General practice needs to improve recruitment and income of GP researchers

General practitioners (GPs) lack incentives to become a PhD student. Medical PhD students have in general the lowest income of all doctors in Scandinavia. GPs lose the most money doing a PhD [1]. The result is that general practice has a low number of doctors with a PhD compared with other medical specialists.

In 2005, 48 PhD theses in medicine per million inhabitants were presented in Norway. In Sweden there were 102 theses [2]. If national research spending is not increased, by 2010 Norway will have too few doctors with a PhD to educate the growing number of medical students [2]. The situation is probably similar in other Scandinavian countries. The most important reasons why British doctors do not want to do a PhD are bad financing and the gap between income in clinical work and research [3]. These reasons will probably be valid also in the Nordic countries. From data on PhD and GP income we can estimate the income gap: it is an incredible NOK 2 605 528 in lifetime income in disfavour of doing a PhD!

Several aspects influence doctors’ speciality choice, among them working hours [4]; night duty burden [4]; flexibility [5]; working environment etc. Many research positions are highly competitive compared with the above factors. This is, however, not enough. Health economy studies have shown that income is important when doctors make their career choices [4], [5], and very important if there are large income differences between different specialities [6]. Increased pay in a speciality will increase recruitment of doctors [5]. By increasing income during research and PhD work the most important argument for not doing research will not survive [3].

We need considerable financial initiatives to improve the interest, the settings and the recruitment to research in general practice. In 2008 hospitals in Norway received NOK 3 billion for research. General practice received NOK 30 million, equivalent to only 1% of the hospitals’ research funding.

Combined positions

Norwegian hospitals have established doctors’ positions combining research and clinical work. These combined positions have resulted in (1) a more efficient progress of hospital specialization and PhDs with a lower finishing age, and (2) increased recruitment of doctors to medical research. Doctors in combined positions keep their basic income as a clinician when doing research. There are no combined positions for GPs in Scandinavia.

Combined positions could be established in general practice with a fixed salary. Every year a certain number of doctors receive authorization to work as a GP in the Nordic countries. Some 25% of these GP establishments ought to be combined positions. Like combined positions in hospitals, 50% of the working hours should be dedicated to research. Today's speciality programme for GPs in Norway will prove fully gainful in a combined position, resulting in a PhD and a speciality degree in general practice after six years. The proportion of GPs with a PhD will increase from 1.9% today to 3.0% in 2020. To make a comparison: today 10% of hospital doctors in Norway have a PhD.

Increased scholarship

The annual number of medical grants in Sweden is today equal to the number in 1994. The number of researchers is in general increasing in Norway, but the proportion of medical doctors in research positions is steadily decreasing [7]. Due to financial problems, part-time PhD work is the rule in Sweden and Finland [8]. There has never been a lower number of full-time medical research doctors in Norway. One reason might be the gap between income as a research fellow and as a clinical doctor. Denmark and Finland have the highest medical scholarships in Scandinavia, but even in these countries they agree on the fact that income for research fellows is too low. A GP will earn 35% of his/her original income as a research fellow. Since 2001 doctors in clinical work in Norway have had a wage increase of 52%. Research fellows have had an increase of 28%. The difference in income between research fellows and other clinical doctors has increased since the 2008 wage settlement.

There is a general agreement that income for medical research fellows is too low in all Nordic countries. The wages of all medical PhD students ought to be considerably increased. Scholarship wages should be a reasonable alternative to wages in clinical work. Most medical research fellows are hospital doctors. The scholarship wages should correspond to average income without payment for duty work for hospital assistant doctors. Even with such a wage increase, a Norwegian GP undertaking a PhD will still lose NOK 1.7 million in lifetime income [1].

After six years of medical school, five years of speciality training, and commitment to the highest academic degree, GP research fellows earn less than an intern, even though they are a highly demanded research resource. GPs represent a large unused resource when it comes to clinical research, and the discipline of general practice is greatly in need of research-based knowledge. The Scandinavian countries publish approximately 10 articles in primary care per million inhabitants. Australia, New Zealand, and the UK publish approximately 20 [9]. Several strategies are needed to increase GPs’ commitment to academic work. I have pointed out a few problems that must be solved. Low wages form the most important argument for not engaging in research [3]. Improving research opportunities and income and making research an inherent part of GP work are important. These factors may have consequences such as increased interest in research and more full-time researchers may come forward. Income must not remain an argument for GPs not doing research!