Medical Students’ Attitudes towards Careers in Primary Care in Singapore

doi:10.21203/rs.3.rs-34481/v1

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Research article

Medical Students’ Attitudes towards Careers in Primary Care in Singapore

https://doi.org/10.21203/rs.3.rs-34481/v1

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published 25 Nov, 2020

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Background: Singapore needs more family doctors to care for its ageing population and their chronic conditions. To boost the recruitment of doctors within primary care, we need to better understand medical students’ attitudes and experience of General Practice and Family Medicine. While many studies have explored the facilitators and barriers to teaching undergraduate medical students in this field of medicine from the perspectives of GP teachers and trainers, few have examined students’ exposure to primary care in medical schools. Although there are works on factors influencing students’ attitudes towards primary care careers, the roles of medical schools, professional bodies and state institutions tend to be discussed independently of one another. This article explores medical students’ perceptions towards careers in primary care and how different stakeholders might collaborate in strengthening the medical school experience.

Methods: Six focus groups involving 54 students from three medical schools in Singapore were conducted. Discussions focussed on their primary care experience, their professional and career aspirations, and perceptions towards the opportunities and challenges of primary care careers. Thematic analysis was used to interpret the qualitative data.

Results: 15 key themes emerged from the discussions; 10 reflected key concerns of pursuing primary care careers whereas 5 others highlighted their positive aspects. The former include society’s perceptions of primary care professions as sub-standard, specialists’ negative attitudes towards family doctors, the emphasis on the lifestyle benefits of primary care careers rather than their professional characteristics, mundane case mix, limited professional opportunities, lack of continuity of care, limited consultation time, low remuneration, need for business acumen, and conflicts created by business in clinical care. However, the respondents also articulated positive views, 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 General Practice and Family Medicine.

Conclusion: The findings demonstrate that coordinated initiatives from multiple stakeholders would help to increase the attractiveness of primary care as a career choice among students. Improvements in the medical school experience will significantly enhance the prestige of General Practice and Family Medicine.

General practice

family medicine

primary care

medical students

medical school experience

career

Singapore

With the increase in the number of complex chronic diseases and in fragmentation of care as a result of specialisation in medicine, more community-based generalists are needed to meet the increasing demand for holistic care for patients (1). Singapore, with its rapidly ageing population, needs more general practitioners and family physicians (henceforth, family doctors) to care for the ageing population and their multi-morbidity (2). Simply increasing the number of trained doctors will not automatically expand the General Practice and Family Medicine workforce: recruitment initiatives need to be informed by a better understanding of the career aspirations of medical students, and their perceptions of the opportunities and challenges of a career in primary care. While many studies have explored the facilitators and barriers to teaching undergraduate medical students in primary care from the perspectives of GP teachers and trainers (3–7), few have examined students’ exposure to primary care in medical schools (8–10). Although there are works on factors influencing students’ attitudes towards a career in primary care (8, 11), the roles of medical schools, professional bodies and the medical fraternity tend to be discussed either fleetingly or independently of one another.

Thus, this article explores medical students’ perceptions towards careers in primary care and how different stakeholders might contribute and collaborate in strengthening the medical school experience. It interrogates the following research questions: (i) What are the key factors influencing the attitudes of medical students in Singapore towards a career in primary care?, (ii) How does the medical school experience impact on the students’ decision to pursue a career in primary care, and (iii) What are the ways in which different stakeholders might contribute and collaborate in strengthening the medical school experience in primary care?

A qualitative study was selected as the most suitable design to explore medical students’ professional and career aspirations, the factors that might hinder or facilitate the attainment of their goals, their experience in and exposure to primary care, as well as their perceptions of the opportunities and challenges of a career in primary care. This method is effective in garnering a rich data as proven by similar studies conducted elsewhere such as the United Kingdom, New Zealand and Malaysia, which seek to explore the attitudes of medical students towards primary care as a career (9, 10, 12). This study involved 54 ‘clinical’ and ‘preclinical’ students from all three medical schools in Singapore. Two focus groups were conducted in each of the three medical schools. One group consisted of eight to 10 Year 1 or 2 students. The other group comprised eight to 10 Year 3 to 5 students. The students were recruited through student representatives and announcements made by the researcher at the end of lectures.

Ethical approval was obtained from Nanyang Technological University Institutional Review Board (IRB Reference Number: IRB 2018-07-007). Participants were given an information sheet about the study before completing the consent form. All the focus groups were conducted in English, were led by researcher HZ and facilitated by a co-worker. They were audio-recorded and transcribed verbatim. Each focus group lasted approximately 90 minutes. Thematic analysis was used to interpret the data. The transcripts were read independently by two of the researchers, HZ and HES to identify key themes and any recurring patterns that emerged from the data before coming to a consensus on the final thematic categories. Code numbers were assigned to every participant to ensure anonymity. Based on a summary of codes found in Table 1 below, the first digit of the identifier represents the school, numbered 1 to 3, the second refers to ‘preclinical’ or ‘clinical’, numbered 1 or 2, whereas the third is the participant’s identifier, numbered 1 to 10.

Table 1

Summary of Participants’ Identifiers
School/ Group	Code Numbers
National University of Singapore/ ‘Preclinical’	1-1-01 to 1-1-10
National University of Singapore/ ‘Clinical’	1-2-01 to 1-2-08
Duke-NUS Medical School/ ‘Preclinical’	2-1-01 to 2-1-09
Duke-NUS Medical School/ ‘Clinical’	2-2-01 to 2-2-09
Nanyang Technological University/ ‘Preclinical’	3-1-01 to 3-1-09
Nanyang Technological University/ ‘Clinical’	3-2-01 to 3-2-09

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)

Lower remuneration

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)

This study has revealed many factors that influence medical students’ attitudes towards a career in primary care. These are society’s perceptions of primary care professions as sub-standard, specialists’ negative attitudes towards family doctors, heavy focus on lifestyle benefits rather than the professional characteristics of primary care, perceptions that a career in primary care offers a mundane case mix, limited professional opportunities, lack of continuity of care, limited consultation time, lower remuneration than a specialty career, need for business acumen, and conflicts created by a business in clinical care. However, their perceptions of what careers in primary care have to offer are not entirely negative. They also articulated positive views, 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.

RECOMMENDATIONS

Role of medical schools:

Medical school experiences shape students’ attitudes towards careers in primary care in many ways, specifically through the formal, informal and hidden curricula. We define the ‘formal curricula’ as the structured education that takes place within the classroom setting whereas by ‘informal curricula’, we refer to learning programmes and activities that occur outside the classroom and that include informal interactions with medical professionals. We refer to the ‘hidden curricula’ as the implicit or unspoken messages that are communicated in the students’ educational and training experience. These influences may occur at an organisational or cultural level (13).

Within the formal curriculum, changes are needed to achieve a comprehensive overview of patient care in its totality: it needs to also train students about the contribution of holistic care provided by a generalist. To expose students to the breadth and complexity of primary care may require increasing the amount of time spent in General Practice placements and considering the format of that time. Longitudinal placements have been favoured in other countries to enable students to appreciate continuity of care and the management of long-term conditions (14). Findings from the interviews have shown that the placements do not allow the students to follow up with the patients on their conditions. Hence, placement programmes that enable students to experience a well-coordinated continuity of care for patients are important since they ultimately underscore the core of General Practice and Family Medicine. These would involve regular and recurrent placements in the same clinical setting with the same mentor and cluster of patients. GP mentors should also provide timely feedback to students on practice-based training programmes to enhance professional development and encourage reflective practice (15). Longer placement programmes would additionally expose students to a variety of cases. A study conducted by Koehler and McMenamin on medical students’ perceptions of a career in General Practice conducted in Australia demonstrates that students who had more than 80 hours of GP placement experience were more likely to appreciate a diversity of patients’ illnesses (16).

In line with this, another initiative is to increase and standardise the amount and quality of students’ exposure to primary care across all three medical schools. As it stands, students from all schools have limited exposure to primary care settings in their curricula. Students from LKCMedicine’s ‘preclinical’ group and those from Duke-NUS’s ‘clinical’ group in particular acknowledged that their exposure to primary care was too little for them to make any informed career decision about General Practice or Family Medicine and be aware of the complexities of the practice in the clinical setting. Table 2 also indicates their limited exposure to primary care within the school curricula.

Table 2

Amount of Students’ Exposure to Primary Care Settings
School/Year of Study	Preclinical	Clinical
NUS	First year: 3 hours of attachment in public primary healthcare clinics for each student Third year: 3 weeks of attachment in public primary healthcare clinics, 2 weeks of GP clinics, 2 days of community hospital for each student	Elective programme in Fourth year: 2 weeks of public primary healthcare clinics/ GP clinics for 30 students
Duke-NUS	Second year: 10 sessions of placement in a GP clinic and 10 sessions in a public primary healthcare clinic	Fourth year: 2 weeks in the public primary healthcare clinics and 2 weeks in a community hospital where family physicians practise
LKCMedicine	First year: 1 week in a public primary healthcare clinic	Fourth year: 7 weeks in the public primary healthcare clinics and private clinics Fifth year: 3-week rotation as student interns in public primary healthcare clinics

Several improvements could also be made to the primary care placements in order to pique students’ interest. Currently, unlike students from Duke-NUS and LKCMedicine, NUS students are not given as much exposure to public primary healthcare clinics, as shown in Table 2. NUS’s greater emphasis on the hospital setting may preclude primary care but in terms of quality, NUS’s GP attachments appear to expose students to a wider socio-demography of patients and a greater variety of cases. Ideally, all students should be exposed to a variety of primary care postings, including private clinics in different locations of Singapore, since social class position has a geographical dimension in the country.

Furthermore, out of the three schools, only LKCMedicine offers a three-week rotation for its final year students to work as interns in public primary healthcare clinics run by National Healthcare Group (NHG), a cluster that runs such clinics in Singapore. As interns, students are given the opportunity to run clinics under the supervision of family physicians, which essentially places the intern in the role of a family doctor. This allows for first-hand experience and insights into what the role entails. Thus, in line with constructing a comprehensive overview of family medicine in formal curriculum, other medical schools could consider offering similar internship rotations in public primary healthcare clinics to students since they expose students who are about to graduate to the holistic care and vast case mix that family doctors encounter in the community.

To heighten students’ awareness and knowledge of what a career in primary care entails, measures need to be put in place in order to transform the informal curriculum from negative to positive. Beyond sharing the job scope, career trajectory and lifestyle benefits of a career in primary care, GP teachers and mentors need to be encouraged to impart the clinical value of their professions to students and the importance of being a holistic doctor. Ultimately, drawing students to the core aspects of primary care will be more valuable than promoting positive lifestyle perks, which research has deemed less challenging and stimulating to students (9). Imparting the value of primary care as the foundation of healthcare and championing the vision of the profession as intellectually challenging and rewarding are meaningful and will help to sustain the true meaning of being family doctors. When students are better able to understand the contribution of primary care, they will then have the ability to make informed career decisions without feeling pressured by society or their peers.

Moreover, it is important for mentors to balance the instillation of passion among medical students with the practical aspects of how the latter can thrive in their career. In addition to highlighting the value of primary care, they can provide mentorship on how students can successfully obtain grants that would enable them to conduct research. For those who are keen in innovations in healthcare, they can alert them to opportunities that will help them to pursue this interest. Additionally, since the lack of knowledge on running a GP practice is a major concern raised by the research participants when asked about the prospect of working in the private setting, schools can engage senior GPs to share their business experience and skills as well as the ways in which they balance patient care with financial sustainability through workshops.

Additionally, measures are needed to tackle the undermining of primary care as a career both within and beyond the medical fraternity. Students should be made aware of the various elements in the hidden curriculum that disparage certain specialties or careers in medicine. Second, feedback mechanisms can be improved in order to enable students to report safely on any disparaging remarks encountered in teaching or on clinical attachments. Medical schools can work with professional bodies such as Singapore Medical Council to improve such feedback systems. In parallel, there needs to be discussions to promote the standing of Family Medicine through mandatory postgraduate training and inclusion on the specialist register.

Role of Ministry of Health and professional bodies

In addition to medical schools, the government and professional bodies such as Singapore Medical Council and Singapore Medical Association play a significant role in ensuring that the status of family doctors are maintained, protected and enhanced. For instance, the Ministry of Health (MOH) can provide guidelines to specialists on the professional code of conduct when dealing with cases that were referred to them by non-specialists. The MOH can advise specialists not to have unrealistic expectations of family doctors. For instance, expecting the latter to have a greater level of knowledge in their sub-specialty when they were actually trained to be generalists. It is also equally important to equip specialists with knowledge on the important role of family doctors. Currently, only NHG and Singhealth Polyclinics, another cluster that runs public primary healthcare clinics in Singapore, have internal clinical guidelines for the management of stable conditions that can be managed in such clinics rather than specialist outpatient clinics. National guidelines can be instituted to encourage more specialists to transfer care of their patients to the community. As more of such care are transferred to family doctors, it would assure specialists that many of their cases can be managed by family doctors. Actions should also be taken against specialists who pass disparaging comments on family doctors to students while the latter are on training. More channels for anonymous whistleblowing could be provided to medical students to report or flag any unprofessional behaviour observed during their clinical rotations.

Moreover, professional bodies can improve the image of family doctors by delegating more roles and responsibilities in healthcare delivery to them. For example, they can provide more avenues and funding for research in Family Medicine and provide platforms such as conferences and conventions to allow Family Medicine researchers to showcase their research. In so doing, it would boost the image of family doctors as both clinicians and researchers. Additionally, encouraging the participation of more family doctors in leadership positions would also help to present them as leaders and role models in the medical community. For example, allocating more positions in professional bodies such as SMC and SMA to qualified family doctors.

Professional bodies such as the College of Family Physicians Singapore (CFPS) should also identify family doctors who can be role models to students and raise their profile within the medical schools through appropriate acknowledgement of their contributions to education. Studies done in Australia and Canada have shown that students and young doctors value the following attributes in their role models: integrity, compassion for patients and a positive attitude to junior colleagues(17, 18). They also identified the following as positive attributes: clinical competency, enthusiasm for the subject and teaching ability. Those doctors who were rated highly as role models were the ones who spent more time teaching and who emphasised the importance of the doctor-patient relationship. Emphasising these qualities among GP mentors would enrich the experience of students on placements. When sharing their professional and personal experiences with the students, GP mentors should also refrain from framing their career choice as an inevitable outcome of their failure to get into a specialty so as not to reinforce the perception that primary care professions are substandard.

Moreover, CFPS can also work with medical schools to standardise the guidelines and instructions for GP teachers and trainers on essential topics to be covered in the schools’ curricula, in examinations, as well as during the students’ attachments. Increasing the representation of primary care in the curricula should occur in tandem with increasing the ratio of primary care lecturers in medical schools.

As insightful as existing studies are in terms of shedding light on the factors that influence the attitudes of medical students towards their career choice, they only provide brief information on the initiatives that can be implemented by different stakeholders. Too much focus was given on the role of medical schools without explaining how state institutions and professional bodies can contribute to improving the recruitment of future graduates into the primary care workforce (3, 4, 6, 8, 15). Thus, our study contributes to the existing literature on primary care education by analysing the different ways in which various stakeholders can collaborate in addressing gaps in the medical school experience. It does so by evaluating the attitudes of medical students in Singapore towards a career in primary care, as well as the roles that different institutions and organisations can play in promoting primary care as a career choice.

In line with these objectives, this study has examined key factors within medical schools that influence primary care as a career option. It shows how the formal, informal and hidden curricula affect students’ choice of career in multifactorial ways. With the findings from this study, we proposed some suggestions on how the medical school experience and primary care training may be adjusted to ensure that messages to students are communicated consistently and accurately. In particular, we have highlighted how the government, professional bodies and medical schools can collaborate to enrich the medical school experience in primary care. In so doing, we have extended the concept of ‘vertical integration’ previously discussed in studies on GP education, such as the one by O’Regan and colleagues (15). According to them, ‘vertical integration’ highlights the interaction between students and trainees at different stages of the GP education, as well as collaboration between organisations, especially agencies and professional bodies involved in planning and delivering of the GP curriculum (15). While such efforts are laudable, there is little involvement from the government to boost the prestige of primary care as a field of medicine at the macro level, a gap that has been filled by our study.

This large qualitative study examines the perceptions of students from all three medical schools in Singapore. It contributes to the growing body of international literature from countries such as the United Kingdom, Ireland, New Zealand, Australia, Japan and Malaysia on medical students’ attitudes towards a career in primary care but informs us specifically about issues important in Singapore (8–10, 12, 14–16, 19). Each focus group achieved diversity in genders, ethnicities and years of study, which contributes to a rich data.

The study’s limitation lies in the sample size. Indeed, a sample size of 54 is small compared to other studies (for example, 357 in Koehler and McMenamin’s 2016 research, 280 in Barber et. al.’s 2018 study and 84 in Parker et. al.’s 2014 work) (8, 9, 16). However, given Singapore’s land size (721.5 square kilometres) and the fact that there are only three medical schools in the country, the students’ attitudes may be generalizable to others’ in the country and provide a glimpse of the current recruitment of graduates into the primary care workforce.

Another limitation pertains to the recruitment strategy. At each school, we entered the field with the aim of purposively recruiting students from different years of study within each focus group. Unfortunately, due to scheduling difficulties, two of the six focus groups only had students from a single year, reducing the interaction and diversity that we were aiming for. As a qualitative study it does not have generalisability and as a cross sectional study, it limits our ability to track change over time. However, the findings from this qualitative study has informed the design of a quantitative survey to medical students, which will enable us to estimate the prevalence of experiences and attitudes, as well as to explore the relationships between socio-demographic factors and perceptions.

Our findings are important to inform initiatives to bolster the image of General Practice and Family Medicine as a career. In terms of educational initiatives, the data have paved the way for medical schools to review the content of primary care-led courses and to explore the means of promoting primary care as an intellectually challenging specialty. The study has also highlighted the unintended consequences of promoting them as a career choice based on reduced training opportunities for specialist career and the positive lifestyle benefits that the former medical professions offer.

From their own personal encounters with health services, many students saw the family doctors’ role as very limited, focusing on ‘coughs and colds’ and the issue of medical certificates. Many practitioners are providing a much more comprehensive service, but the range of care offered is not homogeneous. There remains a need for mandatory training and a remuneration system that empowers family doctors to become more engaged with the prevention and management of chronic illnesses. One of the pull factors for a career in primary care lies in the opportunities for doctors to improve the health of their patients. Additionally, it is important to facilitate closer collaboration and communication with specialty care. By training them to a higher level, they can take on expanded roles.

Our study has explored the factors that influence the attitudes of medical students towards a career in primary care. While factors such as perceived lack of prestige of this profession have also appeared in other studies, the findings point to the causes of such attitudes. They highlight that the students’ concerns are largely attributed to the gaps and issues within the formal, informal and hidden curricula of medical schools. Despite these concerns, the students’ overall perception of the training programmes in primary care in Singapore is generally positive, which suggests that what needs to be addressed are the gaps in the medical school experience. More broadly, this study bears significant policy implications on how the government can improve the overall prestige of General Practice and Family Medicine in Singapore.

A potential line of future research would be to conduct a longitudinal study on how the students’ attitudes towards a career in these fields of medicine may have changed after their postings in primary care, and the factors that may have influenced this change. It would also be interesting to find out the number of students who are enrolled in the Family Medicine Residency Programme. Future research might also usefully incorporate the views of family doctors to evaluate whether or not their career experiences challenge or affirm the students’ concerns about pursuing a career in primary care. Further studies that explore contemporary facilitators and barriers to general practitioner engagement with undergraduate and postgraduate education should also be conducted. Ultimately, the recruitment and contribution of doctors to the primary care workforce can only be improved with stronger collaboration among various stakeholders.

Funding

This study was supported by National Medical Research Council (NMRC) Health Services Research Grant (HSRG-MS17Jun 002).

Acknowledgements

The authors thank all the medical students who participated in this study. They are also grateful to the members of the NMRC Study Advisory Panel, to Dr Shawn Tan Lien Ler and the reviewers of this journal for their useful feedback. They also thank Leong Li Zi and Fang Yang for co-facilitating the focus group discussions.

Authors’ contributions

HZ- Collected and analysed the data, as well as wrote the initial drafts. HES- reviewed and edited the manuscript. Both authors read and approved the final manuscript.

Ethnic declarations

Ethics approval and consent to participate:

Consent for publication:

All participants consented to the findings being published in peer-reviewed scientific journal/s and presented at meetings and conferences. They also consented to the use of code numbers in the reporting of findings in order to ensure anonymity.

Availability of data and materials:

The datasets used and analysed during the current study are available from the authors on reasonable request.

Competing interests:

No potential conflict of interest was reported by the authors.

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Medical Students’ Attitudes towards Careers in Primary Care in Singapore

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Findings

MAIN CONCERNS OF PURSUING A CAREER IN PRIMARY CARE

Perceptions of primary care professions as sub-standards

Specialists’ negative attitudes towards family doctors

Lifestyle benefits emphasised rather than professional characteristics

Mundane case mix

Limited professional opportunities

Lack of continuity of care

Limited consultation time

Lower remuneration

Need for business acumen

Conflicts created by business in clinical care

POSITIVE PERCEPTIONS OF PURSUING A CAREER IN PRIMARY CARE

Good work-life balance

Autonomy of private practice and better patient care

Opportunities for entrepreneurialism and a portfolio career

Breadth of clinical problems presented

Improved future for primary care

Discussion

RECOMMENDATIONS

Role of medical schools:

Role of Ministry of Health and professional bodies

What This Study Adds

Strengths And Limitations

Implications

Conclusion

Declarations

References

Supplementary Files

Status:

Journal Publication

Version 1