Using questionnaires to determine whether medical graduates’ career choice is determined by undergraduate or postgraduate experiences.Crossref | GoogleScholarGoogle Scholar |
[63] Watson J, Humphrey A, Peters-Klimm F, Hamilton W. Motivation and satisfaction in GP training: a UK cross-sectional survey. Br J Gen Pract 2011; 61 e645–9.
| Motivation and satisfaction in GP training: a UK cross-sectional survey.Crossref | GoogleScholarGoogle Scholar |
[64] Kiolbassa K, Miksch A, Goetz K. Becoming a general practitioner: which factors have most impact on career choice of medical students? BMC Fam Pract 2011; 12 25
| Becoming a general practitioner: which factors have most impact on career choice of medical students?Crossref | GoogleScholarGoogle Scholar |
[65] Newton DA, Grayson MS, Whitley TW. What predicts medical student career choice? J Gen Intern Med 1998; 13 200–3.
| What predicts medical student career choice?Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK1c3gtVCmsw%3D%3D&md5=154b45ea95b9dfe7c171d092942f4fe7CAS |
[66] Rabinowitz HK. The relationship between medical student career choice and a required third-year family practice clerkship. Fam Med 1988; 20 118–21.
| 1:STN:280:DyaL1c7ps1Krsg%3D%3D&md5=2aa3603b8015b758140bfc5607b4d98cCAS |
[67] Campos-Outcalt D, Senf J, Watkins AJ, Bastacky S. The effects of medical school curricula, faculty role models and biomedical research support on choice of generalist physician careers: a review and quality assessment of the literature. Acad Med 1995; 70 611–19.
| The effects of medical school curricula, faculty role models and biomedical research support on choice of generalist physician careers: a review and quality assessment of the literature.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2Mzjs1Gksg%3D%3D&md5=e9136923c688fdd74c01ee301aba395cCAS |
[68] Lynch DC, Willis SE. Can a 3-day preceptorship change first-year medical students’ opinions about living and working in small towns? Fam Med 2000; 32 495–9.
| 1:STN:280:DC%2BD3M%2FlvFSqtg%3D%3D&md5=029e2b9bff18dd62854692e8548c4ee8CAS |
[69] McKee NDM, Ramsden MA, Poole VR, Raenelle E. Cultivating interest in family medicine: family medicine interest group reaches undergraduate medical students. Can Fam Physician 2007; 53 661–5.
[70] Stagg P, Greenhill J, Worley PS. A new model to understand the career choice and practice location decisions of medical graduates. Rural Remote Health 2009; 9: 1245. Available at www.rrh.org.au/journal/article/1245 [verified 6 November 2017].
[71] Creed PA, Searle J, Rogers ME. Medical specialty, prestige, and lifestyle preferences for medical students. Soc Sci Med 2010; 71 1084–8.
| Medical specialty, prestige, and lifestyle preferences for medical students.Crossref | GoogleScholarGoogle Scholar |
[72] Pawełczyk A, Pawełczyk T, Bielecki J. [Determinants of primary care specialty choice.] Pol Merkur Lekarski 2007; 22 233–8.
[73] Senf JH, Kutob R, Campos-Outcalt D. Which primary care specialty? factors that relate to a choice of family medicine, combined internal medicine-pediatrics, or pediatrics. Fam Med 2004; 36 123–30.
[74] Buddeberg-Fischer B, Stamm M, Buddeberg C, Klaghofer R. Young physicians’ view on factors that increase the attractiveness of general practice. Gesundheitswesen 2008; 70 123–8.
| Young physicians’ view on factors that increase the attractiveness of general practice.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD1c3lsVKrtA%3D%3D&md5=2fe98d1dc2208f411dbfd0ab5270f996CAS |
[75] Thistlethwaite J, Kidd MR, Leeder S. Enhancing the choice of general practice as a career. Aust Fam Physician 2008; 37 964–8.
[76] O’Connell D. Patient variety in residency, and generalist career choice. Acad Med 1997; 72 91-91
| Patient variety in residency, and generalist career choice.Crossref | GoogleScholarGoogle Scholar |
[77] Hoffman T. Junior doctors languishing in hospital limbo. Australian Doctor. St Leonards: Reed Publishing, 2015.
[78] Hoffman T. Bonded bush doctors bail out of contracts. Australian Doctor. St Leonards: Reed Publishing, 2015.
[79] Tang TL-P, Kim JK, Tang DS-H. Does attitude toward money moderate the relationship between intrinsic job? Hum Relat 2000; 53 213–45.
| Does attitude toward money moderate the relationship between intrinsic job?Crossref | GoogleScholarGoogle Scholar |
[80] Morra DJ, Regehr G, Ginsburg S. Medical students, money, and career selection: students’ perception of financial factors and remuneration in family medicine. Fam Med 2009; 41 105–10.
[81] Tang TL-P. The development of a short money ethic sale: attitudes toward money and pay satisfaction revisited. Pers Individ Dif 1995; 19 809–16.
| The development of a short money ethic sale: attitudes toward money and pay satisfaction revisited.Crossref | GoogleScholarGoogle Scholar |
[82] Bland CJ, Meurer LN, Maldonado G. Determinants of primary care specialty choice: a non-statistical metaanalysis of the literature. Acad Med 1995; 70 620–41.
| Determinants of primary care specialty choice: a non-statistical metaanalysis of the literature.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2Mzjs1Gksw%3D%3D&md5=2a7cec7f4d17dc178a0bc9665beb7fa2CAS |
[83] Senf JH, Campos-Outcalt D, Kutob R. Factors related to the choice of family medicine: a reassessment and literature review. J Am Board Fam Pract 2003; 16 502–12.
| Factors related to the choice of family medicine: a reassessment and literature review.Crossref | GoogleScholarGoogle Scholar |
[84] Thistlethwaite JE, Leeder SR, Kidd MR, Shaw T. Addressing general practice workforce shortages: policy options. Med J Aust 2008; 189 118–21.
[85] Newton DA, Grayson MS, Thompson LF. The variable influence of lifestyle and income on medical students’ career specialty choices: data from two U.S. medical schools, 1998–2004. Acad Med 2005; 80 809–14.
| The variable influence of lifestyle and income on medical students’ career specialty choices: data from two U.S. medical schools, 1998–2004.Crossref | GoogleScholarGoogle Scholar |
[86] Laven G, Wilkinson D. Rural doctors and rural backgrounds: how strong is the evidence? A systematic review. Aust J Rural Health 2003; 11 277–84.
| Rural doctors and rural backgrounds: how strong is the evidence? A systematic review.Crossref | GoogleScholarGoogle Scholar |
[87] Norris TE. The universal importance of the ‘pipeline’. Aust J Rural Health 2005; 13 203–4.
| The universal importance of the ‘pipeline’.Crossref | GoogleScholarGoogle Scholar |
[88] Pretorius RW, Milling DA, McGuigan D. Influence of a rural background on a medical student’s decision to specialize in family medicine. Rural Remote Health 2008; 8 928–9.
| 1:STN:280:DC%2BD1crptVOrsQ%3D%3D&md5=bda6d242601ab5961da033576c3f1f4bCAS |
[89] Somers GT, Strasser R, Jolly B. What does it take? The influence of rural upbringing and sense of rural background on medical students’ intention to work in a rural environment. Rural Remote Health 2007; 7 706
[90] McDonald J, Bibby L, Caroll S. Recruiting and retaining general practitioners in rural areas: improving outcomes through evidence-based research and community-capacity building. Evidenced-based review. Ballarat: University of Ballarat; 2002. pp. 189–198.
