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Postgraduate Attachment to General Practice; Influence on Doctors’ Future Career Intentions

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Postgraduate Attachment to General Practice; Influence on Doctors’ Future Career Intentions A University of Sussex DPhil thesis Available online via Sussex Research Online: http://sro.sussex.ac.uk/ This thesis is protected by copyright which belongs to the author. This thesis cannot be reproduced or quoted extensively from without first obtaining permission in writing from the Author The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the Author When referring to this work, full bibliographic details including the author, title, awarding institution and date of the thesis must be given Please visit Sussex Research Online for more information and further details Postgraduate attachment to general practice; Influence on doctors’ future career intentions Dr Neil Macarthur Munro Doctor of Philosophy University of Sussex February 2011 iii Acknowledgements I am indebted to my supervisor, Professor Michael Eraut, for his expert advice and skilled support during the development and implementation of this study. I am grateful to Stephen Steadman for his statistical guidance in the analysis of questionnaire responses and to Sarah Aynsley for her review of the final thesis. I am also grateful to Professor Abdollah Tavabie, General Practice Postgraduate Dean of Kent, Surrey and Sussex (KSS) Deanery for his active encouragement of my research and the Deaneries’ ongoing financial support. Without this backing the study would not have been feasible. I would like to acknowledge the generosity of Professor Rodney Gale and Professor Janet Grant in permitting use of sci 59 questionnaires and associated analytical software. I am particularly grateful to my wife, Bernadette, and my two sons, Harry and David, for their forbearance, and support, during the time of the study and the preparation of the thesis. iv Table of Contents Chapter Page Summary 1 Chapter 1: Introduction 1.1 Recruitment to general practice 3 1.1.1 Factors influencing recruitment to general practice 3 1.2 Developments in postgraduate medical education 4 1.2.1 Foundation training 4 1.2.2 Postgraduate medical career paths 5 1.2.3 Foundation year 2 general practice attachments 5 1.3 Formulating the hypothesis 6 1.4 Planning a literature review 7 Chapter 2: General Practice in the UK 2.1 The nature and structuring of general practice 9 2.2 The supply and demand for general practitioners 11 2.3 Gender and general practice career choice 15 2.4 Timing of career decision 20 2.5 Career advice 25 2.6 Changing career decisions 27 Chapter 3: Factors influencing career choice in the UK 3.1 Factors influencing career choice prior to medical school/university 29 3.1.1 The influence of A level grades 30 3.1.2 The influence of learning styles 32 3.2 Factors influencing career choice during medical school/university 33 3.3 Factors influencing career choice following graduation 37 3.4 Career decisions outside medicine 42 3.4.1 Early thinking 42 3.4.2 Later thinking 43 v Chapter 4: Evidence from other countries with similar degrees of general practice development 4.1 USA 45 4.1.1 Background 45 4.1.2 Meta-analysis and literature reviews 46 4.1.3 Factors influencing career choice 49 4.1.4 Rejecting general practice 50 4.1.5 ‘Badmouthing’ and general practice 52 4.1.6 Personality and general practice 54 4.1.7 Financial influences 56 4.1.8 Litigation and general practice 59 4.2 Canada 4.2.1 Declining interest in general practice 61 4.2.2 Factors influencing career choice 63 4.2.3 Changing career decisions 69 4.2.4 Rural practice as a career 71 4.2.5 Financial influences 74 4.3 Europe 4.3.1 Declining interest in general practice 76 4.3.2 Factors influencing career choice 78 4.3.3 Gender and career preference 79 4.3.4 Working patterns and career choice 83 4.4 Australia and New Zealand 4.4.1 Declining interest in general practice 84 4.4.2 Factors influencing career choice 86 4.4.3 Gender and general practice career choice 97 4.4.4 ‘Badmouthing’ and general practice 97 Chapter 5: Summarising the Literature Review 5.1 Interest in general practice as a career 99 5.1.1 Factors influencing career choice 99 vi 5.2 Gender and general practice 100 5.3 Lifestyle and medical career choice 101 5.4 Timing of career decisions 102 5.5 Career decision making outside medicine 102 Chapter 6: Background to the Study 6.1 The Calman review and the growing problems of senior house officers 104 6.2 Modernising Medical Careers (MMC) 107 6.3 Foundation training 114 Chapter 7: Methodology 7.1 Aim of the study 120 7.2 Overview 120 7.3 Choice of the sci 59 questionnaire 123 7.3.1 Choice of sci 59 123 7.3.2 Development and history of sci 59 123 7.3.3 Practical issues around sci 59 during the study 126 7.3.4 Issues around the development of sci 59 127 7.4 Approaching participants 128 7.5 Interviews 129 7.6 Ethical approval 133 7.7 Case study consents 138 7.8 Governance approval 139 7.9 Statistical analyses 140 Chapter 8: Results from Questionnaires 8.1 Invitation and response rates 141 8.2 The impact of MTAS (Medical Training Application System) 142 8.3 Change in career rankings after general practice attachment 143 8.3.1 Change in career preference 144 8.3.2 ‘Q1 to Q2 movement’ – a new measure 144 8.3.3 Changes in sci 59 rankings 145 8.3.4 Comparing mean rankings between questionnaires 145 8.3.5 Questionnaire 1 rankings and ‘Q1 to Q2 movement’ 146 vii 8.3.6 Investigating national differences 146 8.4 Exploratory regression analysis 146 8.4.1 Selecting variables 146 8.4.2 Examining the correlation matrix 147 8.5 Exploring potential contributions of independent variables 148 to ‘Q1 to Q2 movement’ changes 8.5.1 Basic data used in the sci 59 side of the study 148 8.6 Summary of questionnaire results 148 Chapter 9: Results from Interviews 9.1 Themes from thirty interviews 151 9.1.1 Before medical school 151 9.1.2 Undergraduate/medical school and foundation year 1 152 9.1.3 Foundation year 2 experience 153 9.1.4. MTAS (Medical Training Application System) 153 9.2 Interviews -analysis of thematic coding 161 9.2.1 Before medical school 164 9.2.2 Influences before the age of 16 164 9.2.3 Influencing factors between age 16 and medical school 168 9.2.4 Summary of influences before university/medical school 174 9.3 Undergraduate/medical school and foundation year 1 175 9.3.1 Undergraduate experience 176 9.3.2 Foundation year 1 and general practice 188 9.3.3 Summary of influences during undergraduate/medical 191 School and foundation year 1 9.4 Foundation year 2 experience 194 9.4.1 GP activities 195 9.4.2 Practice environment 201 9.4.3 Teaching and learning 204 9.4.4 Summary of influences during foundation year 2 211 general practice attachments 9.5 MTAS (Medical Training Application System) 214 9.5.1 Demoralisation with MTAS (Medical Training Application System) 215 9.5.2 Summary of influences of MTAS (Medical Training Application System) 219 viii Chapter 10: Discussion 10.1 Background to the study 221 10.1.1 Developments in postgraduate training 221 10.2 Formulating a hypothesis 222 10.3 Developing a methodology 222 10.4 Findings from sci 59 questionnaires and participant interviews 223 10.5 Thinking around early career choices in medicine 224 10.6 Career thinking as an undergraduate 227 10.7 Career thinking post graduation 229 10.8 Career thinking during foundation year 2 230 10.9 Foundation training and general practice choice 233 10.9.1 Choosing career paths 233 10.10 Recruitment to general practice 234 10.10.1 Advanced nurse practitioners 234 10.10.2 Physician assistants 235 10.11 Impact of foundation training on medical careers 236 10.11.1 Recruitment to general practice training programmes 236 10.11.2 Managing career expectations 237 10.11.3 Workplace based assessment (WPBA) in foundation training 237 10.11.4 Timing of career choice 238 10.12 The need to understand career thinking among doctors post-graduation 239 10.13 New information and new questions emerging from the study 239 10.14 Limitations of the study 242 Chapter 11: Conclusion 243 References 245 ix List of Tables Table 1: Differences between the first and fifth year students and between genders 22 Table 2: Likelihood of choosing general practice as a career before, and after, an undergraduate attachment in general practice and after a year as a pre-registration house officer 34 Table 3: Negative comments heard by medical students about family practice 53 Table 4: Comments about family physicians heard ‘often’ by students 54 Table 5: Comparison on NEO PI-R for 11 specialty choices: Tulane school of medicine classes (2003-2006) 55 Table 6: Comparison on NEO PI-R for graduates who changed and did not change specialty choice between matriculation and graduation: Tulane school of medicine classes (2003–2006) 56 Table 7: Salary and residency match data 58 Table 8: Factors in choosing a high or low-risk specialty 60 Table 9: Odds ratios for predictor variables associated with choosing family medicine first as a career 68 Table 10: Demographic differences according to career choice 73 Table 11: Students’ estimates of physician income compared with actual physician income 74 Table 12: Perception of remuneration by specialty and students considering family medicine 75 Table 13: Extrinsic and intrinsic factors influencing choice of specialty of Australian doctors in vocational training, by general practice trainees and trainees in other clinical specialties, 2002 88 Table 14: Timing of decision on specialty training program of doctors in vocational training in Australia, by training program, 2002 89 Table 15: Career prestige ranking among Australian medical students 96 Table 16: Lifestyle friendliness
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