The starting point of this thesis (chapter 1) referred to the needs and demands of care, increasing in volume and complexity by the fact of demographic, technical and economic changes. Thereby, WHO recommended new orientation of health services towards primary care in order to become socially more relevant, to be able to better adapt to changes and to achieve better outcomes. To reach this objective, health systems must have enough workforce in general practice, a core resource for primary care.
Fear about not having enough human resources in general practice to face the evolution of needs does exist in Belgium as in other OECD countries. On one hand, retirement of many active general practitioners, increasing of part-time practice and a large part of inactive general practitioners are decreasing the offer of care. On the other hand, the number of doctors specializing in general practice did not reach the foreseen quota until recently; this induced a cumulative deficiency, still objectivized in 2015.
For all those reasons, the question underlying this thesis was to identify the factors directing students’ and freshly graduated general practitioners’ professional pathways and choices with the aim of suggesting strategies to promote attraction and retention in general practice.
We have chosen to target the steps leading students and doctors to general practice – i.e. choice of specialty, choice of practice location and type, choice to continue to practice after doubts – within a holistic approach: their professional pathway. We considered the choice of medical specialty as a choice of professional orientation and stops or modifications of work organization as evolutions of the professional pathway.
The elements triggering the choices of professional orientation and pathways constitute a complex phenomenon considering the number of influencing factors suggested in the literature. Therefore, we used a multidisciplinary approach to guide our analysis. In the second chapter, we used theories of professional orientation designed in psychology and sociology to better understand individual and societal determinants of those choices. These theories also helped us to discuss actions and interactions of those factors for students in medicine and general practitioners, as they appeared in the literature.
This literature review lead to two observations, which constituted the problem setting of our work.
First, university pathway has an impact on students’ choice of specialization in two ways: it influences the students’ personality through their values and interests and the students’ representation of specialties. However, we do not know much about choice of specialty, personality differences and representations of the profession before student’s exposure to the various specialties during their medical studies.
Second, studies that tackled the problem of limited workforce in general practice always provided separate analysis of attraction or retention in the profession. To our knowledge, there exists no study targeting the whole general practitioners’ pathway.
Following these two observations, two research questions emerged:
- Do all the students starting clinical training show the same professional interests and the same representations of the medical career, whatever specialty they consider for themselves?
- What are the students’ and general practitioners’ professional pathways? Which factors influenced them, from their choice of medical studies until their current professional situation?
We concentrated on students and young general practitioners because they represent the future workforce of general practice and because generational differences can influence the way people imagine and build their professional career.
To answer those questions, we designed three studies.
The first study (chapter 3) aimed at exploring choices of orientation, professional interests and representations of the medical career of students of the University of Liège, at the beginning of their clinical work during the first year of Master. Before this year, they had little opportunity to know the various specialties. In a second phase, we looked for possible links between their specialty project and their professional interests and representations.
This study demonstrated that half of the students did not consider any specialty yet and that only one student over five had a precise idea of the discipline he wanted to choose. General practice was second among the most considered specialties and rejected by less than 10 % of the students. While students were sharing some common professional interests, motivation to choose one specialty and not another was based on professional interests and personal representations of the specialty. As an example, students who favored autonomy and human contacts considered general practice. It is also true for those who had the representation of the profession as demanding and focusing on patients. In this study, we also demonstrated that students considered or rejected some specialties in terms of supposed characteristics, though they do not know them yet.
Nevertheless, the final choice of specialty, the orientation choice, is a match between the person and the profession based on a preliminary examination of congruence between representation of oneself (depending of the personality characteristics) and representation of the specialty. However, soon after graduation and beginning of practice, many influences might modify this choice.
Therefore, the necessary complement of this first work was a study on graduates in general practice to improve our understanding of the factors influencing the choices along the general practitioners’ career. This work should complete the analysis on the expression and sense making of professional interests and expectations in the professional pathway.
The second study, developed in chapter 4, was the first part of a research on the career of graduates of the advanced master of general practice of the three Belgian Frenchspeaking Universities (University of Liege, Catholic University of Leuven and Free University of Brussels) from 1999 to 2013. This research aimed at describing the general practitioners’ activities at the time of the study. For those working in general practice, we could determine their working time, kind of activities practiced and kind of organization of their practice. This gave a full picture of the young active general practitioners, data that were inaccurate until now. We thus had reliable data on the proportion of active general practitioners and the way they organize their work. These were important data to look for links between these ways of practice and the working time and to target different profiles of general practitioners to prepare the second qualitative phase of the study.
Results determined that 21.5 % of the young graduates were not working in general practice any more. Most of them still had medical activities and a mere minority did not practice medicine at all. Concerning those who were working in general practice, they had a variety of practices in terms of activities and working time. 45.8 % were working part-time and most of them had complementary activities. This study also showed that the choice of general practice as a specialty when graduated as a medical doctor was correlated to a larger probability of retention in general practice. Describing these activities and organization of work of the young general practitioners underlined that individual trajectories were not linear.
To go further in this analysis, individual interviews of some graduates allowed to better understand the path that lead them to their current professional situation and to render the dynamics underlying these individual pathways.
This was the object of the third and final study, presented in chapter 5, second part of the preceding research. It aimed at describing the young general practitioners’ pathways. Within the recruited group of young graduates of the second study, we conducted 59 semi-directed interviews in order to identify the factors having influenced their pathway as a student or as a professional. In connection with the objective of a better understanding of the diverse professional careers, the questionnaire of the first phase of the study allowed the distinction of three graduates’ profiles: graduates who are working fulltime in general practice, those who work part-time and those who do not work anymore in general practice. We interviewed members of those three groups about their professional pathways in order to detect specificities and common features of these profiles.
We underlined that the graduates’ pathways followed the principles of lifelong development and implied all person’s social roles. This continuous construction of the professional pathway made the prediction of its evolution difficult. However, we objectivized factors common to all graduates. Among them, some were related to intrinsic characteristics of the profession (work content, autonomy, possible practice of various activities), while others corresponded to extrinsic features of the work (possibility to balance private and professional life, workload, remuneration, support and image of the profession). Other factors corresponded to the features of the training (position of general practice in the university, characteristics of the specialty training). Those factors could influence the professional choices by modifying the students’ representations and work satisfaction of the working general practitioners. However, modifications of the pathway did not always result from a choice but could also be the consequences of some constraints.
In conclusion, with these three studies we defined factors influencing the students’ and young doctors’ professional choices from choice of study to choice of staying or not in general practice. Those factors could be linked to the personality features (such as the interests), to the representations of the professions or to external influences (such as the university or the persons’ relatives).
If some factors were stable along the pathway, others took more or less importance depending of the evolution of individual life. Moreover, factors common to most people have a different impact on their decisions; this is due to the individual process of cognitive construction underlying this decision.
We conclude this work by suggesting some strategies to enhance attraction and retention in general practice. Among these strategies, some target the universities to prompt them to promote the students’ exposure to the discipline and a university culture in favor of general practice. Others, addressed to the State, are in favor of a new definition of the general practitioners’ functions within the Belgian health system. This would value the intrinsic characteristics of general practice but also limit dissatisfactions linked to the work conditions.