54 students from National University of Singapore’s Yong Loo Lin School of Medicine (NUS YLL), Nanyang Technological University’s Lee Kong Chian School of Medicine (LKCMedicine) and Duke-NUS Medical School (Duke-NUS) responded to the call to participate in the focus groups, with 18 students coming from each school. 28 of them (52%) were in their first or second year of study where the predominance of teaching is theoretical with some practical exposure. The remainder of students (48%), who were in their third, fourth or fifth year of medical (Duke-NUS programme is four years) undergo rotations at hospitals and clinics affiliated with their schools. The medical students’ ages ranged from 18 to 35, with students from Duke-NUS being generally older than NUS and LKCMedicine students since it is a graduate medical school. 31 of them (57.4%) were males and the rest, females (42.6%). Thirteen students (24%) expressed some interest in pursuing a career in primary care, but it was not necessarily their top choice of career. The career options attracting greater interest included paediatrics, emergency medicine and obstetrics and gynaecology. In total, 15 key themes emerged from the discussions, 10 of which reflected key concerns of pursuing a primary care career whereas 5 others highlighted the positive aspects of primary care as a career.
MAIN CONCERNS OF PURSUING A CAREER IN PRIMARY CARE
Perceptions of primary care professions as sub-standards
The non-recognition of General Practice and Family Medicine as a specialty appeared to be a key factor in career choice; without specialty status, it lacked prestige, a perception that was also common amongst friends and society.
From the general feel, talking to people, it doesn’t seem like it’s a very popular choice, and when non-medical friends ask questions like, so what specialty do you want to do in the future? It’s never what do you want to do in the future, it’s what specialty. So, it sort of gets ingrained in the process. (1-1-04)
I feel like the society’s perception about Family Medicine is affecting our perception of it… some of the students may think: Society expects me to be a great surgeon from a very big general hospital; a chief surgeon is very great. But we spend the same effort, we spend the same tuition fee and we become a family medicine doctor. How do we think about that? It’s not that cool maybe. (2-1-03)
Other students perceive a career in this field of medicine as a failure, an inevitable outcome if not accepted into a specialty training. The excerpts below are representative of the views of most students:
If I have no choice, maybe. Meaning, if I get rejected, then yeah. My interest is low in that subject. (1-1-01)
We all definitely have achieved a lot in our lives so far to be able to get into med school, and none of us want to stop here, and there is a general feeling that if I don't get into a specialty, if I end up in Family Medicine, I have not achieved. (2-2-09)
Just in the communities, there is an unspoken thing that the people doing Family Medicine didn't do so well and they’ve had to settle for it. So, for me, the stigma is one of the things that pushes me, drives me away… we also enjoy medicine because of the pride thing. There is a prestige to being a doctor as well. (1-2-07)
Specialists’ negative attitudes towards family doctors
Disparaging remarks from specialists that careers in primary care are not as prestigious as specialist careers have largely influenced the students’ career choices as well. During hospital postings, specialists spoke in condescending terms about the effectiveness and quality of doctors working in primary care, which have left a poor impression on students. The excerpts below highlight this sentiment:
Before I went to my surgery rotation, I was actually quite interested in Family Medicine. Then during a surgery rotation, all the surgeons were telling me, oh, look at what I can do to the patient. If you’re in Family Medicine, you can’t do this. And actually, that has made me not as inclined to Family Medicine because I realise that a lot of problems that the patients present with, I might not be able to do something. (2-2-06)
One thing that makes me hesitant to want to go into Family Medicine is [when] I’m attached to the specialties; they really bitch on the Fam-Med guys for giving referrals that they think are substandard… I was in clinic with an O&G doctor and he got a referral for a cervical polyp, or something, from the polyclinic. He did the physical exam and he was like, that’s not polyp, so stupid. They bitch on how the Fam-Med guys don’t know what they’re doing, or they’ve lost touch, or they’re not sufficiently skilled… It seems like they sometimes think of them as incompetent and unable to manage patients appropriately… So, I have a fear that that might happen if I choose to go into Family Medicine. (2-2-01)
Students recalled examples of doctors working in primary care needing to justify their roles and assert the importance of primary care in the Singaporean health care system, as exemplified by the following quotes:
I went to a conference and this private GP actually stood up during the Q and A at the end. And he said, don’t think of GPs as secondary doctors, think of them as the first line, the primary line of care for the patients. I found it quite shocking that he actually needed to say this to his fellow colleagues…. he probably said it because he felt that that is how his colleagues were treating him. It probably gives you an idea of what’s actually happening on the ground. (1-1-04)
Lifestyle benefits emphasised rather than professional characteristics
Another reason for the lack of popularity of primary care careers appears to arise from a paucity of information about the attractive aspects of the clinical work. The students recounted how careers in primary care were primarily portrayed as having a good work life balance. They recalled being told about positive lifestyle factors but not the professional content and impact on people’s wellbeing.
I feel that Fam-Med should be framed, not just always promoting the, oh, there’s great work-life balance, you can go home at 4:00, start work at 8:00, take two-hour lunch break, that kind of thing. Those are just very secondary stuff, but if you look at it at a broader level, it should be because these are our health needs. And we do not want to burden our expenditure, our health, by having all these complicated procedures and that kind of thing. (2-2-02)
I feel like people in Medicine, usually, are all basically quite intellectual people, they’re smart and would like take pride in the work that they have. If the main selling point of Family Medicine is just, it’s got a good lifestyle, I think it would be quite a turnoff for a bunch of people like us, who would like to see ourselves as smart individuals. (2-2-05)
Mundane case mix
Repeatedly students also referred to the cases presenting to family doctors as common minor illnesses. They described these clinical encounters as mundane and for the exceptional more complex case they perceived the primary care role being limited to onward referrals.
The job might be slightly mundane when you keep giving people MCs, or you’re just treating them for a cough, or you see a case that you think is very interesting but you don’t have the resources to treat, so you just send it out to A&E. (1-1-04).
When I go to a GP usually, I am going for a cough so I can’t imagine myself in a GP’s position. If I were to see cases, they are maybe the same symptoms. And then you will occasionally catch one rare case there. I don't know whether I would be excited to go to work. If you come across a rare case, you just send it to the hospital, so you always see the same thing and you don't really grow as a doctor. That’s what I think it’s about. It’s as if you’re doing the primary cases and then anything else that’s more advanced goes to the other doctors. (2-1-09)
Limited professional opportunities
The students also expressed concerns about the perceived limited professional opportunities offered by careers in primary care, as captured in the following excerpts:
The amount of funding and emphasis on research and innovation for fam med people is not as much as the other specialty… Let’s say you are trying to apply for a clinical research grant, if you are a fam med physician, there’s almost no way you’re going to get such a grant. (2-1-09)
Actually at this stage I don't think there has been much opportunities specifically for family medicine by the government or by the school, but I mean for each specialty there are the SIGs [Special Interest Groups], there are research opportunities that you can go for, but not specifically for family medicine. (3-2-09)
Lack of continuity of care
Although continuity of care is a traditional characteristic of Family Medicine in Singapore, without patient registration, this is not a strong characteristic. Students discussed their observations of lack of continuity and how this deterred them from pursuing a career in this field. Their comments point to concerns about the disempowered position of family doctors and their role as solely gatekeepers to care:
A lot of times they would come up with a working diagnosis and then the next step would eventually just be referral, which is somewhat upsetting to me. Because I would like to be more involved in the patient’s care and be more involved in the journey as well. So, that brings me to the whole continuum of care… that is something that I think would pull me back from wanting to join Family Medicine. (2-2-05)
I think overseas, maybe in the US… there’s such a thing where you have this doctor who takes care of you. And then only when there’s some additional problem, then they’d refer you to someone else. But you would still go back to that same doctor eventually. I think in Singapore, we don’t really have such a thing. For GPs, it’s just really touch-and-go, they just see you for flu, then that’s all. And maybe for another flu, they might go to another doctor. So, no continuity. (2-2-06)
Limited consultation time
Heavy workload and time pressures were concerns, apparent particularly when on placements in public primary healthcare clinics (or “polyclinics”).
I think [one challenge is] the time for patient interaction because when I go to a polyclinic it’s really just for five minutes, and you feel like the doctor is also being pressured to just keep moving the patients. So, I think that that is a major challenge. (2-1-03)
Primary care has lost its touch. Polyclinics are just funnelling out patients. I see them probably spending, sometimes, no more than three or four minutes with each patient. And you’re right, you can’t have a meaningful bond with your patients. That’s what Primary Care is supposed to be. You’re supposed to care for the family. (2-2-08)
Another factor discouraging them from pursuing a career in primary care was a perception that their earning potential would be less and the incentives fewer.
The Family Medicine pay is not as good as all the other specialties… If you promote, make it feel a little bit better and all, with some incentives, then people would feel good about going into Fam Med. (2-2-08)
I think in the Singaporean context, a family physician consultant is paid 8–9 k lower than senior consultants in a different discipline. At least, that was what it was like five years ago when I spoke to a Fam Med Senior Consultant. That was partly the reason I don’t pursue a PhD or MD in Fam Med. Because if I eventually become a Consultant in Fam Med, then my PhD would not justify the pay difference. (2-2-04)
Need for business acumen
The challenge of managing the business aspects of a private clinic was not a welcome challenge. Students recognised that their training did not prepare them with the relevant skills, and they had concerns about their own abilities to make a business financially viable.
From my past weeks of GP posting experience, [I noticed that] one thing that always bothers them (private GPs) is the pharmacy aspect; that we have to manage our own drugs. It is predicated for [doctors] which drugs to procure and how much they must buy, so it’s not only medicine, you’ve got to think Business as well. (1-2-08)
I think obviously there is a remuneration argument to be made as well in that it’s no secret that the more specialised you get the higher your pay is, and maybe as a GP if you own a clinic, yes, obviously the sky is the limit. You can earn as much as you want, as much as a specialist does, but to be able to do that there are a lot of risks involved. (3-1-09)
If you are thinking of a person who is more enterprising, you want to run your own clinic by yourself, then there are going to be some hurdles because you are basically a businessman and you need to be able to sell to your patients why your clinic is better than the other three neighbourhood clinics which are within three minutes’ walk. (2-1-01)
Conflicts created by business in clinical care
Some of the students viewed the profit motivation of private family doctors as undermining the value of primary care and distorting clinical care:
I worked in a private hospital before. I realised that everything in a private hospital operates like a business. There’s a fine line between business and helping the people, so if you go to the GP, you know that they earn most of their money through the medications. They mark up the price quite a lot… Everybody who starts medical school has an interview question about wanting to help others… in the end, what’s more important to you? Is it the patient or the business? (2-1-06).
If you are to start your own clinic, it becomes a lot of administrative... more the business handling side rather than anything, so you can be distracted by the business handling side. (3-2-07)
POSITIVE PERCEPTIONS OF PURSUING A CAREER IN PRIMARY CARE
The students’ perceptions of what careers in primary care have to offer are not entirely negative. They also articulated positive views about primary care, including its lifestyle benefits, autonomy of private practice and better patient care, opportunities for entrepreneurialism and a portfolio career, breadth of clinical problems presented, and an improved future for primary care. Their views were differentiated by the types of clinical settings they were exposed to during their postings. Interestingly, those students who expressed more positive views were those who had experienced positive primary care postings. Factors like the geographical location of the clinics and the kinds of practices that their mentors were engaged in all contribute to this experience. Excerpts reflecting these views are captured below:
Good work-life balance
One of the factors attracting students to a career in primary care is the good work-life balance that it offers. Compared to a specialist career, primary care is perceived to be less demanding and to offer regular working hours. The less taxing hours also means that doctors would find more time for leisure, as shared below:
I personally don’t mind (pursuing a career in primary care). I wouldn’t treat it as a dumping ground. I honestly don’t mind being a GP because I think there’s a lot of work-life balance that comes with it, and I think that’s something that I value, that my family needs my time. (1-1-05)
I guess I’m more inclined towards the primary sector and more towards private GP because it gives you a good work-life balance and with work-life balance you can achieve a lot of things like rediscovering yourself, your hobbies, your interests. (1-2-04).
Prior to coming to medical school, Family Medicine was not even a consideration at all. It only came into place because of the work-life balance it offered. (2-2-04)
Autonomy of private practice and better patient care
Another perk of a career in primary care as perceived by some of the students is the flexibility of private practice and the greater amount of time spent with each patient. Students also appreciated the continuity of care and interactional aspect of private practice, which are not offered by a specialist career:
If you set up your own clinic, you can get to decide on your working hours and so on. (3-1-02)
With private organisation or if you run your clinics, I think the thing about GPs is it’s mostly about flexibility of the lifestyle and seeing a similar pool of patients in your line of work. (3-2-08)
I’m attracted to family medicine and private GP because you can just talk to your patient for 30 minutes. Well, maybe a bit inefficient but you get more freedom and more time to be with your patients and I think generally because I like to talk to people. And I like it when people talk to me about their own personal lives because that is interesting. (1-2-05)
[One] opportunity that I see in Family Medicine is…a little bit more time to spend with their patient as well (than a specialist career). I feel that it could be used to help with healthcare, health promotion, as well as preventive medicine, by giving simple lifestyle advice to patients. Which is something that I noticed a lot of specialist usually would not have the time for. (2-2-05).
Opportunities for entrepreneurialism and a portfolio career
In addition to the autonomy and potentially more continuity of patient care offered by private practice, some students were also attracted by the opportunities for enterprise:
I think that so far from being in the GP, I realise that family medicine is actually broader than I thought that it was. I thought that it was just that you become a poly doctor or you set up your own clinic, but then because my doctor was doing more corporate things, so he actually taught me a lot about running his business and everything and how he does work with partners and set up the clinic. How they expanded and set up even more clinics and stuff like that. (1-2-03)
I think my exposure with Family Medicine is really through my house tutors. So, my house tutor is a GP and he represents quite a few groups because he is part of a larger healthcare group. And he also has his own clinic, and now as a house tutor he is also quite clinical with teaching as well. So, I think he shared many of his experiences about how his life is as a GP and he sees the pros and cons. So I think that was quite insightful, where previously I would think that as a GP because on the community cases you see are quite run off the mill, it’s quite a standard set, so I thought it can be a bit boring. (3-2-07)
Breadth of clinical problems presented
Students who had witnessed patients with problems other than common minor self-limiting cases were more receptive to considering a career in primary care. These are the students who had gone for placements at clinics that had a wide variety of patients both clinically and demographically:
Initially, before med school, I didn't know anything or even consider anything outside of hospitals, but I think my exposure has actually inspired me to learn more about primary care setting and even consider it. So, I would say that the exposure has been really enjoyable and it’s been quite a good experience to just see the different variety (of cases) as well as to see how it is like. (1-2-03)
I saw quite a wide variety of cases because the patients in my GP ranged from bankers to construction workers because they are all under insurance schemes. So, it was quite cool because I’m happy to say that only 50% of my patients had flu. The rest had injuries from whatever and overseas, because they travelled, infectious disease and stuff like that. So that was a lot broader. (1-2-05)
I’ve been to two GP attachments before I went to med school, and I feel that the area where the GP clinic is based in plays a part in what kind of patients you see. For example, I went to one in my neighbourhood and I can see that mostly patients just come in to get MCs, but then there’s one that I went to that’s in Little India, and there are a lot of Indian construction workers who go to that clinic, and they present with a whole lot of different presentations. It was actually much more interesting in terms of the cases that the doctor sees and the kind of challenges that he faces. For example, not a lot of them are insured, and they struggle to pay the consultation fees, and even if they were supposed to go to A&E for something, or if they had to go for a follow-up, they didn’t go because they couldn’t pay. So, I think that the kind of patients you see plays a part. (1-1-07)
Improved future for primary care
The students recognised places on the Family Medicine Residency Programme (FMRP) becoming more desirable based on their perception of its increasing competitiveness and the government’s greater emphasis on the significance of primary care due to the ageing population:
I actually heard it from my friends who are in the other medical schools and they’re already applying for residency, and comparing it to seniors who are talking about how things have changed as more people are deciding that they want different things in life. And yes, that’s just a thing. Things really change. Fam Med was the last choice and now it’s becoming a very popular choice… Residency slots [in FM] are limited. (2-1-07)
I think Family Medicine is increasingly becoming a competitive specialty, so the issue is not even whether you can get into family medicine or other specialties. Whether you can even get into a specialty versus staying in a hospital to either wait for specialisation or go and be a GP in the future. (3-2-09)
I think in the future there will be more opportunity for fam med, because I think this residency thing started about ten years ago. So, people are starting to have specialising and all this… because of the ageing population so I think they’re pushing towards primary physicians. (2-1-03)