The non-clinical contents of GP training need more attention. Results from the Finnish Physician Study

Abstract

Background: The competencies required of a GP are complex and ever-expanding. GP training should adequately cover all the content areas.

Objectives: The aim was to assess GPs’ and GP trainees’ satisfaction with their specialist training and with the contents of training. Trends in assessments over a ten-year period were investigated.

Methods: Data from Finnish national surveys of physicians conducted in 1998, 2003 and 2008 were analysed with 606, 457 and 324 GPs and GP trainees respectively being sampled in the present study. Respondents were asked how satisfied they were with their own specialist training in general, and how much instruction they had received in 12 specific areas during their specialist training.

Results: Satisfaction with GP training slowly increased during the study years. In 2008, 59% of respondents were satisfied with their training, compared to 46% in 1998. The best covered content area was clinical work. Major shortcomings were reported in many of the content areas analysed, e.g. management and leadership.

Conclusion: Although the trend in satisfaction with GP training in Finland is for the better, there are shortcomings, especially in many of the non-clinical content areas of training. More attention needs to be paid to these areas in the future.

Keywords::

• GP training
• postgraduate medical education
• vocational training
• general practice
• surveys

KEY MESSAGE:

• In 2008, three-fifths of Finnish GPs were satisfied with their specialist training.

• Satisfaction with GP training slowly increased from 1998 to 2008.

• Major shortcomings were experienced in many of the content areas of GP training, with little change over the ten-year period.

INTRODUCTION

To become a specialist in general practice (GP), Finnish physicians have to complete a six-year post-graduate university specialist training programme, which comprises clinical training mainly at health centres, but also in hospital specialties for one to two years. In addition, a specified amount of theoretical study is required, and a national written specialist examination must be passed.

So far, the interest of research in the context of medical education in general practice has concentrated on increasing the general practice content in the undergraduate curriculum, and attracting physicians to this field (1). Research on vocational training in general practice has covered, for example, the appropriate duration and content of training, the development of new innovative programmes, and trainees’ satisfaction with their training (2,3). However, we were not able to find any studies regarding trends in satisfaction with specialist training.

Today, with ever-increasing demands on the GP's work, it is necessary for GP training to cover adequately all the content areas in the curriculum. The aim of this study was to assess GPs’ and GP trainees’ satisfaction with their own specialist training and the contents of their training. Trends in these assessments were studied over a period of ten years.

METHODS

Study design

The Finnish Physician Study has been conducted in five-year intervals since 1988. We analysed data of the surveys in 1998, 2003 and 2008. The response rate decreased from 73.5% in 1988 to 53.7% in 2008. Each year, samples and respondents were representative of the basic physician population in terms of age and gender.

Selection of study subjects

To obtain comparable samples, only physicians with clinical experience from two to 22 years prior to each survey were included in the present study. General practice specialists and trainees were identified by their answers to the question regarding specialization status.

Questionnaire

Each year the questionnaire consisted of a comprehensive body of items, and was kept in the same form to ensure comparability. The questionnaire was mainly created before the first study in the series in 1988. At that time, the study group could not find any international surveys on the subject, so the questions concerning the content areas of specialist training were created based on the general requirements of training programmes.

Physicians were asked how satisfied they were with their own specialist training. Responses were processed by a Likert scale (very dissatisfied, rather dissatisfied, difficult to say, fairly satisfied, very satisfied). The last two categories were combined as ‘satisfied.’ Respondents were also asked how much instruction they had received in 12 specific areas during their specialist training, with answers on a five-point Likert scale (far too little, too little, appropriate amount, too much, far too much) (Table 1). The first two items were combined as ‘insufficient.’

Table 1. The proportion (%) of Finnish general practitioners who thought that the amount of training in a specific content area was insufficient in 1998, 2003 and 2008, respectively.

Content area of GP training	1998 (n = 606)	2003 (n = 457)	2008 (n = 324)	Difference from 1998 to 2008
	%	%	%	%-units	P-value
Management and leadership	70	70	73	3	0.358
Administrative work	67	66	68	1	0.633
Multiculturalism	^a	^a	67
Work as medical teacher	60	61	64	4	0.275
Research	57	52	52	–5	0.095
Personal professional development	51	51	56	5	0.154
Social issues	48	46	54	6	0.048
Ethical issues	46	43	43	–3	0.358
Cooperation between different levels of health care	39	34	41	2	0.560
Health counselling	36	38	38	2	0.684
Prevention	34	32	30	–4	0.268
Clinical work	19	19	16	–3	0.353

^aNot asked in 1998 and 2003.

RESULTS

Study population

The amount of GPs and GP trainees included in this study was 606 in 1998, 457 in 2003 and 324 in 2008. The proportion of women increased through the study years, and was 59% in 1998, 70% in 2003 and 76% in 2008. The mean ages were 39.9 years, 40.4 years and 40.2 years, respectively.

Satisfaction with specialist training

Satisfaction with GP training slowly increased during the study years. In 1998, 46% of the respondents were satisfied with their training, compared to 51% in 2003 and 59% in 2008. Each year the specialists were more often satisfied than the trainees. In 1998, 34% of the trainees were satisfied compared to 53% of the specialists (P < 0.001). In 2003, the corresponding figures were 36% versus 59% (P < 0.001), and in 2008, 50% versus 64% (P = 0.012).

Contents of training

In 2008, the best covered content area in GP training was clinical work (Table 1). The greatest shortcomings in training were found in management and leadership, administrative work and multiculturalism. Over the ten-year period, there were generally no changes in assessments regarding content areas (Table 1). The only exception was social issues, where the proportion of respondents assessing the amount of instruction to be insufficient increased statistically significantly between 1998 and 2008 (6% units, P = 0.048).

DISCUSSION

Main findings

Over the ten-year period from 1998 to 2008, Finnish GPs’ satisfaction with their specialist training had slowly increased. However, there were major shortcomings in many of the content areas analysed, e.g. management and leadership and cooperation between different levels of health care.

Strengths and limitations

The strength of this study was, first, a nationwide randomized sample with a repetitive series of the same questions since 1998, and second, long clinical experience of the respondents. Although the response rate was decreasing in 2008, it may still be considered to be at a good level compared to those in other studies concerning physicians (4). As satisfaction with training was retrospectively reported, it may leave room for recall bias. To obtain more accurate results on recent training, GP trainees’ opinions were included.

Comparison with existing literature and implications

In 2008, three-fifths of GPs and GP trainees were satisfied with their specialist training. The trend is for the better. Nevertheless, the current situation cannot be regarded as satisfactory, as general practitioners were the least often satisfied in comparison with other large medical disciplines in Finland (5). This is precisely the opposite of the General Medical Council survey results in the UK, where GP trainees were the most satisfied (6). This further underlines not only the need for improvement in Finland but also the need to identify and share optimal practices internationally.

According to our findings, the six-year training scheme would appear to be sufficient to gather the clinical experience required. Nevertheless, it seems that other items in the curriculum, e.g. management and leadership, social and ethical issues and personal professional development, might be overlooked. The need to cover clinical contents is naturally of utmost importance in such a diverse and comprehensive field as general practice. However, especially at this time of ever-increasing non-medical demands in this work, the training should adequately cover these areas. Today the proportion of mandatory management and leadership training has been increased several-fold in all Finnish specialist training programmes.

Managing the interface with other specialties is an essential part of the work of the general practitioner (7). It is thus surprising that two-fifths of the respondents were dissatisfied with this aspect of their training. This may be an indicator of some educational problems during hospital posts. The appropriate training contents and settings in these posts for GPs have also been a cause for concern elsewhere in Europe (8), and the appropriateness of these posts to the learning needs of GPs should be revised. Increasing support from GP tutors during hospital posts might be advisable.

Judging from the findings here, the changes in GP training from 1998 to 2008 were modest. Although licensing as a specialist for general practice requires a university degree in Finland, specialist training has not been taken into account in the allocation of university funds. Adequate funding is essential to any quality improvements made in GP training (9). In addition, the role of the university in training has traditionally been vague because of the fact that specialization takes place mainly in health centres geographically remote from the universities. In recent years, the universities have strengthened their support to the health centres participating in specialist training (10). The structures of GP training have been undergoing many improvements, such as implementing the use of log-books and increasing the number of tutoring senior physicians together with their training in tutoring.

Conclusion

According to our findings, the trend in satisfaction with GP training is for the better in Finland. However, shortcomings in many of the non-clinical content areas of the training have remained unchanged with time. More attention needs to be paid to these areas in the future.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

The study received funding from Finland's Ministry of Social Affairs and Health.