Abstract
Objective. To explore the perceptions of general practice trainees regarding their discipline and to compare these spontaneously expressed views with recently proposed definitions of general practice. Material and methods. A qualitative focus-group study was conducted in one Belgian and two French medical schools. Twenty-eight trainees took part (16 from Belgium and 12 from France). The transcripts were analysed by the immersion crystallization method. Results. The participants in this study seemed prepared to take on the many responsibilities outlined in various definitions of general practice, but feared personal commitment to accessibility and continuous care. Being skilled clinicians and patients’ advocates formed their “raison d’être” in the healthcare system. They were reluctant to act as gatekeepers within the system, a role that might jeopardize their advocacy function for their patients. They mentioned the lack of appeal of entrepreneurship aspect of practice. Participants reported that training settings typically offer traditional models of practice, which sometimes led them to feel estranged from a profession that they felt needs reorganization. Conclusions. Participants’ descriptions generally coincided with official definitions of general practitioners’ tasks, except for practice management and gate-keeping aspects. They were willing to accept the burden of general practice as long as responsibility could be shared and as long as there was freedom for flexible progress along a modern career track.
General practice as a profession is under scrutiny in most industrialized countries. A growing proportion of newly trained general practitioners restrict their scope of practice Citation[1–4]. Deteriorating working conditions Citation[5–7] and the greater value that society places on specialty practice Citation[8–10] have been invoked as key factors responsible for this lack of interest in general practice. In an effort to bring the discipline to the forefront of the healthcare system, organizations of general practitioners in many European countries have revisited their definitions of general practice () Citation[11–13]. These definitions now emphasize the key role of general practitioners as providers of first contact and comprehensive ongoing care for a wide spectrum of health conditions. They also introduce the notion of social accountability – the capacity to contribute to the efficiency of the healthcare system through gate-keeping – as a key asset, giving less attention to patient advocacy, the doctor–patient relationship, and a family orientation. In their provocative definition, Olesen et al. have even proposed that continuity of care is not a characteristic specific to general practice Citation[9]. None of these definitions restricts the scope of general practice, and indeed some commentators have suggested that none proposes a novel vision of the discipline Citation[14].
General practice organizations have revisited their definitions of the discipline as the basis for curriculum renewal in the European Community. Little is known about the fit between trainees’ perceptions of general practice and the new definitions.
Trainees feel that the clinical expertise needed to deal concurrently with common and complex problems is one key feature of general practice, along with the doctor–patient relationship.
Social accountability and the gate-keeping function proposed in some definitions of general practice are seen as conflicting with general practitioners’ accountability to patients.
Trainees are exposed mainly to old models of practice, which fosters a sense of a mismatch between the idealistic representation of general practice found in most of the definitions proposed and the reality experienced by young physicians.
Table I. Summary of the most recent definitions of general practice proposed by various European organizations
In this context, it seems important to also explore the views of those who are about to embark on careers in the profession. Can these new definitions help to increase the attractiveness of general practice as a career in the eyes of its trainees?
The redefinition of general practice is not merely a semantic exercise. According to Abbott's systemic view of professions Citation[15], the capacity of a discipline to justify its claims for jurisdiction in a given professional system depends on its ability to clearly establish its role and the effectiveness of its interventions. Disagreement about roles among sub-groups within a given profession may lead to what Abbott calls “internal differentiation”, which can jeopardize the strength of the profession. Although much has been published on medical students’ opinions of general practice as a career choice, few researchers have explored the views of general practice trainees as they prepare to enter the profession Citation[1], Citation[2], Citation[4], Citation[16].
The idea for this study arose during work by three of us (MDB, D Pestiaux, and BG) on the French version of the WONCA (World Organization of Family Doctors) definition of general practice Citation[11]. As practitioners and teachers in the discipline, we wondered if the vision statements proposed by the various organizations of general practitioners would correspond to our trainees’ vision of the profession and their proposed career paths.
We performed a qualitative study among European general practice trainees to explore their perceptions of the discipline and to compare these spontaneously expressed views with recently proposed definitions of general practice.
Material and methods
Design
We used a qualitative focus-group approach, which allowed us to collect a wide range of points of view at reasonable cost in terms of both time and money. Focus groups also allow interactions and debate among participants, giving rise to rich discussions and a better understanding of the reasons underpinning opinions expressed Citation[17].
Participants
The study was conducted in one Belgian and two French universities. Although general practice has been an established part of training in European medical schools for nearly 30 years, a mandatory 3-year training period in general practice was established only recently in these two countries. At the time the study was conducted, trainees could enter such programmes either directly from university or after one or two years in autonomous practice to obtain accreditation as a “full-fledged” GP according to the new European standards. To be eligible to participate in this study, trainees had to be in the final year of their training programme and had to have completed their rotation with a general practitioner.
In Belgium, all 92 final-year general practice trainees at the Université catholique de Louvain (UCL) were contacted by mail. The 20 respondents were all invited to participate, but 4 could not attend on the date set for the focus group. For the French focus groups, volunteers were sought from a convenience sample of 20 residents working near the training hospitals of the Université de Créteil (Paris) and the Université Victor Segalen (Bordeaux), where the focus groups took place. Sampling was purposeful to ensure that the sample would include trainees coming either directly from university or from the practice setting, and a balance of men and women.
Conceptual framework and interview guide
The study was informed by Abbott's conceptual framework on the system of professions Citation[15]. In brief, the concept of professional tasks is central to this framework. It is through the professional tasks carried out by its members that a profession establishes its identity and its legitimacy. Professional tasks have both objective (located outside the professional system) and subjective foundations. The subjective foundations are most important and relate to the way the professionals within the discipline define their roles. In this study we focused on exploring trainees’ representations of the tasks and roles of their discipline. We wanted to explore two dimensions of the professional roles: (1) the perceived roles of general practitioners in the healthcare system, (2) the trainees’ views of their future careers in the discipline. We developed a semi-structured interview guide that explored first their vision of the discipline (the place of general practice within the healthcare system as a whole; what distinguishes the role of the general practitioner; how general practice relates to the other health professionals; and their perception of the stakes for general practice now); and how they envisaged their careers (what motivates them in general practice; what challenges them; how they saw their careers evolve).
Focus-group sessions
We held five focus groups in March and April 2004: three in Belgium, in communities where general practitioners affiliated with UCL host trainees (Brussels, Namur, and Charleroi); one in Paris; and one in Bordeaux. Each 90-minute focus group was moderated by the same researchers (MDB and LB), who were not involved as faculty in any of the participating training programmes. During the focus groups, no official definitions of general practice were provided; as such, all opinions expressed were spontaneous.
Analysis
Because of our deep involvement in the issues under investigation here, we were concerned about potential biases that might affect our analyses. To ensure that these potential biases were minimized Citation[15], the team included researchers from a variety of disciplines (e.g. LB, a social worker with experience in inter-professional collaboration; GR, a sociologist with a strong background in the sociology of professions), as well as a trainee in general practice (VD). We shared our views and hypotheses concerning the research questions. The transcripts were first analysed independently by all of the authors according to the immersion crystallization method Citation[18]. Specific attention was paid to the words used, their context, and the internal consistency, frequency, extensiveness, intensity, and specificity of the comments Citation[17]. Emerging themes related to the two questions under study were identified. We took care to consider these themes from a variety of perspectives and to entertain competing interpretations.
Results
Twenty-eight trainees (18 men and 10 women; mean age 28 years) participated. Ten of the participants had done a general practice rotation in an urban setting, 8 in a suburban setting, and 5 in a rural setting; 5 had been exposed to training in a variety of settings. Eleven had trained in a solo practice and 17 in a group practice.
Roles of the general practitioner
Four themes emerged (Box 1).
Capacity to deal with both common and complex problems
Participants saw the general practitioner as the only healthcare professional able to assume both first-contact care and the management of complex medico-psycho-social situations, as well as the integration of preventive care.
A skilled clinician
Participants described general practice as encompassing the clinical aspects of diagnosis and treatment, which they saw as the foundations of their skills; in particular, they noted that general practitioners must deal with undifferentiated problems, must manage problems in a context of uncertainty, without access to sophisticated investigative technologies, and must use watchful waiting as a diagnostic and therapeutic strategy.
Patient advocacy
Many participants felt that because of their skills, general practitioners represent one of the most efficient resources in the healthcare system. Still, most were uncomfortable with a gate-keeping role, which they saw as undermining their credibility in the eyes of patients and jeopardizing their role in patient advocacy.
Continuing relationships with patients
Participants saw themselves as guardians of the patient's history. Hence, continuity of care was considered a unique characteristic. However, some participants noted that continuity of care need not be linked to an individual practitioner and that working arrangements ensuring access to one of a group of physicians would be a reasonable alternative. Following patients over time was seen as one of the most gratifying aspects of general practice. Paradoxically, the high demands of patients were a source of concern about commitment to practice.
Trainees’ future careers as general practitioners
Three themes emerged (Box 2).
A flexible career
The most appealing aspect of general practice is its flexibility, which allows the physician to shape his or her career according to skills, interests, and personal situation.
A demanding career
General practice was also seen as demanding and inherently tough because of the isolation, the commitment required, the difficult experiences, and the demands of patients. This view was consistent with the opinion that it is impossible to decrease the breadth of the discipline, and hence decreasing the “burden” of availability to patients by joining a group practice or a network is the only solution. Most participants described their postgraduate experiences as determining factors in these perceptions. In most cases, training with general practitioners had provided positive experiences of continuity and fulfilling relationships with patients; however, other participants had felt a need for better balancing of work and personal life and, in some cases, the experience was clearly negative.
Lack of appeal of entrepreneurship aspect
Beginning a career in general practice was seen as both frightening and challenging. Doing locum work for a few years seemed to be the preferred path. Participants saw several advantages to this approach: gaining more experience; being exposed to different practices, which they anticipated would help them to clarify their career plans; and putting money aside before setting up practice. The few participants who spoke of the business side of general practice described feeling unprepared for this aspect.
Discussion
Principal findings
The participants in this study seemed prepared to take on the many responsibilities outlined in various definitions of general practice, but feared personal commitment to accessibility and continuous care. Being skilled clinicians and patients’ advocates formed their “raison d’être” in the healthcare system. They valued highly the family orientation of general practice and the opportunity to develop long-term therapeutic relationships. Although they felt that general practitioners represent the cornerstone of the healthcare system, they were uneasy about the notion of social accountability.
Strengths and weaknesses of the study
Focus-group methodology was particularly appropriate here because, by permitting interaction, focus groups widen the range of responses and help participants to recall forgotten details. However, exploration of opinions can be superficial and the results are sensitive to group dynamics, a phenomenon known as “group censoring” Citation[17]. To avoid this phenomenon we systematically elicited comments from all participants at various points in the sessions. Many participants expressed negative opinions about general practice, which suggests that they felt at ease departing from the social norm. The participants expressed their views consistently and were often very specific about their personal experiences.
We took several measures to ensure that our personal biases did not interfere with the analysis. We shared our personal views and hypotheses at the beginning of the study. All focus groups were conducted by the same two researchers, MDB, who had no professional relationships with the respondents, and LB, a social worker by training. All transcripts were reviewed and analysed independently by each author, including GR, a sociologist with no relationship with general practice academic settings.
This exploratory study was conducted in a specific context and with a limited number of participants. It is important to remember, however, that qualitative research like our study does not aim for representativity of participants to some reference population. Rather, our objective was to document a diversity of opinions and to identify patterns among those opinions Citation[19]. As such, we recruited informants with different experiences and from different geographic areas. No new themes emerged during the fifth group, which confirmed saturation. Obviously, there is a need to replicate such studies in different contexts, given the known impact of university structures and policies on attitudes of trainees toward primary care Citation[20–24]. However, the fact that similar observations have been reported in studies of comparable groups of respondents in France Citation[25] and other European countries Citation[1], Citation[2], Citation[16] suggests that some of these opinions are universal.
Contribution of the study to current knowledge
This study adds to the still-scattered body of knowledge on the vision that general practitioners entering the profession have of their discipline. The importance of the doctor–patient relationship and continuity of care as major sources of gratification conforms with previous observations from the United Kingdom Citation[1], Citation[2] and the Netherlands Citation[16]. Fear of commitment to a practice early in one's career and worries about growing infringement of the state on professional autonomy have also been reported from Britain Citation[1], Citation[2] and France Citation[25]. It is interesting that trainees from different countries had some common views on their careers as general practitioners. Although this study was limited in terms of number of sites, its exploratory nature has allowed broader insight than most related surveys conducted to date.
Implications and further research
Our findings confirm the importance of exploring the vision that future general practitioners have of their discipline in the context of efforts by the profession to redefine its roles and jurisdictions. This is particularly true for European countries, which have the additional challenge of finding a common voice for a profession that is more dependent on workplace organization than any other medical specialty. Clearly, replication of our study in a large variety of contexts is the only way to distinguish universal from context-specific perceptions.
The apparent coherence between trainees’ perceptions of general practice and official discourse should be interpreted cautiously. Two areas should be explored further. The first is the tension between participants’ idealized perceptions of general practice and their experiences. Training experiences were determinant in this regard, offering both positive and negative models of coping with the strains of practice Citation[22], Citation[26], Citation[27]. This finding is consistent with a study of Belgian general practitioners in group practice, in which general practice trainees described this generation gap with their older colleagues in negative terms Citation[28].
The second is the balance between social accountability and patient advocacy. Social accountability often appears in the forefront of new definitions of general practice. However, taken too far, this focus on containing costs and managing the system efficiently could estrange both practitioners and patients, who strongly value the clinical and communications functions of general practice Citation[7], Citation[29]. There is potential here for profound dilemmas between utilitarian and deontological views of professional ethics, but our respondents did not comment in depth on this apparent contradiction. Further exploration of this phenomenon is warranted.
Competing interest statement
All authors declare that they have no conflict of interest related to the present work.
Ethical approval
The Ethics Committee of the Cliniques Universitaires St Luc, Université Catholique de Louvain, Belgium, reviewed the protocol and granted ethics approval.
Funding
The study was funded by the Chaire docteur Sadok Besrour en médecine familiale, Université de Montréal and by the Centre Universitaire de Médecine Générale, Université Catholique de Louvain. There was no interference between the boards of these organizations and the researchers, who had complete independence in performing the study.
The authors would like to thank all of the general practice trainees who agreed to share with them their views concerning their future careers.
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