gms | German Medical Science

The importance of individual educational phases of the medical curriculum in regard to the selection of a specialty by future graduates is the subject of intensive discussions in science and politics. As the licensing regulations in Germany were updated in 2012, special consideration was given to offering more medical students the opportunity to spend one third of the year-long internship in General Practice (IGP). As a result of this, graduates were to be put in a position to make more qualified decisions about a choice of specialty. However, the motives behind specialty selection among students are very heterogeneous [13].

The definition of influencing factors on the prevalence and development of motives during the decision-making process for selecting a specialty shows that, alongside the perceived aspects of a specialty (particularly patient contact, technical aspects, and income), the fulfillment of needs (personal, social, and those of others, e.g. family members) are of direct significance. However, indirect influences on motives, such as the process for assigning places at universities, the existence of institutes for General Practice, or the ethical values and culture of educational institutions, also affect specialty choice and the pre-selection of those who make the “choice” [13], [17].

Physicians undergoing further training who have chosen or have a preference for General Practice showed themselves in the first systematic analyses in the early 1990’s to be more likely motivated by patient contact, diverse patient profiles and problems, and responsibilities in prevention and early detection than others with different goals in pursuing further training [3]. These findings are confirmed by more current surveys in Switzerland and Germany [9]. To be emphasized are also the data from a longitudinal study [5], [4]. It was seen here, as in other studies, that particularly early [1] and practical experience in a specialty have a motivational effect on the selection of a specific field of Medicine [12], [20]. In a Canadian study, interest in a student’s own research activities posed a strong motive for choosing a field with a special focus and for deciding against a specialty in General Practice [19]. In current [15], [17] and older surveys [16] among medical students and doctors undergoing further training, predictors of a likely selection of General Practice have appeared to be female sex, pronounced family ties (in particular to spouse and children), rural background, and expectations that are more focused on free time, a regular work schedule and a predictable professional life rather than desires driven by concerns involving career advancement or qualifications [5], [9], [17], [16], [18]. Connections between (gender-neutral) personality traits and choice of specialty could not be determined [3], [8]. Positive predictors for later practice as a General Practitioner (GP) are – similar as for selection of the specialty – having children, being in a partnership, option of working part-time, a mentoring program and personal relationship with a general practitioner [4], [6], [18]. However, motivating factors can also compete with each other and in some cases be superseded by (current) life decisions, especially if the location for further training is urban and no constant link to a continuing education program exists [6]. The IGP has a significant influence on the choice of specialty possibly through the comparison of individual preferences and motives with the experience of reality as seen in the example of a practicing professional [5], [4]. Yet, despite the current debate about the healthcare needs of the population and the role of medical schools in ensuring access to healthcare, the motives for selecting a specialty in relation to the IGP experience have not yet been analyzed, although conclusions involving healthcare policy have already been drawn, in part with substantial financial cost [http://www.gesetze-im-internet.de/gkv-solg/BJNR385300998.html, last viewed on 22.01.2014]. Over time, studies in the United States have shown success, even though in this case only two-thirds of those given particular support are still active in General Practice for the long term [14].

As a result, we asked which motives former students name for their later choice of specialty in connection with the IGP and how the IGP influenced the individual selection.

A retrospective, pseudonymous cross-sectional questionnaire was conducted among former students of the Halle-Wittenberg University and Magdeburg University who had completed a final-year elective internship in the area of general practice (IGP) between 2007 and 2012. Twenty-nine items addressing three topics (personal attitudes, concepts of personal and professional life, the decision-making process) were answered using single-choice, multiple-choice and bipolar Likert rating scale (1= completely disagree; 5= completely agree). The questionnaire (see attachment 1 [Attach. 1]) was newly developed since a survey of this population had not yet been done in this manner. The basis for the content was the influencing factors named in similar surveys [9], [13], [15]. Due to the small sample size, a pretest of the questionnaire beyond expert verification did not seem purposeful. The collection of the raw data was done using EvaSys and its description and analysis using SPSS 20.0®. Due to the sample size, no sub-group analysis was undertaken; however, a correlation analysis was using Kendall’s tau. As a consequence of the explorative nature of the study, no correction according to Bonferroni took place. Within the scope of describing the results and to avoid bias through the “error of central tendency”, the responses of 4 and 5 on the Likert scale were evaluated as agreement or as being “relevant” and those of 1 and 2 as rejection or “not relevant”.

Of 109 former final-year students, the questionnaire was able to reach 97, with a response rate of 46% (N=45). Distribution of age and sex largely corresponded to that of the overall sample. The number of the reached final-year students corresponded to approximately 5% of all graduates in Saxony-Anhalt during the defined time period. Table 1 [Tab. 1] shows information on social background, whereby any percentage points missing from the overall 100% are to be understood as reflecting an absence of information.

The response rate for earlier graduation years was lower, as was that from the graduates of Magdeburg University. The motives behind the choice of specialty are presented in Table 2 [Tab. 2] according to how often they were named. In respect to the identification of motives in advanced years of further training, it is to be noted that family and free time are named twice as frequently in comparison to income. Only 21% of the respondents indicate that the influence of a teacher or a mentor from practice was relevant to the choice of specialty.

Table 3 [Tab. 3] illustrates the results that were classified as “yes” or “no” on the basis of the Likert scale. Absent percentage points have either the valuation of 3 as group of undecided respondents or indicate the few answers that were missing. It can be seen that given a different financial situation only 18% would consider a different choice of specialty, but that independence in terms of family would have influentially changed the choice in 29% of the cases. Around two-thirds of the respondents had already settled on a choice of specialty upon completing formal medical studies before internship; 86% aim for ambulant work. It is noticeable that 27% of the respondents indicate that they did not receive a positive impression of general practice during the IGP. Only in 30% of the cases was there an indication that the IGP changed the choice of specialty; accordingly, in 67% cases the choice of specialty was reported to have been supported by the IGP (see Table 3 [Tab. 3]).

In the correlation matrix (see Table 4 [Tab. 4]) there are clear connections between the support of the training goals through the IGP and positive professional and patient-related experiences in the IGP. The aspects discussed here have been bolded. An altered perception of the field during the IGP correlated positively with a change in the reason for pursuing the specialized training (r=.36, p<.05) and the influence of the medical teacher (r=.33, p<.05). It is noticeable that all positive impressions from the IGP show a connection with positive experiences involving patient contact (see Table 4 [Tab. 4]). Here, it is demonstrated that encouragement of the decision to pursue a specialty in General Practice depended to a large extent on experiences with patients (r=.45, p<.05). Another important connection to be emphasized is the perceived professional success (r=.54, p<.05). Understandably, a change in the goal for pursuing specialty training corresponded negatively with the previous goal set for obtaining specialized training (r=-.5, p<.05).

The majority of IGP graduates had already decided on a field of specialty before the IGP in the final year of the medical curriculum. A change in the selected specialty as a result of the IGP occurred in only a third of the graduates. Family, patients and mentors are the basic motives behind the decision to pursue this particular specialty.

For the first time, our cross-sectional data covered the motives for and aspects of specialty choice in connection with the IGP for an entire German region (Saxony-Anhalt) with two medical schools. Validated instruments for collecting data on specialty choice already exist for the German-speaking countries; however, these focus on students, not graduates, and therefore not on the influence of the IGP. For this reason, a self-constructed, not externally validated questionnaire was used. As a result of this and due to the small number of cases in terms of retrospective surveys, this study can only claim to be explorative in character. Owing to the response rate of less than 50% of all surveyed, a selection bias is probable and the representativity questionable. The relatively small population also substantially reduces the explanatory power of any statements regarding subgroup analysis and correlations.

The ranking of the motives affecting the selection of a specialty in this study, with family and free time at the top and opportunities for professional development and income coming after, corresponds with more extensive surveys [15], [17], [16], [18]. In contrast to a current study of medical students, sex had no significant influence on the ranking of motives among our respondents [17]. Likewise, the difference in expectations regarding free time and income found by Kiolbassa [9] between future GP´s and those to be trained in other specialties was not seen here. The importance of having a personal relationship with a mentor working in the selected field for the selection of that specialty has already been identified more than once [4], [7]. Indeed, this appears in our survey to be of predominant importance for those whose selection of a specialty was not clear prior to the IGP. In these cases, a change in perception of the medical specialty, presumably through the influence of a mentor, is connected with a change in the selection of the specialty. It is obvious that the influence of a mentor also makes it possible to perceive the IGP as professionally meaningful, important, and a good experience. Not only British, but also Swiss findings confirm this interpretation and emphasize the importance of personal contact between students and medical teachers acting as authentic examples also in terms of showing how a balance can be achieved between work and private life [4], [7].

A remarkable influence on the choice of specialty is the obvious decision-affecting role played by patient contact, possibly as an expression of qualitatively excellent practical instruction given by the mentor [3], [4], stressing the importance of careful selection of the medical teachers and their preparation for teaching.

Another important aspect is the sustained tenability of the specialty choice made by two-thirds of the graduates of the IGP. Our data confirm the American long-term data which show that even with programs that intensively promote setting up practice as a GP, over time 68% of the graduates profiting from these programs could be retained in General Practice [14]. However, according to the analysis of the SwissMedCareer study only 38% of those who originally chose this area of specialty found themselves to be practicing as GPs eight years after completing medical school [5], [4]. Thus, a decision to participate in the IGP does not necessarily result in the desired effect of selecting General Practice as a specialty or in opening a GP-practice. Much more needed here are the currently demanded stable financial situations and social environments, in particular for improving the compatibility of job and family [16], [18].

The graduates not included in our study, who decide to specialize in General Practice without participating in the IGP, very possibly form a population that is influenced early on and did not need the experience of the IGP to make the decision or probably was not influenced in a relevant manner by it. Overall, approximately two-thirds of the students have selected a specialty prior to the final year, relativizing not only the influence of the IGP, but underlining the importance of early contact with the field of general medicine during formal medical studies [4], [7], [14]. The repeatedly discussed measures to acquire future specialists in General Practice during medical school should therefore be embedded in an advancement program that allows for early intervention and respects the life realities and personal priorities of the future physicians. From our perspective, a great deal is dependent upon the authenticity of the medical teachers / mentors and their ability to motivate – including their ability to show the compatibility of job and private life, as well as job satisfaction [2], [3], [5]. The current expansion of the IGP program should therefore be monitored through longitudinal studies to evaluate if and how the desired social and political benefits occur. It is not only crucial that more doctors-to-be decide on a specialty in ambulant medical care, in particular in General Practice, but also how medical teachers influence the decision made by those who are still undecided.

The authors declare that they have no competing interests.