The impact of role modelling on the future general practitioner workforce: a systematic review

Figures & data

Table 1. PICO framework used to develop review criteria.

Population	Undergraduate medical students, junior doctors, speciality trainees
Intervention	Role models/role modelling
Comparator	Not applicable
Outcome	Impact on future workforce, career choice, attitudes towards general practice

Box 1. Review search terms, databases, inclusion criteria and process

Review search terms: General practice; general practitioner; primary healthcare; family doctor; family practice; primary care AND role model; role modelling AND medical education; medical students; medical schools; junior doctors; registrar; GP trainee; graduate medical education; internship; residency

Databases searched: Medline, Embase, Scopus, Web of Science, Cochrane, ERIC and CINAHL. Hand searches of Medical Teacher, Education for Primary Care, British Journal General Practice and British Medical Journal were also undertaken. All databases were searched from 1990 to 2020 (studies published before 1990 were excluded as an initial scoping review suggested very little literature on this subject specific to GP pre-1990) and limited to English language due to lack of translation budget

Inclusion criteria (see appendix 1): All primary research studies which discussed role models and role modelling in general practice and the influence of these on either medical students or junior doctors were included. Published between 1990 and 2020.

Process: Articles identified in the search databases were uploaded to Rayyan software (https://rayyan.qcri.org/), these articles were screened based on their title and abstract. All authors were involved in article screening; where there was discrepancy in opinion EL retrieved the full text of the article and made a final decision on whether to include the article. References used by the included papers were also screened and full text retrieved in cases where the reference appeared relevant. All references were uploaded to an EndNote X9.2 library.

Figure 1. Prisma 2009 flow diagram [20] detailing the article selection process.

Table 2. A summary of the included articles and their allocated themes.

Author/Title	Year	Country	Method	Conclusions	Theme	Score
Biringer, A; Forte, M et al What influences success in family medicine maternity care education programs?	2018	Canada	Semi structured interviews with 18 participants	Credible role models support belief that low risk obstetric care is within scope of family medicine	2	10
Burack J, H; Irby, D A study of medical students speciality choice pathways, trying on possible selves	1997	USA	Survey of 157 students, focus groups with 47 students	The process of speciality choice can be described as a socially constructed process of ‘trying on possible selves’	1	9
Delva, D; Kerr, j Continuity of care, differing conceptions and values	2011	Canada	Semi-structured interviews with 30 participants	Different perceptions, settings, and skills can influence how continuity of care is valued, trainees learn about continuity through role models.	1, 2	7
Deutsch, T; Honigschmid, P Early community-based family practice elective positively influences medical students’ career considerations–a pre-post-comparison	2013	Germany	Survey of 140 students	Exposure to primary care role models early in training encourages students to consider family practice as a career option.	3	9
DeWitt, D.E; Curtis, J. What influences career choices among graduates of a primary care training program	1998	USA	Survey and semi-structured interviews with 88 participants	A substantial minority of primary care residents pursue speciality careers rather than primary care, lack of positive primary care role models cited as one of the reasons for this career change.	4	8
Essers, G.Van Weel-Baumgarten, E.Bolhuis, S. Mixed messages in learning communication skills? Students comparing role model behaviour in clerkships with formal training	2012	The Netherlands	Survey of 289 students	Role models in general practice are not reliably demonstrating the sort of communication taught during undergraduate training.	1	8
Jordan, J; Brown, J et al. Choosing family medicine. What influences medical students?	2003	Canada	Semi-structured interview with 11 participants	Exposure to GP role models in training validate and reinforce students’ decision to go into FM. Role models demonstrate importance of patient-doctor relationship and continuity of care.	2,4	9
Knox, K; Getzin, A et al. Short report: factors that affect speciality choice and career plans of Wisconsin’s medical students	2008	USA	Survey of 304 students	Students choosing primary care are more likely to be influenced by role models than those pursuing other specialities, particularly for males	4	8
Mann, K et al Community family medicine teachers’ perceptions of their teaching role	2001	Canada	Interviews of 17 teachers	Teachers’ perceptions of their role, importance of conscious role modelling, demonstrating skills, attitudes, knowledge	1	7
Matthews, C Role modelling: how does it influence teaching in Family Medicine?	2000	Saudi Arabia	Semi-structured interviews and survey with 15 teacher participants	The four best-remembered teacher behaviours were: positive behaviour towards patients, negative behaviour towards junior colleagues, effective presentation of subject content and encouragement to participate in patient care.	1, 3	4
Meli, D. N.et al General practitioner teachers’ job satisfaction and their medical students’ wish to join the field – a correlational study	2014	Switzerland	Survey of 184 student/ teacher participants	Medical students’ perception of their GP teachers’ job satisfaction positively affect their wish to become GPs, and their satisfaction with their internships adds to this.	3,4	9
Schafer, S et al Rejecting family practice: why medical students switch to other specialities	2000	USA	Survey of 320 medical graduates	Students rejecting family practice were more likely than their colleagues rejecting other specialities to cite insufficient prestige, low intellectual content, and concern about mastering too broad a content area as reasons.	3	8
Nicholson, S et al. Influences on students’ career decisions concerning general practice: a focus group study	2016	UK	Focus groups of 58 students	Early, high-quality, ongoing and, authentic clinical exposure promotes general practice and combats negative stereotyping.	3,4	11
Reitz et al. Balancing the Roles of a Family Medicine Residency Faculty: A Grounded Theory Study	2016	USA	Interviews with 121 family medicine teachers	The perspective of GP educators, confirm that being a role model is a primary role of family medicine educators	1	11
Risenberg, L,A et al. Medical student and faculty perceptions of desirable primary care teaching site characteristics	2001	USA	Q sort exercise/ survey of 39 students and 20 educators	Preceptors make the difference in primary care educational experience, though teachers tend to see role modelling as more important than the students.	1	7
Saigal, P et al. Factors considered by medical students when formulating their speciality preferences in Japan: findings from a qualitative study	2007	Japan	Interviews with 25 students	Role models are reported by Japanese students as influential factors when formulating their speciality preferences.	4	7
Silverstone et al. Students’ conceptual model of a good community attachment	2001	UK	Focus groups with 31 students	A theoretical model based on student conceptualisation of ‘a good GP’ was developed consisting of the GP as a teacher, as a role model and as an indicator of a positive learning environment.	1	9
Vohra, A.et al. Factors that affect general practice as a choice of medical speciality: implications for policy development	2019	Australia	Interviews with 47 participants ranging from students to practicing GPs	Effect of role models found to be a key factor affecting choice of speciality- lived experiences and personal relationships with individuals had a lasting effect on participants choices of speciality.	4	10
Wiener-Ogilvie, S et al. Foundation doctors career choice and factors influencing career choice	2015	UK	Survey of 543 foundation doctors	Undergraduate GP placement was reported as the strongest influence in favour of a career in General Practice	4	8
Henderson, E et al. Attitude of medical students towards general practice and general practitioners	2002	UK	Survey of 700 students	Personal experience of GP role models is the most important factor influencing attitudes to GP which improve over the course of their training.	3	10
Ambrozy, D. M et al. Role models’ perceptions of themselves and their influence on students’ speciality choices	1997	USA	Survey of 177 student identified faculty role models	The role models in this study agreed with their students about what is important to model including demonstrating enthusiasm and a sincere love for what they do.	1	8
Barber, et al. UK medical students’ attitudes towards their future careers and general practice: a cross-sectional survey and qualitative analysis of an Oxford cohort	2018	UK	Survey of 280 students	Medical students may be put off careers in general practice by three main things: low perceived value of community-based working and low status of general practice, observing the pressures under which GPs currently work; and lack of exposure to academic role models and primary care-based research opportunities.	1,3	10
Bien, A et al. What influence do courses at medical school and personal experience have on interest in practicing family medicine? – Results of a student survey in Hessia	2019	Germany	Survey of 361 students	Positive role models influence attitudes towards GP and subsequent career choice.	3,4	9
Campos-Outcalt, D.; Senf, J.et al A Comparison of Primary Care Graduates from Schools with Increasing Production of Family Physicians to Those from Schools with Decreasing Production	2004	USA	Survey of 1457 graduates	Positive and competent family medicine role models encourage students towards careers in family medicine	4	7
Connelly, M, T; Sullivan, A.M et al Variation in predictors of primary care career choice by year and stage of training: A national survey	2003	USA	Survey of 1665 students and residents	Primary care role models are a significant predictor for entering a career in primary care	4	10
Deutsch, T.; Honigschmid, P.et al Early community-based family practice elective positively influences medical students’ career considerations–a pre-post-comparison	2013	Germany	Survey of 140 students	Exposure to primary care role models early on in training encourages students to consider family practice as a career option.	4	9
Elnicki, D. M.; Kolarik, R et al. Third-year medical students’ perceptions of effective teaching behaviours in a multidisciplinary ambulatory clerkship	2003	USA	Survey of 276 students	Teaching effectiveness in primary care was found to be independently associated with providing a role model.	1	7
Firth, A.; Wass, V.; Medical students’ perceptions of primary care: The influence of tutors, peers and the curriculum	2007	UK	Open in depth interviews with 11 students	Poor-quality attachments and negative role modelling of primary care reinforced negative views and impacted detrimentally on career choice	1, 3	11
Jochemsen-Van Der Leeuw, H. G. A. R.; Van Dijk, N.et al Assessment of the clinical trainer as a role model: A role model apperception tool (RoMAT)	2014	Netherlands	Survey of 279 GP trainees	The RoMAT proved to be a valid, reliable instrument for assessing clinical trainers’ role-modelling behaviour.	1	11
Kutob, R. M.; Senf, J. H.;The diverse functions of role models across primary care specialities	2006	USA	Survey of 1457 physicians	For family medicine and internal medicine graduates, having a role model was related to more contact and more-positive views of faculty in their speciality. Those with a role model reported that primary care was encouraged at their medical school and were more satisfied with their speciality choice.	1, 4	10
Miettola, J.; Mantyselka, P.; et al Doctor-patient interaction in Finnish primary health care as perceived by first year medical students	2005	Finland	Written reports from 127 students	Medical students’ perceptions in this study support the importance of role models (good or bad) in making good doctors. Students saw witnessing poor role modelling as an opportunity for learning.	1, 2	9
Moyer, C. A.; Arnold, L.;et al What factors create a humanistic doctor? A nationwide survey of fourth-year medical students	2010	USA	Survey and focus groups with 80 students	Students viewed a variety of factors as influencing their development of humanism, with role models being of greatest importance	2	10
Mutha, S.; Takayama, J et al Insights into medical students’ career choices based on third- and fourth-year students’ focus-group discussions	1997	USA	Focus groups with 52 students	Role models affect speciality choice, negative role models, based on the students’ assessments of interpersonal interactions and career satisfaction, were particularly influential in closing doors to certain fields.	3, 4	11
Nicol, J. W. Gordon L.J. Preparing for leadership in General Practice: a qualitative exploration of how GP trainees learn about leadership	2018	UK	Interviews with 15 GP trainees	Role modelling important part of informal curriculum in learning about leadership. Fallibility of leaders can positively influence learning	2	11
Reid, K.; Alberti, H.; Medical students’ perceptions of general practice as a career; a phenomenological study using socialisation theory	2018	UK	Focus groups with 14 students	Medical students perceive general practice to lack prestige and challenge. These perceptions come, at least in part, from a process of socialisation within medical school, whereby medical students internalise and adopt their role models’ perceptions and values, and the values portrayed by the hidden curriculum in their medical school culture.	1,2,3	10
Rodríguez, Charo, López-Roig, Sofía et al. The Influence of Academic Discourses on Medical Students’ Identification With the Discipline of Family Medicine	2015	Canada/ France/ Spain/ UK	Focus groups with 132 students and semi-structured interviews with 67 educators	In UK perceptions of GP positive and role models mentioned in the formation of positive perceptions, in other countries disgruntled role models had a negative impact on perceptions.	3	11
Alberti, H. Banner, K.et al Just a GP’: A mixed method study of undermining of general practice as a career choice in the UK	2017	UK	Survey of 780 foundation doctors and focus groups with 49 foundation doctors	GP role models consistently a positive factor influencing participants and other clinicians’ perceptions of GP. Role models in hospital specialities making negative comments about GP.	3,4	11
Ie, K. Tahara, M. Factors associated to the career choice of family medicine among Japanese physicians: The dawn of a new era	2014	Japan	Survey of 41 primary care physicians	Family medicine role models in Japan are important in choosing a career in family medicine, but lack of role models is an issue	4	7
Lublin, J. R Role modelling, a case study in general practice	1992	Australia	Survey and interviews, 22 GPs and 93 students	Modelling good patient relationships was most the most desirable attribute for students, and students admired skill and knowledge, role modelling is a powerful influence on students.	1	9
Amalba, A. Abantanga, F. Community-based education: The influence of role modelling on career choice and practice location	2017	Ghana	Survey of 149 students	The desire and willingness to work in a rural community combined with good communication and excellent interpersonal skills as well as good leadership skills are attributes of good role models with potential to influence medical students’ career choice.	1, 2	10
Dallas, A. Van Driel, M. Antibiotic prescribing for the future: exploring the attitudes of trainees in general practice	2014	Australia	Semi-structured interviews and focus groups with 17 GP trainees	Role models in primary care important in shaping antibiotic prescribing habits.	2	10
Passi V, Johnson, N The impact of positive doctor role modelling	2016	UK	Focus groups with 52 medical students and semi-structured interviews with 5 students and 30 consultants	Role models are critically important in the professional development, character development, and career development of modelees. Role modelling effectively enhances the transformation of the student to a doctor.	2, 4	11
Roos, M, Watson, J et al Motivation for career choice and job satisfaction of GP trainees and newly qualified GPs across Europe: a seven countries cross-sectional survey	2014	Germany	Survey of 3722 GP trainees and newly qualified GPs	Role models influence career choice in male rather than female participants.	4	10
Curtis, A. Main, J. ‘Getting them early’: the impact of early exposure to primary care on career choices of A-level students – a qualitative study	2008	UK	Interviews with 11 students	Role models are important in the professional development of medical students	3	8
Passi V, Johnson, N The hidden process of doctor role modelling	2016	UK	Focus groups with 52 medical students and semi-structured interviews with 5 students and 30 consultants	This research study generated a detailed explanation of the process of doctor role modelling and how this subsequently influences professional development.	2	11
Mackie, E. Alberti, H. Longitudinal GP placements- inspiring tomorrow’s doctors	2020	UK	Semi-structured interviews with 5 students	The GP tutor role model and ‘authentic’ experiences to consult patients themselves developed a growing sense of self-efficacy within students, all of which resulted in a significant internal desire to become future GPs.	1, 4	10

Figure 2. A summary of the attributes of GP role models and the influence of the role modelling process on perceptions, behaviours and career choice.

Table 3. Implications for practice.

Conscious role modelling	Institutions must ensure that family medicine educators are aware of their role modelling potential and are supported to demonstrate appropriate professional behaviours and attributes.
Supporting positive role modelling	Consideration of the emotional status and support needs of those involved in providing a role model for future doctors is important, particularly in those who are junior and potentially at greater risk of burnout.
Training the future generalists	GP role models are ideally placed to support the development of key generalist skills therefore, all future doctors should receive regular and ideally longitudinal exposure to GPs throughout their medical training.
Exposure to GP role models	Medical students must receive appropriate exposure to GPs throughout training. Institutions should seek to support academic GP role models to raise the profile of general practice as an academic speciality and dispel the view that it lacks intellectual challenge.
Denigration of general practice	Action must be taken to highlight the detrimental impact of denigration of GP as a speciality, and professional ‘banter’ of GP bashing has no place in modern medicine.

Box 2. Recommendations for future research

Understanding the interplay between intersectional identity, personal attributes (gender, race/ ethnicity, disability etc) and role modelling in family medicine

Exploring the experience of the GP role model and the barriers and facilitators to effective role modelling.

The lived experience of future doctors- how do individuals experience the role modelling process in general practice?

Table

Quality indicator	Score 0/1	Summary
Research question: is the question or hypothesis clearly stated?
Study subjects: is the subject group appropriate for the study being carried out (number, characteristics, selection and homogeneity?)
Data collection methods: Are the methods used reliable and valid for the research question and context?
Completeness of data: Have subjects dropped out? Is the attrition rate less than 50%? For questionanaire based studies is the response rate acceptable (60% or above?)
Control of confounding: Have multiple factors/ variables been removed or accounted for where possible?)
Analysis of results: Are the statistical or other methods of results analysis used appropriately?
Conclusions: is it clear that the data justify the conclusions drawn?
Reproducibility: Could the study be repeated by other researchers?
Prospective: Does the study look forwards in time rather than backwards?
Ethical issues: Were all relevant ethical issues addressed?
Triangulation: Were results supported by data from more than one source?

Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7):e1000100.

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