The perceptions of a GP's work among fifth-year medical students in Helsinki, Finland

Abstract

Objective. To explore medical students’ potential interest in family medicine in the future and their perceptions of a GP's work. Design. A cross-sectional survey in 2008–2010. Setting and subjects. Fifth-year medical students prior to their main course in General Practice at the University of Helsinki. Main outcome measures. The students’ opinions regarding the GP's work and their perceptions of the main aims of a GP's work. Results. 309/359 medical students (mean age 25.7 years, 64% females) responded to the survey. Among the students, 76% considered the most attractive feature in the GP's work to be that it is versatile and challenging. The least attractive features included: too hasty, pressing work, too lonely work, and too many non-medical problems. The majority of the students considered the main aim of a GP's work as to identify serious diseases/disorders in order to refer those patients for specialized care (82%). Treatment of chronic diseases is an important responsibility of a GP's work according to 63% of the students. Only 38% considered health promotion to be an important aim. Conclusions. Medical students may have perceptions of the GP's work that influence their career choices to specialize in other fields.

Key Words::

• Long-term doctor–patient relationships
• non-medical problems
• perceptions of a GP's work
• versatile

• The GP's work has become less tempting for young doctors.

• In their opinion the most attractive features of the GP's work are that it is versatile and challenging, and it includes comprehensive doctor–patient relationships and opportunities to meet people of different ages.

• They also thought that the GP's work may be too hasty, pressing, and lonely, and it has to deal with too many non-medical problems.

• More students believe that the most important goal of the GP's work is to identify serious disorders and refer these patients for specialized care rather than taking care of chronic diseases.

Introduction

Current primary care practice has become pressing [1,2]. The ageing population with chronic diseases and a shortage of physicians has led to excessive workloads [1,3,4]. Physicians must deal with an increasing amount of paperwork [1,2], and new technologies have favored diagnostic skills, diminishing the amount of attention given to patients [5]. These changes have led to a waning reputation for family medicine and, consequently, the GP's work has become less tempting for young doctors [3,4,6–10].

Medical curricula are often hospital-based, and there is little emphasis on community-oriented activities, prevention, doctor–patient communication, and teamwork [3,11–14]. Several reports suggest that there is a tendency for both teachers and students to undervalue family medicine [14,15]. Students’ interest in family medicine declines during their medical studies. Many students perceive a tendency on the part of their professors and peers to dismiss public health issues as being unimportant, thus imparting a hidden message that it is inferior to clinical medicine [7,15]. Positive role models in medical school [4,16,17], clinical training in family medicine [4,15,17] and social orientation [6] have an impact on choosing a career in family medicine. Young doctors often think that a GP's work is too lonely [12].

In a qualitative study, Canadian family physicians considered rewarding dimensions of a GP's work as being diversity and comprehensive care, having relationships with patients and their families, being an absorbed witness to the human condition, and providing continuity of care [2]. Excessive paperwork, workload and time pressure, and demanding patient expectations were considered as challenges in the GP's work [2,18]. Variety of work is also a source of job satisfaction [19].

There are studies reporting medical students’ declining interest in family medicine [20], and family physicians’ opinions on the pros and cons of their work [2]. However, to our knowledge, there are only a few studies investigating medical students’ own perceptions and opinions of a GP's work.

The aim of this study is to explore fifth-year medical students’ attitudes towards and perceptions of a GP's work and their potential interest in family medicine in the future.

Material and methods

Participants

An electronic survey was conducted including all the fifth-year medical students prior to their main course in general practice in the medical school at the University of Helsinki between 2008 and 2010. The medical students in Helsinki have courses in general practice during the first (e.g. following family physicians’ practice), second (early patient contacts in community care) and third or fourth year of curriculum (first own-patient consultations in primary health care). The main course of general practice is during the fifth year of medical studies [21].

Questionnaire

The fifth-year medical students responded anonymously to the survey. The questionnaire was created by the investigators containing 25 different questions clarifying the aspects of the GP's work (available from authors). The questions were retrieved from previous literature [1,2,4,6,12]. They intended to include some dimensions based on WONCA tree competences (community orientation, comprehensive approach, person-centered care) [22]. It also consisted of demographic factors and questions concerning their experience as an undergraduate locum doctor.

The questionnaire was piloted among students, and items were found easy to understand. Of the 359 medical students participating in the course of general practice during the years 2008–2010, 309 responded to the questionnaire (response rate 86%).

The students were asked what kind of features they felt to be the most attractive in the GP's work. We offered alternatives from which the students were requested to choose the five most attractive features and to put them in a ranking order. Their first, second, and third choices were considered to be “the most attractive features” (see Table I). We asked, respectively, what kind of less attractive features they find in a GP's work, and asked them to choose the five least attractive features from the alternatives offered, and to put them in a ranking order from one to five. Their first, second, and third choices were considered to be “the least attractive features”. We assessed the students’ opinions about the main aims of a GP's work. We offered alternatives from which the students were requested to put them in a ranking order. Their first, second, or third choices were categorized as “the most important” and the others as “less important”.

Results were analyzed using SPSS statistical programs. Data were examined with statistical variables (frequencies, percentages, means, standard deviations, ranges). Groups were compared with the chi-squared test for categorical variables. P ≤ 0.05 was considered statistically significant.

Table I. Features of GP's work considered as the most attractive (cumulative percentage ranked as first, second, or third).

Feature of GP's work, %	Males (n = 109)	Females (n = 200)	p-value^1
Versatile and challenging work	74.3	76.5	0.67
Comprehensive doctor–patient relationships	45.0	37.0	0.17
Opportunity to meet people of different age groups and various backgrounds	39.4	41.0	0.79
Long-term patient relationships	38.5	35.0	0.54
Well-paid job	35.8	31.5	0.44
Rewarding work, grateful patients	26.6	28.5	0.72
Secure and respected job	11.0	17.0	0.16
A window to ordinary people's everyday life	13.7	13.0	0.93

Notes: ¹Differences between the groups were tested with a chi-squared test.

Results

The students’ mean age was 25.7 years (SD 3.2), and 64% were females. Their mean experience working as an undergraduate locum doctor was 3.2 months. The largest proportion of the fifth-year students (76%) regarded the versatile and challenging work as the most attractive feature of a GP's work (Table I). The opportunity to meet different kinds of people of all ages and the comprehensiveness of doctor–patient relationships were considered as an important attractive feature by 40% of the students. There were no differences between males and females regarding the attractive features.

A majority of the students (69%) thought that too hasty and pressing work is the least attractive feature in the GP's work (Table II). Of the students, 51% considered “too lonely work” and 53% “too much dealing with non-medical problems” as less attractive features in the GP's work, respectively. A larger proportion of the female students found a GP's work too lonely compared with the males (p = 0.037). Male students considered more often than females that a GP's work includes too much dealing with non-medical problems (p = 0.043) and that it includes too many routine tasks and is tedious (p = 0.0048) (Table II).

Table II. Features of a GP's work considered as the least attractive (cumulative percentage ranked as first, second, or third).

Feature of a GP's work	Males% (n = 109)	Females% (n = 200)	p-value^1
Too hasty, pressing work	67.9	69.5	0.77
Too lonely work	43.1	55.5	0.037
Too much dealing with non-medical problems	60.6	48.5	0.043
Long-term doctor–patient relationships also with demanding patients	24.8	27.5	0.60
Too challenging and difficult work	23.9	26.5	0.61
Too routine and tedious work	30.4	16.5	0.0048
Difficult to advance in one's career	14.7	11.5	0.42
Too much responsibility	13.7	16.0	0.60
Poorly paid job	5.5	5.0	0.85

Note: ¹Differences between the groups were tested with a chi-squared test.

The students’ opinions regarding the aims of a GP's work are presented in Figure 1. Among the students, 82% considered that the most important aim of a GP's work is to identify serious diseases/disorders in order to refer those patients for specialized care. Some 63% of the students considered the care of chronic diseases as an important aim of a GP's work. The proportion considering health promotion as an important aim was 38%.

Figure 1. The main aims of the GP's work in order of importance.

Discussion

Students appreciate the GP's versatile and challenging work, the GP's opportunity to meet people of different ages and various backgrounds, and the comprehensive doctor–patient relationships. However, they have preconceptions that the GP's work is too hasty and pressing, too lonely, and that it consists of dealing too much with non-medical problems. The majority of the students (82%) considered that the most important goal of the GP's work is to identify serious diseases in order to refer patients for specialized care.

To our knowledge, there are only a few studies exploring the pre-graduate medical students’ conceptions of the GP's work [20]. Three in four students considered that versatile and challenging work is the most attractive feature of a GP's work. This feature has been recognized in many studies as an important feature attracting young doctors into family medicine [23], as well as a source of job satisfaction among GPs [1,2,18,19,24–26]. Students appreciated that the GP's work provides an opportunity to meet people of different age groups and various backgrounds, as well as an opportunity to have comprehensive and long-term doctor–patient relationships. These dimensions have also been recognized as rewarding features of the GP's work among both medical students [4,23] and family physicians [1,2]. These findings, in line with international studies, suggest that our students are aware of many features of the GP's work. Our students are exposed to family medicine during their first year of medical school, and also during their second year and third or fourth year of curriculum, which seems to give them a view of the GP's work.

The students considered the least attractive features of a GP's work to be too hasty and pressing work, a feature appearing in many studies as a source of dissatisfaction in a GP's work [1,2,18,24]. The students thought that one of the less attractive features of a GP's work is that it consists of too many non-medical problems, and is too ordinary and tedious. Some studies have suggested that family practice is rejected because of its low clinical or intellectual content [12, 27], and because it consists of too much routine work [1]. In line with previous studies, a large proportion of the students thought that the GP's work is too lonely [12].

The male and female students differed in their attitudes towards a GP's work. The males highlighted more often than the females that the GP's work consists of too many non-medical problems (p = 0.043), and it is too ordinary and tedious (p = 0.0048), whereas the females more often considered the GP's work lonely than the males did (p = 0.037). In addition, unlike previous studies [1], income seemed to play a minor role among our students and their perceptions of the GP's work.

Large proportion of students considered the most important goal of the GP's work to be to identify serious diseases and refer them for specialized care. This proportion was larger than the proportion considering care of chronic diseases or health promotion as the most important aim of a GP's work. There might be several reasons for this finding. First, fifth-year medical students have been trained during two clinical years primarily at the university hospital prior to their course in general practice. In Finland the medical faculty of Helsinki has a hospital-based curriculum. At the university hospital students meet only seriously ill patients, and specialist doctors emphasize that while working in primary care they have to be able to identify various serious diseases in order to refer such patients to hospitals. Students have readily picked up this message. Second, at this stage of medical studies, students are worried about their professional skills and they are afraid of making such mistakes, which might harm their patients [28]. Therefore, they are eager to consult specialist care and refer their patients to hospitals. In this respect it is understandable that they have this kind of conception of the GP's work. At this stage, medical students have not realized yet that in over 90% of the GP's consultations the patients are treated by the GPs themselves [29–31]. Only 4–10% of a GP's patients need specialized care [29–31]. In fact, the work in public health care centers in Finland concentrates on primary and secondary prevention, care and rehabilitation of various chronic diseases, as well as health promotion [32], although identification of chronic diseases is also important.

Our findings imply that it is important to be aware of medical students’ attitudes towards and perceptions of the GP's work. Having positive role models in medical schools and guiding the medical curriculum to have more emphasis on community-oriented activities, prevention, and doctor–patient communication may influence students’ orientation towards family medicine.

The strength of our study is a high number of respondents and a high response rate. The students seemed to respond honestly about their attitudes, feelings, and fears related to working as a GP in the future. One limitation of this study is its cross-sectional nature. The predefined questions in our survey may have guided the students’ responses. The students responded to this questionnaire before their main course of general practice. Thus, the responses could have been different after this course and rotation as suggested in a study performed in the USA [20]. However, our students had had at least three weeks of experience of primary health care during their prior studies before this survey. In addition, the findings may not be generalizable in other cultures or not even to other faculties in Finland with a more community-oriented curriculum. However, many of our findings are supported by international studies.

Conclusion

The students seem to be well aware of the attractive and less attractive features of the GP's work. They pay great attention to the possibility of missing some patient with (a serious) disease since they think that identifying serious diseases is a more important part of GP's work than treatment of chronic diseases or health promotion. These conceptions may influence their career choices. It is important to be aware of students’ perceptions in order to focus on the medical studies and courses of general practice.

Ethics

Permission for this study was obtained from the Planning Committee for Undergraduate medical education.

Declaration of interest

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