gms | German Medical Science

The academization of General Practice influences its position in the health care system and vice versa [1]. In countries with well-developed primary care there is also more valuable research to be conducted in and around General Practice [2]. A broad representation of General Practice at medical schools strengthens the position and prestige of General Practice within a health care system [3].

In Germany, academic General Practice has expanded over recent years [4], [5]. The number of medical schools with a department of General Practice is steadily increasing [3]. Thus, there is a need for young researchers who combine research and training in the field of General Practice and Family Medicine [6], [7]. There is a need for dual-qualified doctors to ensure the scientific basis of medicine in the future [8]. In other clinical subjects, such as internal medicine, trainees can work within university departments, qualifying both in clinical practice and research. Thus, research can be combined with specialty training with no delay, or only a short delay to their finish date [9]. In General Practice, scientific and clinical activities usually take place with different employers. Hence, there is usually a significantly prolonged overall duration of specialist training when it is combined with research [10].

In Germany, only very few of the heads of university departments of General Practice are authorized as GP trainers [11]. Few composite specialist training programs in General Practice allow scientific activities [12], [13].

So far, little is known about the situation of GP trainees involved in research. It is not known how many GP trainees in Germany conduct research or how many departments offer the possibility of combining research and specialist training. Furthermore, it is not known to what extent scientific activities are perceived as an obstacle to training or whether they are even considered a path on the way to becoming a GP. Moreover, the point of view of GP trainers on this topic is as yet unknown.

Thus, the objective of our study was:

• to explore the perspectives of heads of departments of General Practice, GP trainees and GP trainers on the combination of scientific activity and specialist training; and,
• to estimate the number of GP trainees doing research at university departments and the qualification as GP trainers of the heads of departments of General Practice.

We conducted a three-arm cross-sectional study. We surveyed the heads of all university departments of General Practice in Germany, GP trainees doing research and their GP trainers.

As there was no extant questionnaire available to us, we jointly developed one questionnaire per group (i.e., for the heads of departments, trainees and trainers). The questionnaires included both closed-ended questions, which were quantitatively evaluated, as well as open-ended questions, which were qualitatively evaluated.

The questionnaire for the heads of departments included questions on their own qualification as GP trainers, on the amount of practical clinical work and on the trainees working in their department. It also included questions about training programs. The open questions related to barriers, solutions and future visions regarding the combination of scientific activity and specialist training in General Practice. To ensure anonymity, we did not ask for demographic variables.

The questionnaire for GP trainees contained demographic questions as well as items on how much time they spend on research, teaching and clinical work. We asked about the trainees' satisfaction with their training situation and about their future plans. The open questions related to the same aspects as the open questions in the questionnaire for the heads of departments. The survey for heads of departments and trainees was web-based (Platform: http://de.surveymonkey.net/). The questionnaire for the GP trainers contained three open questions about experiences with and the advantages and disadvantages of employing trainees who are also involved in research.

We conducted a pre-test for the questionnaires to evaluate the instrument for comprehensibility, acceptability, technical problems and time requirements: The questionnaire for the heads of departments was tested by seven scholars in General Practice who were in leadership positions (e.g., Deputy Director of a department). The questionnaire for trainees was tested by nine researchers in General Practice who are not trainees.

There are 36 medical schools in Germany. For a more detailed description of the representation of General Practice in these schools refer to [6,7]. We searched for the email addresses of the heads of departments via the universities' websites. We established a contact in each of 34 schools.

The number of trainees doing research in Germany is unknown. Thus, we asked the heads of department for contact information for the trainees in their departments. Additionally, we tried to recruit potential participants through the email lists of GP trainees.

There is no information available about GP trainers who train trainees who are scientifically active. Thus, we asked all participating trainees to print out the questionnaire for their trainers and to pass it on to them.

The heads of departments and the trainees were reminded twice by email to take part in the survey.

We aimed to reach all relevant persons in Germany, thus we did not conduct a sample-size calculation. The analysis of the quantitative responses was done by software (IBM SPSS Statistics, version 20.0) using descriptive statistics. As a measure of central tendency, we used the median, and as a measure of dispersion, the range [14].

The qualitative free-text responses were analyzed by coding and categorizing. The entire corpus of material was coded line by line by all three researchers in joint meetings. In comparing these codes, categories were formed and clustered consensually.

The study was approved by the local ethics committee (University of Lübeck, reference number 12-173).

Of the 34 Heads of Departments of General Practice included in the mailing, 28 participated the survey. More than half of them (15 out of 28) have a training authorization. Figure 1 [Fig. 1] shows the distribution of months of scientific activity accountable towards the GP specialist training. The majority (62%) of participants who have training authorization, or who have ever applied for one, report having had difficulties in this context with the federal state medical board; for example, it refused to count scientific activity as part of the GP specialist training. About 2/3 of the Heads of Departments of General Practice employ GP trainees, and a median 2.5 employed GP trainees per department (range: 1-5). Many departments participate in composite specialist training programs and offer participating GP trainees the possibility of conducting research (see Table 1 [Tab. 1]).

Overall, 20 out of 34 potential GP trainees included in the mailing participated in the survey. 2/3 of these are female: their median age was 33 years (range: 28-46), most lived as part of a couple (almost 80%), and over 50% had children. The amount of research / teaching / patient care / was 20.5 hours per week, median 15.5 hours. Four GP trainees plan to complete a postdoctoral lectureship qualification, nine are not yet sure whether they will, and six said they had no intention of doing so. Thirteen of the 20 GP trainees (65%) are satisfied or very satisfied with their own training situation (see Figure 2 [Fig. 2]).

We did not receive any completed questionnaires from the clinical trainers of the GP trainees included in this survey.

25 of the 28 participating Heads of Departments of General Practice and 17 of the 20 participating GP trainees completed the open questions.

The response of GP trainees concerning the effective reconciliation of scientific activity with GP specialist training can be assigned to three areas:

• Frustration
• Recognition
• Promotion

The GP trainees considered substantive questions and the organizational reconciliation of the two working areas of hospital or outpatient care, respectively, and research as the main obstacles ("You have to serve two or three masters (practice, teaching and research) at the same time."). The substantive reconciliation is marked by competing, because in the sum they are not satisfiable, claims on two areas: "Your own demands, and the demands of the environment, to fully complete both jobs and have the feeling that you have done so well, while also not getting everything from either place of work". The desire to focus on one of these areas confronts the demand to further development in both areas. This results in a feeling of inner conflict and fear of not doing the job “properly”: "Neither in patient care nor in the scientific field can I acquire knowledge in addition to what is absolutely necessary.". The organizational effect of reconciliation is hindered by the difficulty of finding a (patient care) part-time job. The GP trainee also suffers financial disadvantages due to lower wages in the research field compared to those in patient care, as well as tax disadvantages as a result of multiple employment ("There is a financial burden: the university does not pay according to the doctor’s tariff while, the second job is taxed according to Tax Card 6, which results in additional losses of 3500 Euros per year according to the annual employment tax declaration.").

To summarize, these difficulties lead to significant frustration among GP trainees: "Sometimes I’ve had the feeling of doing everything, but not doing any one thing properly; consequently, the desire is to limit myself to just one field of medicine and to understand that one thoroughly.".

From the GP trainees’ point of view, another key barrier is the lack of recognition of scientific activity: “It's not just about the lack of accountability of scientific activity towards the specialist training by the federal state medical board, but also the lack of recognition, or a lack of understanding, by colleagues in the practice or hospital”; "There is a lack of understanding of the turnover for the department for relevant training and events as part of the scientific activity". This results in a stressful feeling for the trainees that there is a lack of appreciation for their work: "one must be careful to ensure not to play second fiddle forever.".

The GP trainees named a number of already implemented solutions strategies, particularly dealing with organizational amelioration tasks. Herein, time management strategies play an essential role: a weekly turnover between patient care and research, or single full-time research days per week during the training period: "Clearly structured turnovers with agreements about when to work in patient care and when to work in research".Furthermore, there are comprehensive strategies, such as composite GP specialist training programs / turnover programs ("Employment at a Department of General Practice with turnovers in hospital / outpatient care, managed by the department, with an accompanying day / week release from patient care to work in the department, as well as half-year periods of full-time research in the department, which count towards the specialist training in General Practice."). As another solution, a complete, co-existent separation of patient-care training and research activities is suggested. Spatial and temporal proximity as well as flexible working hours and several part-time jobs are other existing strategies to improve the reconciliation of research and clinical training: "The primary care center in which I work is close to the department (only five minutes by bicycle)."

From the perspective of the GP trainees, future actions to be implemented to improve reconciliation should be particularly concerned with the accountability of research towards the specialist training period. This, they claim, should be clearly regulated in a uniform way ("easy recognition by the federal state medical board even in the case of research without direct patient contact."). The GP trainees called for the possibility of working in patient care and research under one contract. Nevertheless, a range of flexibility between the full-time equivalents should be maintained by adjusting the ratio of workload between patient care and research activity in order to respond to periods of excessive workload as is common in the context of research projects: "Furthermore, turnovers should be switched easily in the context of the turnover schedule according to the workload.". The Head of Department of General Practice is considered by the GP trainees as someone who will remain a supporter and co-ordinator of both activities in the future ("a co-ordinator of research and education in the department, and someone who will support the organization, etc. "). The GP trainees rejected ongoing unpaid overtime due to their multiple employment situation.

The comments of the Heads of Departments on the reconciliation of research with working as a doctor in specialist training can be assigned to three areas:

• Organisation
• Recognition
• Qualification

From the point of view of the Heads of Departments, the difficulty in coordinating both tasks of routine patient care and research is a key obstacle in reconciling training and scientific work: "It is possible for a hospital employee to work in research for only a year and still continue receiving a certificate for this training period; however, this is not possible in a primary care practice.". Specialist training seems to compare unfavorably due to the inevitable part-time work required and serious research activity and systematic research education seem to be difficult to implement successfully in this part-time post: "Good scientific practice is possible only to a limited extent in a Practice part-time position". Combining these two tasks causes a heavy workload, scheduling conflicts, family conflicts and conflicts for the individual between the requirements of two employers: “Research and patient care are usually two jobs with two different employers whose interests and requirements are sometimes difficult to bring together under one banner; more particularly, organizational efforts are high.". The extension of the training period, aggravated by the lack of accountability of scientific work towards the specialist training by the federal state medical board, is addressed as a further obstacle: "If one is a Gynecologist, you can casually disappear into the animal lab for six months, if you prefer this (and nobody notices). In the GP situation, it is more obviously apparent.". Financial disadvantages ("Being employed as a scientist at the university, I do not get a salary according to the doctor’s tariff, which will lead to enormous financial disadvantages over the longer term.") and reservations about research in GP practices and in non-scientifically-working General Practitioners are seen as further barriers. However, the statement of one participant, that there are "no" obstacles, forms an opposite pole.

When asked about current approaches to support flexibility in the organization of working time, release of work, home offices and job offers with small-time equivalents (e.g., 25%) were named. For the Heads of Departments, personal (e.g., mentoring, minimal hierachial structures, accessibility, use of personal contacts in the mediation of jobs in General Practice) and professional (e.g., training in research methods, reimbursement for advanced training courses and conferences, offering possibilities to publish research results) support of the GP trainees seems to be of particular importance. They underlined that effective reconciliation of training and scientific activity is already supported by composite specialist training programs (“Creating a training network"), involvement of the GP trainee in the internal co-operation between university hospitals ("However, co-operation between some university departments exists, so turnovers in these (optional) medical specialties would be possible for training") and thus the realization of research and patient care under one banner ("with internal turnovers and release from patient care for research activity.").

The Heads of Departments stated as the primary objective for the future the implementation of a nationwide consistent and reliable counting of research periods towards the specialist training period ("Reliable counting of periods in research towards specialist training in General Practice"). The envisaged scope of accountable periods of scientific activity varies in the survey between six and 18 months.

Long-term contracts, for example in the context of composite specialist training programs or co-operation between departments of General Practice with hospital- or university hospital-affiliated medical centers, are required in order to meet the organizational barriers: "Composite specialist training programs involving universities and universities with Departments of General Practice! Even easier if the university GP department is involved in outpatient care". This involves payment according to the doctors’ tariff ("uniform payment conditions (doctors’ tariff) even in theoretical institutes and departments of GP."). In order to increase scientific qualification, the expansion of relevant programs for young scientists is desirable. Different funding bodies such as health insurance companies, Medical Associations, federal state medical boards ("provision of funds by federal state medical boards, associations of statutory health insurance, registered doctors and health insurance companies in order to support research in university GP departments") and the universities themselves (“sufficient basic staffing must be secured for more than one year.”) are reminded of their duty to promote scientific activity. Thereby, prevention of a gap emerging between General Practitioners in science and patient care was named as an important task (“the academic GP deals with relevant issues of primary care practice and in part with the existing gap between academic and routine patient care in GP so that it does not grow even wider”). In conflict with the required accountability of research periods, one participant demanded that dilution of training not be allowed by research periods (“otherwise we will be breeding researchers living in an ivory tower, only focusing on Impact Factors and external funding and not the reality of daily GP. I am really afraid of those ‘primary care physicians' generated in university departments.”). The statement, "Science is not the backbone of the GP! Patient care, then teaching, teaching, teaching and afterwards research! We are not internal medicine specialists...", also states a skeptical attitude taken by some general practitioners against scientific activity as part of training.

While the GP trainees addressed list issues such as lack of possibility to concentrate on professional topics and lack of recognition / appreciation, the Heads of Departments focus primarily on organizational and financial difficulties when asked about reconciling science and advanced training in General Practice.

More than half of the heads of departments of General Practice have a training authorization and thus allow their GP trainees to be involved in research, and to count 6-24 months of scientific activity towards the GP specialist training. However, concomitantly, lack of accountability is considered an important obstacle for a job at a department of General Practice. Consequently, a consistent, reliable, and nationwide accountability of scientific activity at departments for General Practice towards the GP specialist training is called for by the heads of departments and the GP trainees.

Almost two thirds of GP trainees simultaneously working at a department for General Practice are satisfied or very satisfied with their current training situation. From the replies to the free-text questions, however, a deep frustration about the conditions for a combined scientific and clinical activity can be seen. A lack of recognition in both senses (by colleagues and superiors as well as the federal state medical boards) seems to be the main reason for this.

These discrepancies between quantitative and qualitative results, both in the answers of the heads of departments as well as in those from the GP trainees, could result from the heterogeneous conditions at the different departments of General Practice in Germany [3]. According to our results, some departments already create good conditions in which to be scientifically active during GP specialist training: accountability of scientific activity, payment in accordance with the doctor’s tariff, practical clinical training in the same house or in the context of composite training or rotational programs designed by the department and intensive mentoring including promotion of methodological skills, networking and publication of research results ("capacity building" [15]). Some German departments take a pioneering role [12], [13], [16], and at many locations these conditions exist only partially or not at all so far. According to our results this seems to be mainly due to a lack of resources in the departments or to a restrictive stance on the accountability of many federal state medical boards, but also to reservations within the General Practice community in relation to the usefulness of scientific activity during GP specialist training.

Other German professional societies, such as the German Society of Internal Medicine [17] and the Medical Faculty Association [18], are calling for the accountability of scientific activity towards specialist training. The University of Göttingen has developed, together with the Lower Saxony medical board, a model curriculum for specialist training and the postdoctoral lectureship qualification in Cardiology, in which six months of research can be counted towards the specialist training [http://www.herzzentrum-goettingen.de/de/content/lehre/579.html]. In many other countries, scientific activity is not possible without increasing the duration of specialist training, although it is strongly encouraged (e.g., USA [19], Denmark [http://www.equip.ch/files/6/competences_119_final.doc], [http://www.helsedirektoratet.no/helsepersonell/spesialistgodkjenning/lege/Sider/allmennmedisin.aspx], Norway [20]). Accountability is also required by the World Organization of National Colleges, Academies and Academic Associations of General Practitioners / Family Physicians (WONCA) [21], [22].

For the first time the situation of German GP trainees involved in research was assessed quantitatively and qualitatively. No validated survey instrument for this purpose is available, so we used self-developed questions which were pre-tested. Given an estimated similar potential gain in knowledge compared to, for example, semi-structured telephone interviews, the preparation effort was high. This effort was, however, counterbalanced by the relatively efficient data collection by the web survey. The high response rate in the survey from the heads of departments makes a non-responder bias unlikely.

In the case of GP trainees involved in research the risk of selection or non-responder bias cannot be estimated reliably as it is not guaranteed due to the limited direct accessibility that we have fully reached the target population. It was not possible for all contacted GP trainees to clarify whether they actually belong to the target population. Therefore, we can neither specify the exact number of GP trainees involved in research working at departments of General Medicine in Germany nor define a reliable denominator for calculating the response rate. Therefore, a valid estimation of the total number of GP trainees involved in research in Germany (objective 3) is not possible. Due to the overall small size of the target population and the good subject knowledge of the authors, we assume, however, that we have almost fully reached the target population. Moreover, during the analysis of the qualitative results, we saw a content-saturation in the answers. Therefore, in relation to objective 1, we can consider our results a full survey of both the GP trainees involved in research as well as the heads of departments.

Another limitation of the results is the lack of answers from the clinical trainers of the GP trainees. This could be due to both the generally low willingness of GPs to participate in scientific projects [23] and the (in contrast to the heads of departments and the GP trainees) lower self-interest in an investigation of the topic, a lack of time and the lack of anonymity. Maybe there also existed barriers within the GP trainees with respect to forwarding the questionnaire to their trainers, due to the additional effort or the dependent relationship.

Due to the anonymity of the survey, we cannot assign the different training authorizations to certain departments of General Practice. However, avoiding bias due to social desirability or non-participation due to lack of anonymity seemed more important than a clear assignment of training authorizations.

Our results underscore the need for a nationally consistent, reliable accountability of scientific activity at departments of General Practice towards the GP specialist training [24].

An anchorage in the specialist training rules, as it already exists in other European countries and in Germany in the above-mentioned pilot project, could promote continuing scientific activity in the context of a composite specialist training program. This would help to overcome the organizational and financial barriers for parallel scientific and clinical practice activities during training. The lack of recognition expressed in terms of appreciation, or at least acceptance of scientific activity suggests that the departments of General Practice should specifically look out for clinics and practices that are interested in training scientifically-active GP trainees and providing them with flexible working conditions.

The frustration and lack of recognition expressed in the qualitative responses of the GP trainees involved in research should be systematically addressed in terms of the systematic promotion of young researchers. The manageable number of scientifically-active GP trainees opens up the possibility of concerted action, for example in terms of a junior academy that promotes GP trainees involved in research and promotes networking.

The effectiveness of such measures on the willingness of young doctors to do research in addition to specialist training should be investigated in future studies. Such studies should investigate the rate of successfully filled research staff jobs at departments of General Practice, investigating the number of scientific publications with authors who are still in specialist training and the number of General Practice postdoctoral lecturing qualifications as indicators.

• Scientific activity is currently perceived by the respondents as rather an obstacle to GP specialist training. Well organized and arranged, however, the combination of the two activities could even enrich the GP specialist training.
• To make scientific activity in departments of General Practice attractive for GP trainees, respondents call for accountability of those activities towards the specialist training, a reduction of organizational barriers to parallel activities in research and practice (for example, by integrating scientific activity in composite training and rotation programs), payment according to the doctor’s tariff and systematic "capacity building".

The authors would like to thank all study participants. Special thanks go to the pre-testers of the questionnaires.

Thomas Kötter, Solveig Carmienke and Wolfram Herrmann are GP trainees involved in research.