54 students from YLL, LKCMedicine and Duke-NUS responded to the call to participate in the focus groups with 18 students coming from each school. About half of the students (52%) were preclinical and 57.4% were males. Overall, 13 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. The respondents shared eight key concerns and three positive views of pursuing primary care careers based on their medical school experience.
Concerns arising from formal curriculum:
Limited professional opportunities
The students 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 FM is not as much as the other specialty… Let’s say you are trying to apply for a clinical research grant, if you are an FM physician, there’s almost no way you’re going to get such a grant.
Actually at this stage I don't think there has been much opportunities specifically for family medicine by the government or by the school. For each specialty, there are the SIGs [Special Interest Groups], there are research opportunities, but not specifically for family medicine.
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 professional or 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 FM 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 secondary stuff. 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.
I feel like people in Medicine, usually, are all 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.
Lack of training on 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 the private GPs is the pharmacy aspect; that they have to manage their 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.
I am not inclined to pursue Family Medicine because we are not equipped with the necessary skills to run our own business if we were to go private. 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 neighbourhood clinics that are within three minutes’ walk.
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?
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.
Concerns arising from informal curriculum:
Mundane case mix
Students repeatedly referred to the cases presenting to family doctors as common minor illnesses. They described these clinical encounters as mundane and for the exceptionally more complex cases, they perceived the primary care role as being limited to onward referrals.
The job might be slightly mundane when you keep giving people MCs (Medical Certificates), 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 (Accident and Emergency department).
I can’t imagine myself in a GP’s position… If you come across a rare case, you just send it to the hospital, so you always see the same thing and don't really grow as a doctor. It’s as if you’re doing the primary cases and then anything else that’s more advanced goes to the other doctors.
Lack of continuity of care
Students also discussed their observations of lack of care continuity during their postings and how this deterred them from pursuing a career in primary care. 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. Then the next step would just be referral, which is somewhat upsetting to me. I would like to be more involved in the patient’s care and their journey. So, that is something that would pull me back from wanting to join Family Medicine.
In Singapore, we don’t really have such a thing as a doctor taking care of a patient. For GPs, it’s just touch-and-go, they just see you for flu, that’s all. And maybe for another flu, they might go to another doctor. So, no continuity.
Limited consultation time
Time pressures and heavy workload formed other concerns, apparent particularly when on placements in public primary healthcare clinics (or ‘polyclinics’).
I think one major challenge is the time for patient interaction because at the polyclinic, the consultation time is just for five minutes, and you feel like the doctor is also being pressured to just keep moving the patients.
Primary care has lost its touch. Polyclinics are just funnelling out patients. I see them probably spending no more than three or four minutes with each patient. 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.
Concerns arising from hidden curriculum:
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. During hospital postings, specialists spoke in condescending terms about the effectiveness and quality of doctors working in primary care, creating a poor and lasting 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.
I’m hesitant to pursue Family Medicine because when I’m attached to the specialties; they bitch on the Fam-Med guys for giving referrals they think are substandard… I was in clinic with an O&G doctor and he got a referral for a cervical polyp from the polyclinic. He did the physical exam and 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 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 go into Family Medicine.
Positive perceptions arising from informal curriculum:
The students’ perceptions of what careers in primary care have to offer are not entirely negative; they also articulated positive views about primary care, as cited below.
Opportunities for entrepreneurialism and a portfolio career
Some students shared that they were attracted by the opportunities for enterprise:
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. He also has his own clinic, and now as a house tutor he is also quite clinical with teaching as well. He shared many of his experiences about how his life is as a GP, the pros and cons. That was quite insightful. Previously I would think that as a GP, the community cases you see are quite run off the mill, quite a standard set, so I thought it can be a bit boring.
I realise that family medicine is actually broader than I thought that it was. I thought that it was just that you become a polyclinic doctor or you set up your own clinic, but then because my doctor was doing more corporate things, so he taught me a lot about running his business, how he works with partners and sets up the clinic, how they expanded and set up even more clinics.
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 placements at clinics that had a wide variety of patients, both clinically and demographically:
I saw quite a wide variety of cases because the patients in my GP ranged from bankers to construction workers since they are all under insurance schemes. So, it was quite cool. I’m happy to say that only 50% of my patients had ‘flu. The rest had injuries from work, and because they travelled, infectious disease and stuff like that. So that was a lot broader.
I feel that the area where the GP clinic is based in plays a part in what kind of patients you see. For example, in one neighbourhood, most patients just come in to get MCs, but then in Little India, where there are a lot of Indian construction workers, they present with a whole lot of different presentations. It was much more interesting in terms of the cases that the doctor sees and the kind of challenges 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 or for a follow-up, they didn’t go because they couldn’t pay.
Positive perceptions arising from hidden curriculum:
Improved future for primary care
The students perceived that places on the Family Medicine Residency Programme were becoming more desirable and increasingly competitive with the government’s greater emphasis on the need for primary care with an ageing population.
I heard from my friends in other medical schools that residency slots in FM are limited. Things have changed. FM was the last choice but now, it’s becoming a very popular choice.
I think FM is increasingly becoming a competitive specialty. In the future, there might be more opportunities for FM. Because of the ageing population, they’re pushing towards primary physicians.
 SIGs are Special Interest Groups that aim to be a platform through which medical students can gain insights about a particular field of medicine, such as the scope of the specialty and what the discipline entails.