gms | German Medical Science

GMS Journal for Medical Education

Gesellschaft für Medizinische Ausbildung (GMA)

ISSN 2366-5017

Predictors of a positive attitude of medical students towards general practice – a survey of three Bavarian medical faculties

research article medicine

  • corresponding author Antonius Schneider - Technische Universität München, Klinikum rechts der Isar, Lehrstuhl für Allgemeinmedizin, München, Deutschland
  • Marlies Karsch-Völk - Technische Universität München, Klinikum rechts der Isar, Lehrstuhl für Allgemeinmedizin, München, Deutschland
  • Alica Rupp - Technische Universität München, Klinikum rechts der Isar, Lehrstuhl für Allgemeinmedizin, München, Deutschland
  • author Martin R. Fischer - Klinikum der LMU München, Lehrstuhl für Didaktik und Ausbildungsforschung in der Medizin, München, Deutschland
  • Hans Drexler - Friedrich-Alexander-Universität Erlangen-Nürnberg, Medizinische Fakultät, Institut und Poliklinik für Arbeits-, Sozial- und Umweltmedizin, Erlangen, Deutschland
  • Jörg Schelling - Ludwig-Maximilians-Universität München, Klinikum der Universität München, Lehrbereich Allgemeinmedizin, München, Deutschland
  • Pascal Berberat - Technische Universität München, Klinikum rechts der Isar, Studiendekanat TUM MeDiCAL, München, Deutschland

GMS Z Med Ausbild 2013;30(4):Doc45

doi: 10.3205/zma000888, urn:nbn:de:0183-zma0008881

This is the English version of the article.
The German version can be found at: http://www.egms.de/de/journals/zma/2013-30/zma000888.shtml

Received: April 30, 2013
Revised: August 15, 2013
Accepted: September 17, 2013
Published: November 15, 2013

© 2013 Schneider et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Abstract

Objective: Germany is witnessing an increasing shortage of general practitioners (GPs). The aim was to determine predictors of the job-related motivation of medical students of three medical faculties with different institutionalisation of general practice as an academic discipline.

Methods: Medical students were surveyed with a standardised questionnaire about their attitudes towards general practice and their motivation to work as a GP in different working conditions. Predictors for positive attitudes and motivation were calculated using logistic regression models.

Results: 940 (15.2%) out of 6182 medical students from three Bavarian medical faculties participated in an online survey. 585 (62.7%) were female, and the average age was 25.0 (standard deviation 3.7). The average grade of a university-entrance diploma was 1.6 (standard deviation 0.5). 718 (76.4%) could imagine working as a GP. However, they favoured being employed within another organisation and not having their own private practice (65.5% vs. 35.1%). “Presence of a professorship of general practice” was associated with a positive attitude towards general practice (OR 1.57; 95%CI 1.13-2.417). Motivation for working as a GP was associated with “being female” (OR 2.56; 95%CI 1.80-3.56) and “presence of a professorship of general practice” (OR 1.68; 95%CI 1.14-2.46). Having a lower grade for one’s university-entrance diploma was associated with a higher preference to work in one’s own practice (OR 1.39; 95%CI 1.02-1.90).

Conclusion: A high amount of medical students were open-minded towards general practice. However, they favoured employment within an organization over working in their own practice. Institutionalisation of general practice as an academic discipline might be of importance to gain positive attitudes towards general practice and motivate medical students to work as a GP.

Keywords: general practice, institutionalisation, medical students, medical profession, motivation


Introduction

There has been an increasing shortage of physicians for more than ten years [1], in particular in rural areas and in primary care [2]. Several factors might be responsible for that, like migration into cities, migration into other countries [3] or a lack of attractiveness in dealing with patient care [4] that might be explained by the pressure associated with such work [1]. The shortage of general practitioners (GPs) is a challenge as reasons for this are referred to an image problem [5]. It needs to be stated that this development is a worldwide phenomenon, e.g. in the USA [6], Australia [7], Switzerland [8] and Norway [9]. The shortage of GPs is also developing dramatically due to the increasing age of practicing GPs. It is expected that around 52,000 physicians will retire by 2020 [4]. Furthermore, both the number of board certifications and general practitioners with their own practices is decreasing while the number of specialists in private practices is on the rise (general practitioners and specialists are allowed to work in private practices in Germany). 54.8% of private practices were owned by GPs in 1996 whereas 42.8% were owned by specialists. This proportion reversed starting in 2005. By 2010, 47.1% of practices were owned by GPs and 52.9% were owned by specialists. Additionally, there is a decreasing willingness to work in solo practices [10].

Several strategies are implemented in Germany to impede the shortage of GPs. Beyond political strategies, important roles are given to the medical curriculum and the structure of vocational training. Structured networks for vocational training were established by the university-based institutes of general practice several years ago, and increasingly the chambers of physicians and the Associations of Statutory Health Insurance Physicians are active in this field. These networks should provide for a structured traineeship and transparent conditions for vocational training. Beyond that, it is well known that role models are important to motivate medical students to pursue general practice and their respective, chosen specialities in the future [11], [12]. Both the amount of lessons and of concrete experiences in general practice during the course of study are essential factors for the development of a sustainable positive attitude towards family medicine [13], [14], [15]. Therefore, the Medical Licensure Act was changed in 2012, to include an extension of the internship time period to two weeks and the implementation of a compulsory, four-week medical clerkship in general practice, internal medicine or paediatrics in private practice. Moreover, it is postulated that a stronger institutionalisation of general practice at the universities would increase the motivation of medical students to become a GP [16], [17].

In 2012, family medicine institutes or divisions were established at 25 medical faculties, including 19 chairs for general practice. There were no institutes or divisions at the five Bavarian medical faculties developed until 2009. The first institute in Bavaria was established as a foundation chair, which was sponsored by the Bavarian Association of Staturory Health Insurance Physicians and the health insurance fund AOK Bayern, in July 2009 at the Technische Universität München (TUM). This chair is active in research and medical teaching. New institutes of general practice will be established in Erlangen and at the Ludwig-Maximilians-Universität München (LMU) soon. Senior lecturers who are working full-time in general practice are engaged in medical teaching at the medical faculties of TUM, LMU and Erlangen. The aim of this study was to identify influential factors regarding the motivation of medical students for being a general practitioner by comparing three universities with different levels of institutionalisation of general practice as an academic discipline.


Methods

In the cross-sectional survey, all clinical semester students were asked one-time via email to participate in an internet-based survey by the Offices of Student Affairs of the Medical Faculties of the Ludwig-Maximilians Universität München and the Technische Universität München. At LMU and TUM a matriculation number could be indicated voluntarily; for the rest the survey was completely anonymous. Approval by Ethical committees was obtained. The Medical Faculty of the University Erlangen also participated in the survey and sent the email to clinical and pre-clinical semester students.

The Questionnaire by Kruschinski et al. was used as a basis [13]. It was especially developed to determine students’ attitudes toward general practice. This questionnaire presents an appropriate variety of culturally adapted items selected from instruments in the Anglo-American literature against the background of the characteristics of the German educational and health system [13]. Additionally, self-developed questions were added in order to assess the disposition to work in one’s own private general practice versus working as an employee. Additional items were introduced to determine the impact of the institutionalisation of general practice at the university. All items were reported on a five-point Likert scale (1="strongly disagree" to 5="strongly agree"). The significance of group differences was computed using the Kruskal-Wallis-Test for continuous data and the Chi2-Test for categorial data. Two categories were generated with respect to motivation for occupation as a general practitioner: “Motivation present” = “5” or “4” and “Motivation not present” = “3” or “2” or “1”. The binary coded variable “motivation” was used as dependent variable for binary logistic regression. A binary logistic regression was also computed as an inclusion model regarding the sum scale “Appreciation of General Practice” as an additional dependent variable. In order to provide validity, the following dichotomization was conducted: “High Appreciation” is present if the mean of the scale is ≥ 4. “No Appreciation” is present if the mean of the scale is < 4. As LMU and TUM preclinical semester students are taught collectively in common pre-clinic courses in Munich and are not allocated before clinical semesters, preclinical semester students have not been surveyed. In order to allow control of effects of preclinical semester students from Erlangen, a sensitivity analysis was conducted by removing preclinical semester students from the regression model.


Results

In total 940 students participated in the survey. With 6182 students at all three universities altogether, the participation rate was 15.2%. In terms of the particular medical faculties, the following participation rates could be observed: TUM – 336 (23.0%) participants of 1458 clinical semester students, LMU – 386 (15.4%) participants of 2505 clinical semester students, Erlangen – 218 (9.8%) participants of 2219 students in total (clinical and pre-clinical semester students). Five-hundred and eighty-five (62.7%) were female; seven participants provided no information about their gender. Altogether, the mean university-entrance diploma grade was 1.6 (standard deviation 0.5). Only 32 students had a university-entrance diploma grade of 3 or worse; the worst grade was 3.6. Participants of the University Erlangen were in slightly earlier semesters, although no significant differences with respect to age were recorded (see Table 1 [Tab. 1]). Furthermore, students in Erlangen came significantly more from rural areas than LMU and TU students. In total 718 (76.4%) students could generally imagine working as a general practitioner. These students stated in at least one of the items “employee in practice / medical service centre” or “general practitioner in own practice” (either “5” or “4”). 617 (65.6%) could imagine working as an employed practitioner (practice or medical service centre). 330 (35.1%) could also see themselves working as self-employed general practitioner in own private practice. The disposition to work as a general practitioner was highest among TUM students. 669 (71.2%) students could imagine employment in a hospital. In this respect, no significant differences between the universities could be observed.

The analysis of the questionnaire about students’ attitudes towards general practice showed a notable ceiling effect. In other words, answer options are strongly shifted to the “socially requested” sphere, thus much upwards or downwards depending on the direction of the answer options. Nevertheless, differences between students as a function of the particular universities can be observed and partly also develop significance (see Table at attachment [Attach. 1]). Analysis indicates that TUM students estimate general practice in numerous aspects better than LMU and Erlangen students. In the logistic regression with “appreciation of general practice” as the dependent variable, “presence of a professorship of general practice” is observed to be the strongest predictor (see Table 2 [Tab. 2]). Furthermore, female gender and rural origin were significantly associated with a stronger appreciation.

A binary logistic regression regarding the motivation for “generally working as a GP” as the dependent variable indicated that “female gender” and “presence of a professorship of general practice” were the strongest predictors (see Table 3 [Tab. 3]). In this respect, university-entrance diploma grade had no influence. ´Female gender´ is also a generally strong predictor for the preference to work as an employed person. With regard to self-employment, “grown up in a rural area” is the strongest predictor. University-entrance diploma grade also matters in this regard – the worse the university-entrance diploma grade, the more likely the preference to work in one’s own GP surgery. Regarding this, it should be considered that on average, university-entrance diploma grades are very good. Therefore deviations towards worse grades should be interpreted with caution. The sensitivity analysis of the logistic regression model without pre-clinic semester students from Erlangen did not result in significant differences in comparison with the collective group; only discrete changes of odds ratios (OR) which were about 0.1 or 0.2 without a change in the weighting of the models could be observed.


Discussion

The online survey among students of the University Erlangen, LMU and TUM indicated three important circumstances: (1) women have a stronger tendency to take up an occupation as a general practitioner, (2) institutionalisation of general practice is also connected with this attitude, and (3) it is important if students are from a rural area. These three characteristics were also connected with a higher appreciation of general practice as a medical specialist area. University-entrance diploma grades, however were not crucial regarding attitudes towards general practice.

The preference of female students for general practice is already known from international studies, though the results have been inconsistent (11). Studies from Canada (18) and the Netherlands (19) showed no gender effect. Related to German circumstances, Kruschinski et al. demonstrated that female students showed higher appreciation for general practice (13). A recent survey in Baden-Württemberg illustrated that female medical students are more in favour for general practice (20). However, this was also true for medical specialist areas such as gynaecology, paediatrics and internal medicine. The preference for being a general practitioner was pronounced in our study, in particular with a focus on employment within an institution. Enhanced willingness to work as general practitioner can be explained from an individual as well as from a structural perspective. On the one hand, women show more appreciation for key aspects typical for general practice such as patient orientation (21). On the other hand, more opportunities for compatibility of family and career are facilitated by part-time work or abandonment of shift-working (22). For example, training terms in general practice are easier to realise as part-time work than in the clinical setting. Later on, collaboration in group practices or medical service centres alleviates part-time work, which is not easy to do in a hospital. More qualitative research would be necessary to confirm these assumptions, as it can not be revealed from structured questionnaires alone. As already mentioned in a Dutch study, it has to be questioned why the ´feminization of medicine,´ which has been persisting for years, is not leading to a significant increase of recruitment of young doctors for the area of general practice (19). It could be observed in their study, that women’s motivation to choose an occupation as general practitioner could not be preserved in the long term and decreased severely shortly after graduation. Reasons for that were not analysed in their study. Our study is not able to make a statement concerning the progress of motivation after graduation. However, the high preference for an occupation as employed general practitioner could indicate that entrepreneurial challenges and responsibilities of self-employment are more likely to be depreciated.

The frequently assumed coherence that students who tend to have worse university-entrance diploma grades are more likely to be prone to general practice could not be confirmed. Nevertheless, there was an association between ´worse´ university-entrance diploma grades with the motivation to work in one’s own, private general practice. It could be speculated that this is more likely to be associated with a disposition for autonomy than with general practice. But basically it has to be stated that university-entrance diploma grades of the participants generally reach a fair average, which might limit the informative value.

The impact of the presence of a professorship of general practice for the motivation of students for general practice has already been postulated repeatedly (16; 17). To our knowledge this was never firmly verified before. The inclusion of one medical faculty with a chair of general practice and two faculties without a chair allowed estimating a relevant difference with regard to the appreciation of general practice as well as regarding the willingness of a future occupation as general practitioner. This might be explained by the fact that an academic presence draws more attention among the students and increases awareness of the scientific content by promoting and intensifying medical dissertations. Beyond that, networking with other academic fields is possible, and role models for academic careers are also established. There is some evidence that short term or single-teaching activities (like two-week practical training) have some immediate effects, however the motivation might not be sustainable enough [13], [19]. It might be speculated that the institutionalisation of a chair leads to a more sustainable effect on the teaching activities, which in turn could lead to a more positive attitude towards general practice.

An important limitation of our findings is that only three universities were included in our survey. Therefore, it remains unclear which factors at the chair of general practice contributed in detail to the positive attitude of the medical students. A reason might be an enhanced motivation of all personal staff – scientific assistants and senior lecturers – in terms of a ´honeymoon-effect,´ which contributes to this effect. Beyond that, a higher resource investment might allow more intensive teaching. Another limitation is that despite 940 participants, only 15.2% of the medical students responded to the invitation of the deans of student affairs. This might be a typical response rate for an internet-based survey if compared with the response rate of a German wide survey of Heinz & Jakob (15.7%) [23]. However, our results might overestimate the motivation in general as there might be a bias towards students who are motivated to be a GP. Therefore, the survey should be repeated with the inclusion of more universities with and without chairs of general practice, ideally in combination with mandatory participation (e.g. during educational lessons). The analysis was not adjusted for multiple testing due to the explorative character of the study. Indeed there is a clear tendency that medical students of the TUM (with a chair for general practice) are more in favour for general practice than the other students. Heinz & Jakob did not find striking differences related to the popularity of general practice between students with and without institutionalisation (28.6% versus 30.2%) [23]. However, they did not make a difference between the various institutes with respect to resources or degree of institutionalisation (e.g. amount of personal staff, financial resources, honorary or full professor).

Interestingly, motivation towards general practice is doubled if compared with the study of Heinz & Jakob [23]. This might be explained by the fact that we have explored the general attitude in a very common manner which allows to leave more options open if compared to a mandatory ranking. This might have been misleading in particular with respect to the possibilities of working in an employed position, both as general practitioner and specialist in primary care. A possible reason is that a high amount of medical students could also imagine working in a long-term position as a physician in a hospital. General practice was an option to choose competitively between different medical specialities in the studies of Heinz & Jakob [23], respectively Gibis et al. [10]. However, the numbers of our study related to the motivation for employment versus working in own private general practice were similar to them. This is analogue to the surveys of Zupanic et al. [24] and Osenberg et al. [25]. They also listed general practice as a competitive option. This illustrates that the kind of questioning might indeed result in a different response pattern.

Our study demonstrates that a considerable amount of students could imagine working as a general practitioner despite these limitations. However, they prefer employed positions and not own private practices with entrepreneurship. The increasing institutionalisation seems to be central for a positive attitude towards general practice. Further research has to evaluate why ultimately only a small amount of students finish as a GP. There are specific challenges because of the complexity of traineeship [26], but also structural barriers in the German healthcare system, notably with respect to employment versus single-handed practice. This should be kept in mind by the stakeholders, in particular with respect to the attitude of the female students. This might be a valuable resource to impede the shortage of GPs as the majority of medical students are female now. New working models and structures are necessary to meet the preferences of the young. Further potentials are given by the positive attitude of students from rural areas. In particular these students should be informed about and motivated with grants which need to be combined with obligatory future work as a GP, possibly for a certain time. Grants are provided by the federal ministries of health andsometimes also by hospitals in rural areas.


Acknowledgement

The authors want to thank PhD Dr. Carsten Kruschinski for allowing the use of his questionnaire to evaluate the medical students´ attitudes. We want to thank Andreas Forstner and Dipl.-Ing. Matthias Holzer for technical support. Finally, we want to thank the Bavarian Ministry of Health for the funding of the study.


Competing interests

The authors declare that they have no competing interests.


References

1.
Stork G. Arztberuf/Krankenhäuser: Vom Traumjob zum Albtraum. Dtsch Arztebl. 2001;98(42):A2700-A2701.
2.
Korzilius H. Hausärztemangel in Deutschland: Die große Landflucht. Dtsch Arztebl. 2008;109(8):A373-A374.
3.
Aden P, Beske F. Studienplatzvergabe - Fakultäten in die Pflicht nehmen. Dtsch Arztebl. 2011;108(15):A838-A839.
4.
Richter-Kuhlmann E. Arztzahlstudie von BÄK und KBV - Die Lücken werden größer. Dtsch Arztebl. 2012;107(36):A1670-A1671.
5.
Natanzon I, Szecsenyi J, Gotz K, Joos S. Das Image der hausärztlichen Profession in einer sich wandelnden Gesellschaft. Med Klin (Munich). 2009;104(8):601-607. DOI: 10.1007/s00063-009-1131-6 External link
6.
Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff (Millwood). 2002;21(1):140-154. DOI: 10.1377/hlthaff.21.1.140 External link
7.
Kamien M, Cameron WI. Solving the shortage of general practitioners in remote and rural Australia: A Sisyphean task? Med J Aust. 2006;185(11-12):652-623.
8.
Schaufelberger M, Trachsel S, Rothenbühler A, Frey P. Eine obligatorische longitudinale Ausbildung von Studierenden in 530 Grundversorgerpraxen. GMS Z Med Ausbild. 2009;26(2):Doc21. DOI: 10.3205/zma000613 External link
9.
Iversen T. The effects of a patient shortage on general practitioners' future income and list of patients. J Health Econ. 2004;23(4):673-694. DOI: 10.1016/j.jhealeco.2003.10.001 External link
10.
Gibis B, Heinz A, Jacob R, Muller CH. The career expectations of medical students: findings of a nationwide survey in Germany. Dtsch Arztebl Int. 2012;109(18):327-332.
11.
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(6):502-512. DOI: 10.3122/jabfm.16.6.502 External link
12.
Howe A, Ives G. Does community-based experience alter career preference? New evidence from a prospective longitudinal cohort study of undergraduate medical students. Med Educ. 2001;35(4):391-397. DOI: 10.1046/j.1365-2923.2001.00866.x External link
13.
Kruschinski C, Wiese B, Eberhard J, Hummers-Pradier E. Attitudes of medical students towards general practice: Effects of gender, a general practice clerkship and a modern curriculum. GMS Z Med Ausbild. 2011;28(1):Doc16. DOI: 10.3205/zma000728 External link
14.
Scott I, Wright B, Brenneis F, Brett-Maclean P, McCaffrey L. Why would I choose a career in family medicine?: Reflections of medical students at 3 universities. Can Fam Physician. 2007;53(11):1956-1957.
15.
Sinclair HK, Ritchie LD, Lee AJ. A future career in general practice? A longitudinal study of medical students and pre-registration house officers. Eur J Gen Pract. 2006;12(3):120-127. DOI: 10.1080/13814780600780833 External link
16.
Schmacke N. Das Ansehen der Allgemeinmedizin. Z Allg Med. 2010;86:113-115.
17.
Wissenschaftsrat. Stellungnahme zu den Perspektiven des Faches Allgemeinmedizin an den Hochschulen. Berlin: Wissenschaftsrat; 1999. Zugänglich unter/availabel from: http://www.wissenschaftsrat.de/download/archiv/3848-98.pdf External link
18.
Scott I, Gowans M, Wright B, Brenneis F, Banner S, Boone J. Determinants of choosing a career in family medicine. CMAJ. 2011;183(1):E1-E8. DOI: 10.1503/cmaj.091805 External link
19.
Maiorova T, Stevens F, van der Zee J, Boode B, Scherpbier A. Shortage in general practice despite the feminisation of the medical workforce: a seeming paradox? A cohort study. BMC Health Serv Res. 2008;8:262. DOI: 10.1186/1472-6963-8-262 External link
20.
Kiolbassa K, Miksch A, Hermann K, Loh A, Szecsenyi J, Joos S, Götz K. Becoming a general practitioner-which factors have most impact on career choice of medical students? BMC Fam Pract. 2011;12:25. DOI: 10.1186/1471-2296-12-25 External link
21.
Bland CJ, Meurer LN, Maldonado G. Determinants of primary care specialty choice: a non-statistical meta-analysis of the literature. Acad Med. 1995;70(7):620-641. DOI: 10.1097/00001888-199507000-00013 External link
22.
Gjerberg E. Gender similarities in doctors' preferences--and gender differences in final specialisation. Soc Sci Med. 2002;54(4):591-605. DOI: 10.1016/S0277-9536(01)00054-5 External link
23.
Heinz A, Jacob R. Medizinstudenten und ihre Berufsperspektiven. Bundesgesundheitsbl Gesundheitsforsch Gesundheitsschutz. 2012;55(2):245-253. DOI: 10.1007/s00103-011-1413-z External link
24.
Zupanic M, Hofmann M, Osenberg D, Gardeik K, Jansen P, Fischer MR. The aimed or feared professional future of medical students at the Univesity of Witten/Herdecke. GMS Z Med Ausbild. 2011;28(2):Doc25. DOI: 10.3205/zma000737 External link
25.
Osenberg D, Huenges B, Klock M, Huenges J, Weismann N, Rusche H. Wer wird denn noch Chirurg? Zukunftspläne der Nachwuchsmediziner an deutschen Universitäten. Chirurg. 2010;6:308-315.
26.
Steinhäuser J, Paulus J, Roos M, Peters-Klimm F, Ledig T, Szecsenyi J, Joss S. "Allgemeinmedizin ist trotzdem ein schönes Fach" – eine qualitative Studie mit Ärzten in Weiterbildung. Z Evid Fortbild Qual Gesundhwes. 2011;105(2):89-96. DOI: 10.1016/j.zefq.2010.11.003 External link