https://orcid.org/0000-0002-3443-6190
Abstract
Background
The shortage of general practitioners (GPs) is a worsening problem in many countries and poses a threat to the services provided by primary care and by extension for the entire healthcare system. Issues with GP workforce recruitment and retention can be reasons for this shortage.
Objectives
To describe GP trainees and newly qualified GPs experiences and perceptions on how their training and early experiences of work influence their career intentions in primary care in Estonia.
Methods
A qualitative study with GP trainees (n = 12) and newly qualified GPs (n = 13) using semi-structured group interviews (n = 6) was conducted. Interviews were conducted from October until November 2020. Data were analysed using thematic analysis with NVivo Software.
Results
Although early-career GPs in Estonia envision their future roles as GP practice owners with patient list, this is often postponed due to various reasons. Early-career GPs expressed a sense of unpreparedness to fill all the roles of GPs’ and found the process of establishing a GP practice and taking on a patient lists very complicated. They value work-life balance and prefer workplaces, which offer flexible working conditions.
Conclusion
Potential strategies were identified to enhance the willingness of early-career GPs to continue their career as GP practice owners with patient list: improving the GP training program by placing more emphasis on managing skills and making the process of establishing GP practice and taking on a patient list less bureaucratic and more accessible.
KEY POINTS
This study highlights the career intentions of GP trainees and newly qualified GPs in Estonia.
Participants of this study perceive the many different roles of being a GP as very challenging.
Understanding early-career GPs ideas about the future work environments can be helpful in shaping future workforce strategies.
Introduction
To ensure effective access to healthcare, a sufficient number of different specialists are required. Although the number of doctors per capita has increased in all OECD countries between 2010 and 2019 [Citation1], the share of general practitioners has decreased [Citation2]. The benefits of well-established primary care are well described in terms of better health outcomes and more effective use of healthcare resources [Citation3, Citation4]. Therefore the shortage of GPs can be a threat to the organisation of the entire healthcare system [Citation4–6]. The reasons for the shortage include problems with the recruitment and retention of GP workforce [Citation7].
To become a GP in Estonia, one has to complete a 4-year GP training program, which used to be 3 years until 2018 [Citation8]. Similarly to Norway, Denmark and Germany, GPs in Estonia work as practice owners with a patient list as part of a group practice or alone, the latter being more common [Citation5, Citation8]. Only GPs can apply for a patient list and the Estonian Health Insurance Fund sets the total number of these lists. A GP can have one patient list at a time and the size of this list is usually 1600 ± 400 individuals. In Estonia GPs exercise a partial gatekeeping function and are directly funded by the Health Insurance Fund [Citation8].
The total number of GPs in Estonia has decreased over the years. In 2020 the average age of Estonian GPs was 57 years and 20% of working GPs were of retirement age. The number of GP trainees has increased in recent years, but it is still challenging to find replacements for GPs who have left primary care. In 2020 approximately 60,000 Estonians did not have a permanent GP and were mostly served by locum doctors. Only half of all Estonian GPs who qualified in 2009–2020 have taken a patient list [Citation9]. There is no information about the career choices of GPs who decided not to take a patient list.
Several factors determine whether there will be enough GPs in healthcare: medical students’ interest in GP as a career, the career intentions of early-career GPs, the migration of GPs and the drop out of GPs at any stage during their career [Citation7, Citation10]. Few studies to date have explored early-career GPs career intentions in Europe. Previous studies conducted in Europe showed that most early-career GPs prefer to work first part-time or have a ‘portfolio career’ and see themselves as owners of a practice later in their career [Citation11–14]. The main reasons mentioned for not committing to practice immediately after the training were shortcomings in specialty training, wish for a work-life balance and reluctance to work in the current primary care system [Citation12,Citation13].
The aim of this study was to describe GP trainees and newly qualified GPs experiences and perceptions on how their training and early experiences of work influence their career intentions in primary care in Estonia.
Methods
Design
The qualitative study using semi-structured group interviews was chosen to explore this topic. The study design and interview guide were developed under the supervision of a medical researcher (MKK) with experience in qualitative methodology. Data was analysed using thematic analysis and the study is reported with the help of the SRQR checklist [Citation15].
Recruitment
Using convenience sampling last year GP trainees and GPs within five years of completing training was recruited. The invitation letter was sent via the official University of Tartu mailing list to the GP trainees and via the official organisation mailing list to the members of the Estonian Society of Family Doctors’ and shared on the closed Facebook groups for Estonian GPs. Voluntary participants were asked to contact the researchers for enrolment in the study. Informed consent was obtained in writing. To collect general information participants completed a questionnaire using SurveyMonkey® (Supplementary Material 1). All GP trainees and newly qualified GPs who expressed their wish to participate were included.
Data collection
The interview guide (Supplementary Material 2) was developed based on previous findings [Citation14, Citation16] and the review by Kallio et al. [Citation17]. The interviews were carried out by three researchers (MV, AU, EÕ) in pairs using the Microsoft Teams program. Interviews were conducted online because of the on-going COVID-19 pandemic. The group interview method was chosen to enable discussion of perceptions and experiences of the shared topic [Citation18]. The groups were kept small, three to five participants per group, for people to feel comfortable and express their thoughts freely [Citation19]. Trainees and GPs were interviewed separately to avoid GPs influence over trainees’ answers. Otherwise, groups were formed randomly. The content and order of the interview guide was tested in the first interview and no changes were made. The first interview was included in the analysis. Interviews were audio recorded and later transcribed verbatim in Estonian using a web-based speech recognition program [Citation20]. First, six group interviews were conducted. No new themes were added with the sixth interview and therefore it was concluded that data saturation was reached and recruitment of additional participants was stopped.
Analysis
Thematic analysis following steps set out by Braun and Clark [Citation21] was conducted using NVivo (Release 1). Thematic analysis was chosen because of its inductive approach and because researchers were familiar with it. The data from trainees and GPs was analysed together by three researchers (MV, AU, EÕ). First, these data were read individually by the researchers multiple times to get an overview. After that, initial codes and themes were generated separately and finally, common themes were created. Final themes were reviewed with the entire research team [Citation21]. Quotations were translated to English and marked according to the participant’s career stage (GP or TR) and numbered based on the order of appearance in interviews including the number of the group.
Results
Between October and November 2020, six group interviews with 25 participants were conducted: 12 final year GP trainees and 13 GPs. Group interviews lasted for approximately 90 min. The characteristics of the participants are shown in .
Table 1. The characteristics of the participants.
The perceptions and experiences of GP trainees and newly qualified GPs on how training and early experiences of work influenced their career intentions were grouped under five themes: career as a GP practice owner with the patient list, preparation for GPs everyday work, an opportunity to prioritise work-life balance, process of becoming a practice owner with patient list and finding a suitable workplace (Supplementary Material 3).
Theme 1: Career as a GP practice owner with patient list
Although GPs in Estonia are welcomed to work in different healthcare settings (ambulance, emergency departments, nursing homes, etc.), the participants agreed that the main aim for entering the GP training program was to become a practice owner with patient list in the future.
Where you need GP training, you need it when working in a GP practice as a GP with or without a patient list. (GP2 FG2)
The interviewed trainees see themselves working as a locum or employee after completing the training and consider becoming GP practice owner with a patient list later in their career. A similar pattern was seen among the GPs who participated in the interviews.
I finished in 2017 and then I worked as a locum in different GP practices … But from the beginning I actually wanted to establish my practice and take a patient list. (GP7 FG4)
Participants agreed that the career path in general practice differs compared to other medical specialties. Here the career path doesn’t follow a typical vertical trajectory where one has the opportunity to move step by step to become a higher authority. It culminates in achieving autonomy by becoming a practice owner with patient list. Therefore many participants were not in a hurry to achieve this career peak and predicted they would be ready to commit to it within 5–10 years after completing the training.
In general a GP’s career, it’s not a career where you somehow develop vertically to become a bigger boss. Well, usually at the end you’re your own boss. (GP6 FG4)
Theme 2: Preparation for GPs everyday work
Participants believe that a well-thought-out and comprehensive GP training program is needed to inspire early-career GPs to pursue a career in primary care. Participants emphasised that the training program prepares well for the clinical work of GPs. GP rotations were considered by the participants more substantial and helpful for preparing for the clinical work compared to hospital rotations.
I have learned many times more with a few-months working in a GP practice than I have in the hospital. Because in the hospital they go into such detail that I often feel like why I have to know from this point forward, I would refer this patient to another specialist anyway. (TR8 FG3)
The opportunity to work in different GP practices together with different supervisors during the training gave participants a broader overview on how other GPs work and manage their practices and helped to form a better understanding in which work environment they prefer to work in the future.
I was definitely influenced … since I always had a plan to take a patient list and start my own practice, then actually it was very helpful. When I was working there, I was thinking, what I would do the same way, what would I do differently. (GP7 FG4)
However, according to the participants a major shortcoming of the training program was the insufficient preparation for the non-clinical tasks of GPs’ work. Among others were mentioned the lack of knowledge on the process and requirements of taking on a patient list, establishing and managing a GP practice. Participants mentioned that the topic was avoided by the supervisors and superficially covered in the training program.
How to manage a patient list and a general practice in real life this was not talked about in my opinion. In this regard I find that the training did not prepare us at all. (GP4 FG2)
Theme 3: Opportunity to prioritise work-life balance
When making decisions about their future career, new GPs want to prioritise work-life balance. Participants wish to have time for family, planned vacations, opportunities for self-development and their hobbies. Being a practice owner and working with a patient list was seen to impose a lot of responsibilities, which can make it difficult to achieve desired work-life balance.
Because I have a family and children, I hope to have a planned vacation in the future. This is my main fear that suddenly I will sink under the responsibilities of having a patient list. And it’s a little scary … If you look at the young GPs who have given up their patient lists or who haven’t managed, it raises questions. (GP8 FG4)
Family planning was affecting the career intentions of the participants greatly. GPs, who entered the training immediately after graduation and had plans to start a family, felt that taking a patient list before family planning is finalised was substantial commitment and also unfair to the patients. On the contrary, GPs, whose career intentions were no longer influenced by family planning, were ready to take a patient list immediately after completing their training.
I am certainly not initially interested in taking a patient list, just in terms of a purely private background. If there may still be plans to raise a family, then taking the list would immediately bind me so much to the work that I am not ready for it at the moment. (TR2 FG1)
Related to the wish to achieve work-life balance, the difficulties with finding a locum doctor to fill in for short- or long-term leave were highlighted as one of the significant obstacles. Several participants indicated that they would be more likely to take a patient list earlier if there was a well-organised system of locum doctors to cover during the period of parental leave, vacation, sick-leave and self-development courses.
I'd like to take a patient list, but only if there was a substitution system … If I take the list, it means that I might not be able to take a vacation and also, if I wanted to have another child, it might not be possible, I would have to look for a locum doctor myself, which can be very difficult. (TR4 FG3)
Theme 4: Process of becoming a practice owner with patient list
Participants talked about their own or their colleagues’ experiences with establishing a practice and taking on a patient list. For the participants the overall process seemed very bureaucratic, time-consuming and demotivating. Although some of these steps of this process have been clearly listed by the authorities, others may not be mentioned and can create unforeseen situations, which can be overwhelming and frustrating for new GPs.
When starting, I took the list that was sent by the authorities as an example … Additionally there was a series of documents and requirements I needed to fulfil before opening the practice … Fortunately I had a colleague who helped me with going through these documents and requirements. I don’t think I could have done it on my own and might have left dealing with it until the last minute. (GP12 FG6)
Early-career GPs voiced their need for more support and specific guidance from colleagues who have gone through this process as a form of mentoring. Participants also believed that the motivation and willingness of GPs to become practice owners and work with a patient list would be higher if the authorities provided more assistance and simplified the overall process.
… and it would be helpful if there was some kind of clerk who encourages and helps you. Or there would be a ready-made general practice where you can start working the next day; you don’t have to have any hustle associated with how to get things up and running. (GP11 FG6)
According to the participants, establishing a GP practice and taking on a patient list is also inhibited by the lack of initial capital needed to set up a practice. Many are not able or willing to invest personal funds in their own practice especially at the beginning of their career and think governmental financial aid could be helpful.
I think it is important to talk about initial capital… in the situation where I don’t know whether or not I should take a patient list, I would not invest any personal money to manage a patient list and GP practice. (TR5 FG2)
Theme 5: Finding a suitable workplace
Before committing to a patient list, participants wished to find a suitable workplace. GPs prefer to work in a familiar practice, somewhere they have worked before or a workplace their colleagues have recommended. Working in different practices during their training has shaped participants’ idea of a suitable working environment and the expectations for the future workplace. After finding a suitable workplace, participants are ready to take a patient list sooner.
After I completed the training, I was absolutely sure I would not take a patient list … Then colleagues from my main training post approached me a few months later and asked if I would like to take a patient list and come work with them in a group practice … I could not pass this opportunity, because well, it seems that taking a patient list should be the ultimate goal at one point. (GP1 FG2)
Being aware of the various difficulties that the process of becoming a practice owner with patient list can lead to, participants prefer to be a part of a group practice. This means less bureaucracy, avoiding dealing with the authorities and worrying about getting the necessary premises and equipment.
In the group practice you shake hands and you have an office and equipment and you can immediately start working as a GP and see patients. On the other hand with solo practice, especially, if you start on your own, you have to get all the equipment. Not to mention all of the other things, in addition to the equipment and furniture. (GP4 FG2)
Other advantages of working in a group practice were mentioned: working in a team and the possibility to share tasks, the opportunity to focus on clinical work and to delegate non-clinical tasks, also better possibilities to manage the workload and arrange substitutions, which allow flexible working hours and reduce the risk of burnout, especially at the beginning of the career.
If you work in a solo practice, you have to do all this work yourself, so that in addition to clinical work, you’re a business manager, human resources manager, an accountant, at times a cleaner, etc. But in group practice you can share these tasks … Working in group practice you don’t have to worry if you want to go on a vacation or you want to go to a conference or you’re planning to have a baby. (GP1 FG2)
Discussion
Main findings
This study highlights GP trainees and newly qualified GP’s experiences of training and early work-life and the influence on their career intentions in Estonia. It reveals their goal of becoming a GP practice owner with the patient list as the pinnacle of their career, but not right after finishing the training. Initially, early-career GPs envision themselves working as locums or employees to gain experience before taking on the responsibilities of practice and patient list ownership. They express a desire for work-life balance and career flexibility, which greatly influences their career intentions and choice of initial employment. Concerns about the potential impact of practice ownership on family time, vacation and personal development lead many to prefer starting their careers in roles that offer more flexibility.
While early-career GPs feel that the training program prepares them effectively for GPs clinical work, it falls short in equipping them with the managing skills of running a practice and working with a patient list. The bureaucratic challenges and financial requirements of establishing a practice and fear of burnout have led to wish for more support from the government and colleagues. As a result early-career GPs lean towards group practices, as they offer a more conducive environment for achieving their desired work-life balance.
Strengths and limitations
The participants of this study were geographically scattered and their demographic profile was similar to the Estonian GPs demographics. Almost half of the last year trainees participated in our study. The interviews were conducted while the trainees had still 6 months until finishing their training, so it may have been difficult for them to fully disclose their career intentions.
Researchers, who conducted interviews and analysed the data, have background in general practice and therefore most of the participants were familiar to them. It may be that due to the acquaintance with the researchers some participants did not feel comfortable to express their honest opinion or on the contrary felt more comfortable to do so. As the focus of this study was not the impact of the COVID-19 pandemic on the participants’ career intentions, it is difficult to estimate how it may have affected their ideas. The participants did not raise this topic either. Since a convenience sample was used, the generalisability of the research findings is limited. It is not possible to report on the viewpoints of trainees and GPs who did not participate or who may already have left primary care.
The interviews were held online and two participants had problems with the internet connection, which to some extent impaired their ability to fully participate. Conducting group interviews online can be challenging, and it can be more difficult to ensure that all participants have the opportunity to express their opinions. For this reason, we kept our groups small and conducted interviews in pairs, so the second interviewer could observe and intervene if necessary.
Comparison with literature
Findings in this study are consistent with previous studies conducted in Europe and Canada. Previous studies have reported that early-career GPs favour work that is compatible with their desired lifestyle [Citation11–14, Citation16, Citation22–24] and that work circumstances that provide work-life balance are prioritised over income and advancement in career regardless of gender [Citation23–25]. This is one of the reasons why early-career GPs prefer to work first as locums or employees and are thinking of becoming a GP practice owner or co-owner later in their career [Citation11–14, Citation22, Citation23]. The impact of the content of the GP training program and training experiences on early-career GPs’ career intentions was similarly reported among GPs in the UK, Belgium and France. Feeling unprepared for the managing tasks of GP practice can decrease early-career GPs’ desire to take upon this responsibility [Citation14, Citation22, Citation26]. Therefore, early-career GPs are searching for a suitable workplace, where achieving work-life balance and sharing non-clinical tasks is possible. Previous studies have emphasised the importance of working conditions when choosing a workplace and their influence on career intentions [Citation12, Citation26–29], having in some studies a bigger influence than remuneration [Citation26]. Similarly to our findings, young GPs in Switzerland prefer to work in the future in a small GP-owned group practice [Citation12].
Implications for research and practice
Having a patient list is one of the ways to ensure continuity in primary care. From a recent study published in Norway we know that long-lasting relationships with a regular GP are associated with lower use of out-of-hours services, fewer acute hospital admissions, and lower mortality [Citation3]. Our study identifies key strategies to enhance the willingness of early-career GPs to continue their career as a GP practice owner with patient list.
Understanding the career intentions and preferred work environments of early-career GPs can help with developing effective recruitment strategies and preventing fallout at the beginning of their careers. Improving GP training programs and offering extra training for supervisors can better prepare future GPs prepared for the multifaceted roles of GP. Early-career GPs should be equipped with both clinical and managing skills for successful practice management. Integrating stress management, resilience and self-care training, and establishing peer support groups where early-career GPs can share experiences, challenges, and coping strategies, can help them cope with the profession’s demands. More comprehensive preparation of GP trainees for the realities of their future work will lead to more confident, competent, and satisfied GPs.
Although there is room for improvement in the GP training program, the complex administrative process and significant initial investment associated with establishing a practice and taking on a patient list, and future working conditions seem to be decisive factors in choosing in favour of or against taking on a patient list. Early-career GPs are cautious of compromising family planning and work-life balance and therefore seek initially to work in group practices for better support and collaboration. While there’s a global shift towards group practices [Citation30], solo practices are still predominant in Estonia [Citation8]. Establishing a centrally coordinated system of locum doctors, could support GPs who work alone with substitutions as needed. It is also essential to implement a detailed strategy and political measures to simplify the initiation process for establishing a GP practice and taking on a patient list and make available support from the government and colleagues when necessary. Furthermore, the concentration of GPs in group practices should be encouraged on a national level.
Similarly to Estonia, in some other European countries, GPs are also practice owners who work with a set patient list. Although there may be some differences, these results can be helpful for these countries when developing recruitment and retention strategies. Further research with early-career GPs who have left primary care and/or given up their GP practice and patient list could give additional insight into difficulties, which can arise later in the career.
Conclusion
This study reveals a preference among early-career GPs for roles that offer work-life balance and career flexibility. It also highlights a gap in the GP training program and the need for simplifying the bureaucratic processes involved in establishing a GP practice and taking on a patient list. Understanding early-career GPs’ career intentions is the first step towards developing strategies that could lead to a more satisfied GP workforce and, potentially, a greater willingness to take on practice and patient list ownership in the future.
Author contributions
MV led the study. MV, MKK, AR, EÕ and RK were involved in study design. MV, AR and EÕ conducted the interviews and analysis. All listed authors have directly contributed to writing and finalising the paper.
Ethical approval
Ethical approval was granted by the Research Ethics Committee of the University of Tartu (ref: 322/T-8). The participation was voluntary, and all participants gave written consent in accordance with the Declaration of Helsinki. All participants received information on this study’s aim, methods and procedures and their right to withhold or revoke their consent at any time.
Supplemental Material
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Download MS Word (7.3 KB)Acknowledgements
We want to thank all the doctors who participated in the interviews.
Data sharing statement
The complete codebook with code definitions, anchor examples and pseudonymised interview material can be shared on request.
Disclosure statement
MV is a PhD student at University of Tartu. The authors report no conflicts of interest.
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