Sociodemographic characteristics of participants
There were no refusals of consent or dropouts during interviews, with a total of 21 trainees participating. Of these, fifteen were female; seven had experience of a GP placement for one year, eleven for two years and three for three years; eight were married and the rest among them were single.
Key themes
The study presented five overarching themes that described negative factors influencing the career intention of the trainees in SRT: low social recognition, low professional identity, low remuneration level, imperfect teaching system and influence of policy factors. Table 2 shows the results of the interview analysis.
Table 2
Results of qualitative analysis with themes, subthemes and number of codes
Themes
|
Subthemes
|
No. of codes
|
low social recognition
|
Little knowledge
|
13
|
Negative impression of GPs
|
9
|
Patient distrust
|
8
|
low professional identity
|
Unrecognized value
|
5
|
Limited career development
|
12
|
Concern of the prospect
|
16
|
low remuneration level
|
Guaranteed minimum remuneration
|
16
|
Imperfect training system
|
unprofessional supervisor
|
6
|
Unreasonable training programs
|
12
|
Influence of policy factors
|
Incomplete supporting policies
|
10
|
Poor implementation of policies
|
5
|
Low social recognition
A feeling of low social recognition was expressed by many of the trainees. They stated that general practice received little recognition and acknowledgement from public. There was little recognition even from senior colleagues and peers in hospital.
I am a doctor of this hospital where I’m also a trainee. When I go to other departments for rotation, I find almost none of them know what general practice is. They would ask what general practice do, and lots of my friends also ask me this question. (02, M, 36years)
People think it doesn’t really matter if there’re no general practice, or, the recognition of GPs is really low, even not well among doctors. (01, F, 31years)
There was also a negative impression about GPs among the public, as some of the trainees illustrated how family or friends portrayed GPs.
My family and friends know very little (about GPs). They’d say “those are the doctors in town health centers, isn’t it right? You really would work there?” Some of my schoolmates working in county hospitals would say “that’s where you would go? You might as well come home and work at this county hospital.” (18, F,24 years)
Eight trainees indicated patients had doubts about the ability of the GPs and tended to favor specialist in secondary or tertiary hospitals.
Patients’ acceptance is still not well. When we take the training, if we tell patients we’re GPs, they’d question our ability. (05, M,29 years)
Patients usually don’t trust the results in community health centers, and would go to a big hospital again for reassurance. (10, M,30 years)
(Some) patients don’t know the difference between primary and tertiary hospitals. They think they must go to a tertiary hospital for the best doctors when they’re sick. (19, F,27years)
Low professional identity
Although general practice trainees should be regarded as those who tend to take a more holistic approach than their specialist counterparts, in our interviews, five trainees judged themselves as less competent than other specialties. They tended to have negative opinions regarding the professionality and competence of general practice. They expressed that there was less value out of the work of general practice.
I do think general practice are not as proficient as specialists. Specialists do focus more on their own research areas. (01, F,31years)
I don’t think general practice can meet the primary needs. Even chronical diseases require deep understanding of each symptom, which I don’t have. I can’t give them specific instructions. They still need specialists. (12, F,28years)
Twelve trainees felt it would be a waste of their medical degree since there was lack of clinical work content and there is little room for career development at the grassroots level for general practice, compared to hospital medicine.
If I work at grassroots level, I would probably be doing some clerical work such as making health records. I wouldn’t like it if my job is not clinic related. All these years of study and 3 years of training would go to waste if I were not a doctor. (14, F,30years)
The prospect of general practice also caused concern for most of the trainees, which seemed to drive trainees away from primary care.
From higher levels to grassroots level, many big hospitals might have already understood the importance of general practice and established general practice departments, but there’s still a long way to go for hospital of lower levels. It’s impossible for patients to acknowledge this general practice department within a couple of years. (01, F, 31years)
Currently the general practice’ career path is not so clear, or the career prospect is not so promising. If it stays this way, not providing a prospect of development, I wouldn’t work at community levels. (17, F,25years)
Low remuneration level
Trainees expected to earn a guaranteed minimum remuneration, since salary was considered to be a fair return on trainees’ years spent in medical education and a way to make their lives secure. However, most of the trainees from our interviews expressed that they were unsatisfied about the current remuneration of GPs. Low remuneration level appeared to be a primary driver to intention to not choose GPs.
Doctors are people too, and have family to support. Medical students work very hard to go through all these years, 5 years of undergraduate study and 3 years of training. It’s not easy. (11, M,28years)
The least is to support life. That’s the first point. You have to meet all the living needs before you can focus on your job. This is the most basic. (13, F,26years)
(I’ve) never thought about working at grassroots level. Of course, if you can only make a few hundred or one or two thousand yuan a month working there, I can barely make ends meet. Why would I go there? (08, M,28years)
Imperfect training systems
Some supervisors appeared to design their teaching syllabus based on their own preference and sometimes used fixed syllabus, rather than responding to the needs of the trainees.
My supervisor doesn’t care which discipline we’re from. When she takes us on ward rounds, she teaches us something based on what diseases we see, not on each trainee’s discipline. (09, F, 29years)
In addition, the curriculum of general practice training did not highlight the characteristics of general practice. Twelve trainees thought there was a lack of outpatient experience in their training.
I think the curriculum needs to be improved. When we take the training, we spend most time doing ward rounds. But at grassroots levels, most work we do would be at the outpatient clinic. And admitted patients at a tertiary hospital could have rather severe symptoms, which are rare at grassroots levels. (10, M, 30years)
Influence of policy factors
Some of trainees argued that a series of improved medical policies must be in place. Trainees stated that the first-visit care system and the two-way referral system between GPs and specialists should be helpful for guiding patients and for reducing the waste of resources; yet, such systems were too weak in China.
(The process should be that) an almost recovered patent of a higher level hospital should go to a lower level hospital for further recovery, and a patient from a lower level hospital should go to a higher level hospital for treatment if requested. But now many policies are defective. (10, M, 30years)
A few of trainees expressed frustration at the implementation of policy, because there were gaps between what were called for and what were actually done.
Some policies are not well implemented. They’re only talked about but not truly carried out. For example, in this hospital where I’m taking the training, the building of general practice department has been talked about for years, and now only one department is built. For lower level hospitals, people don’t think this is important, as if it would make no difference with or without it. (01, F, 31years)
I think more efforts should be made on implementation. Otherwise they’re all empty promises. (03, F, 28years)