A postal survey using a structured questionnaire was performed.

Addresses were identified for 253 of the 266 graduates (95%). A total of two hundred and nine responses were received (84% of those with an identifiable address). 173 (83%) have remained in general practice; 90% in Ireland and 60% in the same health board of their training programme. The preferred career option for 79% was to be a general practice principal; this differed significantly between males (89%) and females (74%) (p=0.016). Being a single-handed general practitioner was the preferred option for 2%; 43% considered this unacceptable. A half would prefer to work in a country town; one third considered a rural location as unacceptable. Out of hours commitment and availability of local posts were the most commonly perceived barriers to career progress (53% and 45% respectively). 26% were not prepared to do any out of hours work; this differed significantly between males (10%) and females (30%) (p<.001). 17% have permanently left a career in general practice. Female general practitioners were not significantly more likely than male general practitioners to have left (19% vs. 14%, p=0.3). The most common reason given for leaving general practice was other career interest (78%).

The significant increase in female general practice graduates over the past twenty years is highlighted. The vast majority of these female graduates wished to be a principal in a group practice and were prepared to undertake out of hours work. There is also a mismatch between career aspirations and the present structure of general practice in Ireland. The urgent need for changes in health system organisation to ensure that these intentions can be fulfilled is emphasised.

Introduction

The past thirty years has seen the development of structured training for general practice throughout Europe. Although structures differ between countries, standardisation is occurring as required by a European Union directive which states that training must be centred, and where possible at least fifty percent should occur, in a general practice setting. However two important trends are influencing not only training for general practice but also the core nature of general practice. Firstly, the number of females choosing a career in general practice has increased markedly. Previous studies have shown that women are less likely to stay in general practice than men, and that those who do are more likely to work as non-principals^1-3.

Secondly, there has been a shift in the attitudes of general practitioners towards the provision of out of hours care with fewer doctors now willing to do onerous out of hours work. This has had a dramatic impact on the recruitment and retention of general practitioners^3-6. Many now prefer flexible working arrangements, spending time abroad or initially working in assistant, locum or sessional posts before making a long-term commitment^7,8.

The impact of these trends will be probably most acute on recent graduates from training schemes. The aim of this study was to therefore follow the career pathways of all graduates of Irish general practice training schemes between 1990 and 1996 inclusive, with specific reference to their current positions, hopes for the future, perceived barriers to their ideal career and attitudes to out of hours work. For those no longer in general practice, we aimed to address which alternative careers they chose and why.

Method

A register of all graduates of g eneral practice training programmes in Ireland between 1990 and 1996 inclusive was constructed as previously described². The total number of graduates of the ten general practice training schemes in Ireland between 1990 and 1996 inclusive was 266. An initial questionnaire was piloted with nine general practice graduates and some minor changes incorporated. The final version was sent in September 1999 to those graduates for whom an address was available. Information was sought regarding demographics of respondents, current career status, experience obtained both before and after vocational training, ten-year career preferences (e.g. Where would you most like to see yourself in ten years time?), perceived barriers to achieving the ideal career, attitudes to out of hours work and, where relevant, reasons for leaving general practice. A second mailing, to non-responders, was carried out two months later. No further follow up was made. Data was analysed using STATA software.

Results

Addresses were identified for 253 of the 266 graduates (95%).

Demographics of respondents

A total of two hundred and nine responses were received (79% of all graduates; 84% of those with an identifiable address). There were no significant differences in age, gender and number of years since graduation between responders and non-responders. Further figures refer to respondents, unless otherwise stated.

Sixty one per cent were female. This compares to 21% of graduates between 1980-1984 and 42% between 1985-1989².The mean age was 34 for women and 35 for men. Seventy-four percent of respondents were married and 59% had children. In the age group 35 to 39, women were significantly more likely than men to be married and have children (p <0.009).

Experience prior to vocational training

Seventy two percent were accepted onto training schemes directly from their pre-registration year. The remaining twenty eight percent of respondents held other medical posts prior to commencing vocational training. These included general hospital medicine (21%), paediatrics (10%), accident and emergency (7%), obstetrics and gynaecology (6%), and psychiatry (3%). One third of those who delayed entry into general practice training schemes spent at least three years in other medical jobs. Twenty nine percent of all respondents felt that training programmes perceived prior experience to entry as a positive factor and 21% felt it was perceived negatively. This differed significantly between those accepted directly from their intern year and those who delayed entry; the latter were more likely to believe that programmes regarded prior experience positively (p<0.001).

Current career status

One hundred and seventy-three respondents (83%) had remained in general practice. Of this group, 90% were working in general practice in Ireland with 60% in the same health board of their training programme. Five percent are in general practice in the United Kingdom. Men were more likely than women to remain in the health board of their training scheme (70% and 53% respectively; p = 0.03) and female graduates were more likely to be working outside Ireland (2% and 16% respectively; p = 0.003). Those who went directly into general practice training were no more likely to stay in general practice than those who delayed entry into general practice (p=0.78). Fifty percent of those still in general practice had gained further work experience outside general practice since completion of the training scheme. The additional clinical experience took place in obstetrics/ gynaecology (25%), accident and emergency (21%), psychiatry (18%), general medicine (14%), gerontology (11%), and paediatrics (8%).

Career preferences

Graduates currently in general practice documented their ten-year aspirations and preferences both in relation to job description and practice location. These results are summarized in the table below.
 
 

Significant gender differences were identified related to career preferences. Part-time assistantship or sessional work was preferred by 16% of female graduates compared with 1% of male graduates (p=0.002) and 89% of male graduates compared with 74% of female graduates (p=0.016) indicated a preference for principalship in a group practice. A trend towards females preferring urban locations was also noted, but there were no other significant differences in responses by gender. Graduates of the two Dublin-based training programmes were significantly less likely to state a preference for working in a rural location (p<0.003). Otherwise there were no significant differences between graduates of different training schemes regarding career.

Respondents were asked to describe factors that they considered have or could impede their career pathway within general practice. Fifty three percent cited out of hours commitment as a significant impeding factor. Other important factors were availability of local posts (45%), having children (43%), other family demands (34%), and gender (16%). There was no significant difference between men and women for any of these answers.

Attitudes to out of hours commitment

Twenty six percent of all graduates currently in general practice stated that they were not prepared to do any out of hours work. There was a significant gender difference with 30% of female graduates not prepared to work out of hours compared with 10% of male graduates (p<.001). Responders were grouped into three different age groups: those aged 30-34 years, 35-39 years and those aged forty or over. There was no significant difference between the different age groups regarding willingness to perform out of hours work. Of the 74% prepared to provide out of hours cover, 24% were prepared to work up to a 1 in 4 rota, 42% were prepared to work a 1 in 5 or 1 in 6 rota, and 34% were prepared to work a maximum of 1 in 7 nights on call.

Those who have permanently left a career in general practice

Thirty-six respondents (17%) have permanently left a career in general practice. Female general practitioners were not significantly more likely than male general practitioners to have left (19% vs. 14%, p=0.3). Twenty eight percent of those who have left are pursuing a career in public health medicine, with 23% choosing a career in general hospital medicine, 20% opting for a career in psychiatry and 8% working in paediatrics. Smaller numbers were doing Accident and Emergency, Obstetrics/ Gynaecology and surgery. Three graduates have left clinical medicine, with two pursuing a career in the pharmaceutical industry. One graduate had decided not to work.

The most common reason for leaving general practice was another career interest (78%). This was followed by out of hours commitment (53%), frustrated with/ disillusioned with general practice (44%), availability of local posts (36%), having children (19%), other family demands (16%) and gender (13%). Three people (8%) stated that income was a contributing factor to their decision to leave general practice.

Discussion

These results need to be interpreted cautiously as no contact address was available for 5% of all graduates and a further 16% failed to respond. For example, the numbers who have left general practice may have been underestimated. Nevertheless, both the response rate of 79% and the fact that the study represents a national census of Irish graduates over a six year period are noteworthy. Much similar work to date has been performed in the United Kingdom which has relatively low levels of doctor emigration⁹. The findings therefore may be of special interest in the context of free movement of qualified general practitioners in the European Union.

The study highlights the increasing proportion of general practice graduates who are female. However common perceptions regarding female graduates are challenged; almost three quarters wished to be a principal in a group practice, 70% were prepared to undertake out of hours work and females were not significantly more likely to have left general practice. Certainly, there were significant gender differences; however these overall figures resonate with Allens finding that the concept of women returners in medicine is fallacious¹⁰. As this is a survey of recent graduates, these findings could be considered somewhat premature; however it is apparent that the intention of most female graduates is to participate fully in the provision of health care. To achieve this, flexible working arrangements, such as permanent part-time principalships, need to be provided urgently¹¹. These have operated successfully in the NHS for several years^12,13 but are, at present, not available in the Irish General Medical Services Scheme.

There is also a mismatch between career aspirations and the present structure of general practice in Ireland. Only 2% would choose a single-handed practice and 43% stated that they would not accept such a position. Ten per cent would choose a rural practice location and 30% stated that they would not accept such a position. However, 51% of Irish practitioners are single-handed and 38% are in a rural location¹⁴. These results highlight the importance of the development of group practices and enhanced support services for single handed and rural practitioners. Central and regional agencies are attempting to address these issues¹⁵, but the present rate of change will not fulfil the aspirations of these recent graduates.

26% were not prepared to do any out of hours care and 53% considered out of hours care to be a barrier to career progression. This is reflected in the recent development of out of hours co-operatives in Europe^16,17. Such changes are occurring also in Ireland¹⁵, but must include rural areas to ensure practitioner recruitment and retention¹⁸ and to avoid the doughnut effect where co-operative development would occur around urban populations, leaving rural practitioners in a more inequitable position than before.

This study highlights some important points relevant to the selection process and structure of general practice vocational training schemes. The 28% of graduates who had deferred entry onto training schemes were no more likely to have left general practice than those who had entered directly from their pre-registration year. We could not find any comparative data from other studies in this regard. Of the graduates who have remained in general practice, 60% are working in the Health Board region of their training. This is similar to UK5 and US¹⁹ figures and suggests a need to match numbers of training places and manpower requirements on a regional, and especially rural, basis.

In conclusion, this study highlights the significant increase in female general practice graduates over the past twenty years. The vast majority of these female graduates wished to be a principal in a group practice and were prepared to undertake out of hours work. Females were also not significantly more likely to have left general practice. It emphasises the urgent need for changes in health system organisation to ensure that these intentions can be fulfilled.

Acknowledgements

This study was supported by the Manne Berber Research Fellowship Award and a grant from the ICGP Research and Education Foundation Grant which were both awarded by the Irish College of General Practitioners in 1999. We are grateful to Ms. Patricia Henry for her help with administration. We are especially grateful to all the respondents for making this study possible. The interest and support of Fiona Louise Bradley was both noteworthy and much appreciated.

Correspondence:
Andrew W Murphy,
Department of General Practice,
National University of Ireland,
Galway,
Ireland.
Email:[email protected]

References

1. Osler K. Employment experiences of vocationally trained doctors. BMJ 1991: 303, 762-4
2. Bradley F, Murphy AW, Lambe S. A national survey of career pathways of all graduates of vocational training programmes in GP in Ireland. Eur J Gen. Practice 1996. 2 : 157-161.
3. Taylor DH, Quayle JA, Roberts C. Retention of young general practitioners entering the NHS from 1991-2. Br J Gen Pract 1999; 49: 277-80.
4. Taylor DH Jr., Leese B. Recruitment, retention, and time commitment change of general practitioners in England and Wales, 1990-4 : a retrospective study [see comments]. BMJ 1997 : 314 ; 1806-10.
5. Johnson N, Hasler J, Hayden J, Mathie T, Dobbie W. The career outcomes for doctors completing general practice vocational training 1990-1995. Br. J. Gen. Practice 1998: 48 ; 1755-8.
6. Bonsor R, Gibbs T, Woodward R. Vocational training and beyond-listening to voices from a void. Br. J. Gen. Practice 1998 ; 48: 915-8.
7. Elwyn GJ, Smail SA, Edwards AGK. Is general practice in need of a career structure? BMJ 1998: 317 ; 730-3.
8. Baker M, Williams J, Petchey R. GPs in principle but not in practice: a study of vocationally trained doctors not currently working as principals. BMJ 1995 ; 310: 1301-4.
9. Goldacre MJ, Davidson JM, Lambert TW. Career choices at the end of the pre-registration year of doctors who qualified in the United Kingdom in 1996. Med Educ 1999; 33: 882-9.
10. Allen I. Doctors and their careers: A new generation. PSI Publishing, London, 1994, page 180.
11. Young R, Leese B. Recruitment and retention of general practitioners in the UK: what are the problems and solutions? Br J Gen Pract 1999; 49: 829-33.
12. Nicol EF. Job sharing in general practice. BMJ (Clin Res Ed) 1987 ; 295: 888-90.
13. Douglas A, McCann I. Doctors retainer scheme in Scotland: time for change? BMJ 1996 ; 313 : 792-4.
14. ICGP, Dept. of Health and Children, and NUI, Galway. National General Practice Survey. 1997.
15. Lanigan AM. Development of the first co-operative in Ireland: Caredoc. MBA Thesis, University College Dublin.
16. Jessopp L, Beck I, Hollins L, Shipman C, Reynolds M, Dale J. Changing the pattern out of hours: a survey of general practice co-operatives. BMJ 1997 ; 314: 199-200.
17. Hansen BL, Munck A. Out-of-hours service in Denmark: the effect of a structural change. Br J of Gen Pract 1998 ; 48: 1497-1499.
18. Ross S, Gillies JCM. Characteristics and career intentions of Scottish rural and urban GP registrars: cause for concern? Health Bulletin 1999; 57: 44-52.
19. Rosenthal TC, McGuigan MH, Anderson G. Rural residency tracks in family practice: graduate outcomes. Fam Med 2000; 32: 174-7.