Developing the intention to pursue a general practice career: a longitudinal survey study from medical school graduation into postgraduate medical training | BMC Medical Education

In summary, we observe a stable commitment to a career in general practice among Danish medical trainees, with the majority (around 70%) maintaining their intention to pursue this path over time. Notably, there is even an increase in the number of trainees who decide to pursue general practice as they transition from undergraduate to postgraduate training.

Results also reveal a significant difference in parenthood status within the group of medical trainees shifting specialty orientation towards general practice during the follow-up period. To evaluate the stability of factors related to the intention to pursue a career in general practice, we examined perceived specialty characteristics, such as working hours and career opportunities, which were previously shown to be associated with a preference for general practice over other specialties [20]. Our analyses show that these associations remain consistent over time, indicating that the same variables are linked to the intention to pursue a general practice career at both baseline and follow-up.

Understanding the intention to pursue a career in general practice

The framework utilized in this study provides insight into specialty choice process over time, emphasizing how medical trainees’ interest in a specialty is shaped by alignment between their personal characteristics and the perceived characteristics of the specialty. Personal characteristics of medical trainees include their values, preferences, and priorities, which in the framework is exemplified by factors such as societal orientation, interest in a diverse scope of practice, rural background, gender, and socioeconomic status.

In an earlier paper, we described how the cohort seemed to have already gained an authentic impression of actual work life in general practice before entering basic clinical training [20]. This is supported by solid evidence in the literature that undergraduate exposure to general practice plays a significant role in shaping the perception of the characteristics of general practice as a specialty [21, 23, 33,34,35], and the importance of authentic experiences in general practice has also been emphasized [36, 37]. However, this phenomenon does have nuances; interviews with junior doctors in the UK during their initial postgraduate training years suggest that their perceptions of medical work, shaped by observations or assisting as students, often differ significantly from the realities of practicing as a doctor [38].

The present study adds to this by including the temporal dimension in the investigation. Interestingly, we find no changes in the specialty characteristics associated with the intention to pursue a career in general practice over time during the first postgraduate training year. However, we have two intriguing observations regarding the dynamic development and personal characteristics of the medical trainees: The proportion of the study population intending to pursue a career in general practice increases over time, but so does the subgroup of medical trainees who are parents and intend to pursue a career in general practice. According to the applied conceptual framework, we suggest that changes in the medical trainees’ personal characteristics can cause changes in the attitudes towards the offered specialty characteristics that might lead to a transition in the medical trainees’ specialty orientations. However, in the period between the observations in this study, the medical trainees gain firsthand experience as practicing physicians, which can also be considered an ‘action’ in the framework [30]. For medical trainees already pursuing a career in general practice, it may positively affect the feedback loop explained in the model since acquiring general practice-specific competencies could hypothetically increase confidence in their ability to complete a GP’s tasks [38]. On the contrary, a medical trainee holding a specialty intention in favor of another specialty than general practice may be surprised by what actual work is like in that specialty, for instance, shift work. This can have a negative effect on the feedback loop caused by a change in the outcome expectations as one realizes that day work is more important than what he or she expected as a medical student. The result would be a decreased interest in the specialty and potentially a shift in specialty orientation.

The subpopulation analysis of personal characteristics in this study provides new insights into the personal life changes for medical trainees, especially regarding family formation during the follow-up period. We find that almost half of the medical trainees intending to pursue a career in general practice at follow-up are parents, compared to only around one-fourth of the medical trainees with other specialty preferences. This raises attention to the life-changing transition that family formation is. Recent research also shows that medical trainees become increasingly lifestyle-oriented in their motives for specialty choice as they progress through medical education. In 2016, Querido et al. reviewed how factors solely associated with specialty preferences in first-year medical students seemed more personally oriented (geography, self-confidence, positive attitude toward patient population), whereas factors associated with final-year students’ specialty preferences appeared more specialty-oriented (lifestyle, workload, personal experiences) [14]. A newly published qualitative study supports Querido et al.’s understanding of the dynamic nature by suggesting that medical trainees’ image of their profession shifts from mainly idealistic at medical school entry to realistic at graduation. Also, priorities change from content-oriented (about what they want to be) towards lifestyle-based (about how they want to work) as medical trainees gain practical experience and insights into the profession [29]. So far, this has been described in the context of undergraduate medical education; however, our results indicate that personal circumstances, especially family formation, also play a role when specialty orientations change later in medical education. This is particularly relevant in the Danish context, where there is no set time limit for specialty choice, allowing trainees to make their decision an indefinite number of years after medical school graduation. This extended timeline creates ample opportunity for changes in career intentions, as well as for the diminishing of the proximity effect, where trainees may show heightened interest in specialties they have recently encountered. The present study cannot assess which mechanisms account for the changes we observe; however, the literature supports that medical trainees change preferences, values, and priorities during medical school [14, 29] and even their sense of identity [39].

Comparison to the existing literature

The reported consistency in medical students’ specialty preferences throughout their undergraduate medical education varies across the available literature. In 2012, a cohort study on 1,542 Canadian medical students reported that around half of the cohort had the same specialty preference at medical school entry and exit, with family medicine being among the most stable career intentions [40]. Recently, a smaller Swiss study reported that only 18% of a cohort of medical students did not change their specialty intention over four years [28]. However, studies agree that medical students’ preference for a primary care career increases along with undergraduate medical education progression [5, 40, 41].

The present study adds to the existing research on the specialty choice process by finding that the stability of specialty preferences in undergraduate medical education continues into early postgraduate training years. Further, the study contributes to the research on recruitment of future GPs to meet the rising demand by indicating that more medical trainees are becoming oriented toward a general practice career over time. Even though we investigate specialty intentions and not final specialty choices, the results are promising as these intentions at medical school graduation tend to transform into actual specialty choices later in postgraduate education.

In 2010, Goldacre and colleagues examined how medical graduates’ early specialty intentions translated into actual specialty choices in the UK [27]. A large prospective cohort study found years 1 to 3 after graduation pivotal in the definitive formation of junior doctors’ career plans. Also, they identified general practice as the specialty with the highest match between specialty intentions in year one after graduation and eventual specialty choice. Interestingly, only half of the doctors who eventually chose a general practice career had general practice as their first choice of career in year 1 [27]. According to the authors, the findings indicate that many doctors fulfilled their early career ambitions but also that many doctors shifted their specialty intentions in favor of general practice during the postgraduate training years. Therefore, we consider the high commitment to a general practice career observed in this study to be an important step in securing the future GP workforce in Denmark.

The interplay between personal and specialty characteristics and the perceived work-life balance among health professionals, including physicians, has been in the spotlight for years [42]. Also, the perception of a good work/life balance has been suggested to be an essential motivator for medical trainees choosing a primary care career [29, 43, 44]. Our findings align with those reported in the UK [38], confirming that medical trainees across specialties prioritize work/life balance as a key concern. Notably, our study suggests that the importance of work/life balance becomes increasingly crucial to medical trainees as they advance in their medical training. This underpins that the personal orientation of medical trainees grows along with medical education, in line with the formerly mentioned results by Querido et al. and Pfarrwaller et al. [14, 29].

In this light, we find it intriguing that the collective results from our study group show that medical trainees’ attitudes toward perceived specialty characteristics are also significantly related to different specialty orientations [20]. Our studies emphasize that although most medical trainees consider work/life balance essential, the perception of a good work/life balance is individual. We suggest this to be closely related to the career decision-making process of the conceptual framework [30] and mainly to the medical trainees’ considerations about ‘how they want to work’ [29]. Gaining firsthand experience as practicing physician during postgraduate training might form medical trainees’ specialty intentions by overriding previous attitudes toward work attributes as part of this decision-making process. We find that positive attitudes towards autonomy in working conditions regarding controllable work hours shape interest in general practice specialization at both baseline and follow-up, which is congruent with findings reported in the international literature [45,46,47]. In a healthcare system undergoing continuous transformation—where an increasing number of patients are expected to be managed in general practice and discussions are ongoing about extending general practice office hours and services in Denmark—understanding the importance of working hours and conditions for interest in general practice specialization is crucial. A controllable lifestyle remains a highly valued aspect of working life among medical trainees entering specialist training, underscoring the relevance of these factors in shaping career preferences.

Strengths and limitations

A strength of this study is that it is a nationwide longitudinal investigation utilizing the same conceptual framework in the study design and interpretation of the results [26]. However, an obvious constraint in the study is that the design only allows an examination of the relationship between the intention to pursue a career in general practice and the suggested factors. The applied mixed models are suitable for analyzing repeated measured data, where measurements are taken on the same subjects over time, as they account for within-subject correlation and individual variability. Nevertheless, they do not provide information about causality, and the estimates do not account for the changes in specialty orientations from baseline to follow-up. Therefore, the reported changes in estimated odds ratios can be either due to changes in attitudes within the group of trainees intending to pursue a general practice career or changes within the group of medical trainees not having such intentions. Despite the significant results, the broad confidence intervals indicate high levels of uncertainty in the estimates. While the guiding conceptual framework aids in understanding the relationship between the medical trainees’ attitudes towards the suggested factors and their specialty intention, establishing causality necessitates an experimental or controlled observational design. Likewise, future qualitative studies are needed to elucidate how changes in personal characteristics affect the intention to pursue a career in general practice. Also, longitudinal studies are needed to investigate whether shifts in specialty orientations due to changes in personal characteristics are persistent after family foundation or if the change in intention towards a career in general practice is only transient due to a changed work/life balance caused by a demanding personal life.