Perceived future career prospects in general practice: quantitative results from questionnaire surveys of UK doctors

Background There are more studies of current job satisfaction among GPs than of their views about their future career prospects, although both are relevant to commitment to careers in general practice. Aim To report on the views of GPs compared with clinicians in other specialties about their future career prospects. Design and setting Questionnaire surveys were sent to UK medical doctors who graduated in selected years between 1974 and 2008. Method Questionnaires were sent to the doctors at different times after graduation, ranging from 3 to 24 years. Results Based on the latest survey of each graduation year of the 20 940 responders, 66.2% of GPs and 74.2% of hospital doctors were positive about their prospects and 9.7% and 8.3%, respectively, were negative. However, with increasing time since graduation and increasing levels of seniority, GPs became less positive about their prospects; by contrast, over time, surgeons became more positive. Three to 5 years after graduation, 86.3% of those training in general practice were positive about their prospects compared with 52.9% of surgical trainees: in surveys conducted 12–24 years after graduation, 60.2% of GPs and 76.6% of surgeons were positive about their prospects. Conclusion GPs held broadly positive views of their career prospects, as did other doctors. However, there was an increase in negativity with increasing time since graduation that was not seen in hospital doctors. Research into the causes of this negativity and policy measures to ameliorate it would contribute to the continued commitment of GPs and may help to reduce attrition.


INTRODUCTION
GP recruitment in the UK is in crisis. 1 Greater patient demand, an ageing population profile, an increasing population coupled with the switching of the management of chronic conditions from secondary to primary care, and an ageing GP workforce, have led to an increased need for more doctors to train in general practice. 2 However, many existing training posts have gone unfilled 1 and the expansion of training schemes alone is unlikely to have the desired outcome. Other areas of concern include increasing numbers of females in their 30s leaving general practice, 1 and high workload. 3,4 In a survey of GPs conducted in 2015, 71% said that high workload negatively affected their personal commitment to general practice. 3 Previous research among GPs has found that low job satisfaction is associated with higher levels of intentions to leave medicine. 5 A study of American physicians found that those who were very dissatisfied with their jobs were twice as likely to retire early as those who were satisfied, and were over three times more likely to reduce their hours to <20 hours per week before retirement. 6 Job satisfaction is higher in individuals who perceive their job to have better career prospects. 7 The aim of this study was to report the views of GPs regarding their perceived career prospects and to compare GPs' views with those of other medical practitioners, with doctors who qualified at different times, and with doctors who were at different stages of their careers at the time of survey.

METHOD
The UK Medical Careers Research Group (MCRG) has surveyed all UK medical graduates from nine year-of-graduation cohorts : 1974, 1983, 1988, 1993, 1996, 1999, 2000, 2002, and 2008. Doctors were surveyed at different times after graduation ranging 3-24 years, in surveys which took place between 1996 and 2013. Some cohorts were surveyed more than once. The MCRG used postal and email questionnaires and up to four reminders were sent to non-responders. Further details of the methodology are available elsewhere. 8 In each of 19 surveys conducted over a 17-year period, among other questions the MCRG asked doctors to rate their level of positivity about their career prospects. In 12 of the surveys this was done by rating agreement with the following statement: 'My career prospects are good' (the statement offered a 5-point scale covering 'strongly agree', 'agree', 'neither agree nor disagree', 'disagree', and 'strongly disagree', with a 'no opinion' option). Occasionally the authors used 'My future career prospects are good', and in seven surveys they used the wording 'I am satisfied with my future career prospects', with the same response rating options. The responses were analysed on the 5-point scale, and re-analysed on a 3-point scale (with 'strongly agree' and 'agree' combined, and 'strongly disagree' combined with 'disagree').

Abstract Background
There are more studies of current job satisfaction among GPs than of their views about their future career prospects, although both are relevant to commitment to careers in general practice.

Aim
To report on the views of GPs compared with clinicians in other specialties about their future career prospects.

Design and setting
Questionnaire surveys were sent to UK medical doctors who graduated in selected years between 1974 and 2008.

Method
Questionnaires were sent to the doctors at different times after graduation, ranging from 3 to 24 years.

Results
Based on the latest survey of each graduation year of the 20 940 responders, 66.2% of GPs and 74.2% of hospital doctors were positive about their prospects and 9.7% and 8.3%, respectively, were negative. However, with increasing time since graduation and increasing levels of seniority, GPs became less positive about their prospects; by contrast, over time, surgeons became more positive. Three to 5 years after graduation, 86.3% of those training in general practice were positive about their prospects compared with 52.9% of surgical trainees: in surveys conducted 12-24 years after graduation, 60.2% of GPs and 76.6% of surgeons were positive about their prospects.

Conclusion
GPs held broadly positive views of their career prospects, as did other doctors. However, there was an increase in negativity with increasing time since graduation that was not seen in hospital doctors. Research into the causes of this negativity and policy measures to ameliorate it would contribute to the continued commitment of GPs and may help to reduce attrition.
To avoid possible confusion with job satisfaction, the authors refer in the analysis to agreement or disagreement that 'My career prospects are good'.
In all, the authors surveyed 37 332 UK doctors from nine different cohorts. The statement about future prospects was included in surveys of the cohorts of 1974, 1983 and 2008 on one occasion, those of 1988, 1999, 2000, and 2002 twice, the cohort of 1996 three times, and the cohort of 1993 five times. The cohorts ranged in size from 2347 graduates in 1974 to 6795 graduates in 2008.
The authors investigated the doctors' level of agreement that their career prospects were good. In particular the authors were interested in whether doctors working in general practice differed from doctors working in other specialties. Doctors' descriptions of their specialty of working were grouped by the authors into 13 specialty groups comprising: adult hospital medical specialties, paediatrics, emergency medicine, hospital surgical specialties, obstetrics and gynaecology, anaesthetics, radiology, clinical oncology, pathology, psychiatry, general practice, community health, and public health.
The authors were also interested in variation in agreement or disagreement about career prospects by time since graduation, by sex, and by year when surveyed.
Responses were compared using χ 2 tests for two-sample comparisons (reporting Yates's continuity correction where there was only one degree of freedom). The authors used binary logistic regression to analyse the effect of factors in combination. Regression analyses used only those variables which were significant as single variables. For convenience of analysis, time since graduation was grouped into 3-5 years, 6-11 years, and 12-24 years; survey year was grouped into 1996 to 1999, 2000 to 2005, and 2010 to 2013; and specialty group for some analyses was further aggregated into four specialty groups: (adult) hospital medical specialties, hospital surgical specialties, general practice, and other hospital specialties combined (paediatrics, emergency medicine, obstetrics and gynaecology, anaesthetics, radiology, clinical oncology, pathology, and psychiatry).

Response rates
The aggregated response rate from contactable doctors, over all 19 surveys, was 68.3% (47 274/69 264; Appendix 1). Of the 47 274 survey responses, 8.4% (3956) answered 'no opinion' or did not select any of the possible responses to the question about career prospects. For the rest of this study, these were omitted, giving a total of 43 318 responses on the 5-point scale.

Results on career prospects, using the latest data from each graduation year
Combining all responses from the latest survey of each graduation year, comprising nine surveys (20 940 responders), 14.1% of GPs strongly agreed that their future prospects were good, 52.1% agreed, 24.1% neither agreed nor disagreed, 7.7% disagreed, and 2.0% strongly disagreed (Table 1). For convenience, for the rest of the results, percentages are reported on a 3-point scale.
The GPs were less positive about their prospects than were the hospital doctors (z = -11.2, P<0.001) and showed 66.2% agreement that prospects were good compared with 74.2% for the hospital doctors. A larger percentage of responses from GPs showed uncertainty about prospects (24.1%) than was the case for the hospital doctors (17.6%). A negative view of prospects was a little higher among GPs (9.7%) than among hospital doctors (8.3%).
Female GPs were marginally less positive about their prospects than female hospital doctors (z = -2.6, P = 0.01; 67.7% satisfied compared with 70.6%). Among males the difference was larger: 64.3% of GPs and 77.0% of hospital doctors were positive (z = -11.9, P<0.001). Appendix 2 shows the aggregated results for all surveys. The overall results for each of the 19 surveys are shown in Appendix 3.

Statistical analysis of 15 surveys
Balance. In further analysis, the authors

How this fits in
Previous research among GPs has found that low job satisfaction is associated with higher levels of intentions to leave medicine. In this context the authors decided to compare the views of GPs and other doctors about their career prospects, using data from the UK Medical Careers Research Group studies collected over many years. Most GPs were positive about their prospects. However, the level of negativity among GPs about their future career prospects increased with increasing seniority: this was not seen in hospital doctors.
wanted to use more of the available 19 surveys, while ensuring that the most frequently surveyed cohorts, those of 1993 and 1996, did not contribute disproportionately to the analysis. The authors omitted four surveys of the 19 undertaken; see Appendix 4 for details. This enabled a balance to be achieved when considering results by year of survey and by years since graduation, whereby the 1996 to 1999 year of survey group featured the graduates of 1974, 1983, 1988, 1993, and 1996

Subgroups
Within the 15 surveys considered here, there were statistically significant differences in the percentages of those who were positive about their future prospects (that is, those who strongly agreed or agreed that their  prospects were good) when comparing groups by each of specialty group, survey year, number of years since graduation, and sex: see the univariable analysis results in Table 2. However, the percentage differences between the subgroups were modest. When all factors were entered into a logistic regression model simultaneously ( Table 2; Multivariable analysis) each factor remained significant. GPs showed a slightly higher level of agreement that their prospects were good, compared with surgeons and those in the hospital medical specialties ( Table 2). There was no evident trend across the three periods of survey year or years since graduation. Re-analysis with 'disagreement' as the criterion (Appendix 5) gave very similar results.
Sex differences. There were modest differences in the views about career prospects between the sexes. However, female GPs were more positive about their career prospects than male GPs, with 72.2% of females and 68.1% of males holding a positive view (χ 2 1 = 19.9, P<0.001). In the other specialty groups males were more positive than females (Table 3: χ 2 1 = 12.6, 14.6, 39.3 for surgery, medical specialties, and other hospital specialties respectively; all P<0.001).
Time since graduation. Much larger differences in views about prospects were found when comparing 'time from graduation' in different specialties.
GPs became less positive about their career prospects the longer they had worked since graduation, while for surgeons the reverse was true (Figure 1). Among doctors surveyed 3-5 years after graduation, GPs held more positive views than doctors in other specialty groups about their future career prospects (χ 2 6 = 514.2, P<0.001; Figure 1): for example, 86.3% of GPs were positive about their future career prospects compared with 52.9% of surgeons.
Comparing doctors surveyed 12-24 years after graduation, however, GPs were less likely than doctors working in other specialties to be positive about their future career prospects (χ 2 6 = 227.6, P<0.001): for example, 60.2% of GPs and 76.6% of surgeons were positive about their prospects.
Year of survey. For each of the four specialty groups, the level of agreement that career  Classifying responders by specialty based on their posts held in year 5, only 6.2% of GPs became more positive about their prospects by year 5, compared with 31.6% of surgeons, and 23.4% of GPs became more negative about their prospects by year 5, compared with 14.0% of surgeons (both Wilcoxon and marginal homogeneity tests gave P<0.001 in each case). This corresponds to the earlier findings of increasing positivity among surgeons and decreasing positivity among GPs, with increasing time since graduation (Figure 1).

DISCUSSION Summary
Overall, most GPs were positive about their future career prospects, as were most doctors in hospital-based specialties. Compared with GPs, surgeons showed slightly lower levels of positivity and doctors working in hospital specialties other than medical specialties or surgery showed slightly higher levels. Onefifth of GPs were undecided about their prospects. Dissatisfaction with prospects was marginally higher among male GPs compared with male hospital doctors: for females the reverse was true.
GPs' satisfaction with their prospects was lower among doctors surveyed later in their careers: for surgeons, the reverse was true. One possibility with some of the hospital specialties (perhaps notably with the surgical specialties) is that, in the early years, the doctors are concerned that they may not progress to senior posts within the specialty. Compared with the GPs at a similar stage, the specialists are still competing for career progression in terms of increasing seniority. As time progresses, and the individuals in the hospital specialties are successful, this in itself may increase their confidence about their future prospects.
Females working in hospital specialties were less likely than males in hospital specialties to be positive about their future career prospects. By contrast, female GPs were more positive about their future career prospects than male GPs.
Female GPs, like females working in the 'other' hospital specialties, were more positive about their future prospects than females working in hospital medical specialties and surgery. Males working in other hospital specialties were more likely than doctors working in the other specialties to agree that they were positive about their future career prospects.

Strengths and limitations
The study was national and included all UK medical schools. It covered many graduation years from 1974 to 2008 and data were collected between 1996 and 2013. The response rates for each survey were good. The authors are an independent research group and they believe they receive honest answers from doctors. Due to the nature of survey research methodology there is the possibility of responder bias.
Some graduation cohorts were surveyed more often than others. To prevent any disproportionate contribution to the analysis from these cohorts, the authors used a balanced design, which means that in some of the analyses not all of the survey data were used.

Comparison with existing literature
Most GPs were positive about their future career prospects. This tallies with other indicators of career motivation observed recently: 47% of GPs would recommend general practice as a career choice; 3 87% of GPs were satisfied with work and training, and 72% were satisfied with work-life balance. 9 Female GPs were more positive about their future career prospects than male GPs; also, female GPs were more positive about their future prospects than females working in hospital medical specialties and surgery. Compatibility of general practice with family life is a factor. 10 Female and male GPs may compare their situations to their peers in other specialties favourably, (in the case of some female GPs or unfavourably, (in the case of some male GPs).
Nearly one-quarter of GPs became more negative about their prospects by their fifth year after graduation. This could be due to a gradual realisation of the many challenges faced by GPs currently in terms of an ageing workforce, increasing workload, and increased patient demand. 2,3 The latest data reported in this study were collected in 2013: in 2016, increasing pressures on service delivery suggest that this negative trend may continue.

Implications for research and practice
Although the profile of views about career prospects was broadly positive for GPs, as it was for other doctors, there were some concerns. Specifically, the authors noted among GPs an increase in negative views of career prospects with increasing length of time since graduation, which is not seen in hospital doctors, and these changes were more noticeable among male GPs than among female GPs. Research into the causes of this negativity, and the introduction of policy measures to ameliorate its causes, would contribute to the continued commitment of GPs and may help to reduce attrition of senior GPs from the profession.

Funding
This independent report was commissioned and funded by the Policy Research Programme in the Department of Health (project number 016/0118). The views expressed are not necessarily those of the funding body. Note that this table excludes 2830 doctors who were working in non-medical jobs or were not in paid employment.