Article Figures & Data
Tables
- Table 1. Illustrative GP quotes relevant to Xu’s dual-process theory of career decision-making (DTC) framework constructs
Framework construct Definition Quote DTC framework 28 (1) Anchor choices Intermediate choices that provide career direction, e.g. medical versus surgical, preferencing specialties or not, case variety, location, or community “I did a rotation in PGPPP [Prevocational General Practice Placements Program] in my second year out, which was a very positive experience. I really enjoyed that. I think that that’s a significant part of why I decided to go into general practice.” (GP5) (2) Agentic adjustment Adjustment of initial career choice based on feedback, using critical self-reflection and career adaptability (that is, concerns about the future, curiosity in exploration, internal sense of control, coping confidence) “[…] a few of my colleagues are leaving general practice now and it’s because they’re burnt out from always bending over backwards trying to accommodate things, so I think you do have to find that sweet point between flexibility and where your boundaries have to be firmer. But if you find that then general practice is great.” (GP6) (3) Strategic planning Non-linear, intentional style of career design with holistic, long-term oriented goals by the individual “[…] but all the time – if someone has started obstetrics training and then halfway through they said, ‘You know what, too many night shifts. I want to have a family. My partner earns enough money. I don’t need to work as a surgeon and, you know what, it’s too hard on my – I want to have kids and it’s not good for my training program. I’m going to leave. I’m going to become a GP.’” (GP9) (4) Managing ambiguity How the individual self-manages thoughts about their career choice which they are not able to confirm or disconfirm before trying it out personally “[…] for that longer length of placement, it was definitely, ‘Yes, if general practice is your path, great. Follow it. If general practice really isn’t your path, great. Follow that.’ The others kind of still figure their own way out.” (GP13) (4a) Satisficing Settling for a choice as ‘good enough’ by approaching and making attempts to understand any ambiguity, and acknowledging any ambiguity is acceptable “I think the number one challenge is – I mean for me it probably didn’t – I guess there was still that kind of lack of ‘I don’t really know what it is to be a GP,’ because you don’t have that exposure. I think that what that was still a challenge because I didn’t – I hadn’t had that kind of personal experience.” (GP1) (4b) Maximising Approaching ambiguity by exhausting decision-making resources and efforts, and denying any ambiguity can exist “I narrowed it down till I was choosing between general practice and paediatrics, and had a whole lot of trouble making up my mind. I did a year at the children’s hospital and was on the paediatrics training pathway without actually having committed to doing that yet. Just thinking, well, I would have a year of that under my belt if I do decide to do that. Ended up applying for both, getting offers for both and taking it down to the wire in terms of the decision making.” (GP5) (4c) Ambiguity avoidance Passive avoidance of ambiguity by denying its existence, since ambiguity is unacceptable; anxiety is a characteristic of this state “[…] I just defaulted to physician training because I didn’t want to do surgery, I didn’t want to do anaesthetics, I didn’t want to do radiology or any of the other super-niche things, so it just seemed like physician training was the default decision. So, I did that and then I just realised the job was crap and then I’m like, ‘Oh wait, there’s GP as an option.’ It almost came as a, not afterthought, but yeah, like a second line consideration for me.” (GP10) (4d) Calling and hope Avoids ambiguity by not particularly doing anything to understand it, but points instead to a ‘higher calling’ to the career choice; accepts that such ambiguity exists. Requires emotionally empowered experiences and intuitive thinking to resolve ambiguity instead, and deliberate evaluation is unlikely to help “I didn’t even know what the pay was until I entered it. I hadn’t looked at the advertised – I should have – I’ve always wanted to do it, so maybe I did look, I can’t remember now but it didn’t faze me […] My plan was always to be a GP and I was quite sad that it didn’t work out that way for me.” (GP8) (5) Managing confusion How the individual seeks out information and knowledge to clarify differences between different specialty career choices, and what this would mean in their individual life (5a) Self-awareness Understanding of self (that is, self-awareness) “[…] during medical school and during internship, I didn’t really find one specialty that I was, like, ‘Oh, this is a specialty that I love and I want to do for the rest of my life.’ I found that I did really like that variety and seeing lots of different things.” (GP1) (5b) Vocational information: non-GP Understanding of non-GP specialties as vocations “Then after my first year of internship and then I already – it just confirmed what I thought before, which was that I couldn’t see myself working in the hospital. […] the problem is that everyone is really overworked and understaffed pretty much. So it’s not because people don’t want to work. It’s the problem you’re overworked and you don’t have enough resources, enough people. But the problem is everyone needs an extra hand.” (GP9) (5c) Vocational information: GP How general practice, GPs and their values were described and contrasted with other medical norms and non-GP specialties “[…] firstly in university, was that I really liked the unit that ran general practice. It seemed to be a unit that actually cared about its students, and it was the first time that I felt that we were able to kind of combine all the medicine that we’ve learnt and really apply in a holistic manner that helped with how we delivered our treatment in the sense of making it patient-centred.” (GP4) (5d) Assessing person– environment fit When the individual is cognitively comparing the person-environment fit for a specialty career choice against their knowledge of the different choices available “I wanted the diversity of location, as well. So, I wanted to be able to potentially work in an urban environment or a remote environment, or a regional town or whatever. I guess I felt like I wanted to be able to have the flexibility to do that. Again, I think general practice offers that where a lot of other specialties don’t.” (GP2) Educational learning construct Threshold concepts Knowledge and experiences that move the individual from confusion (that is, when they don’t know enough about their potential choices) to ambiguity (that is, they know all they can know about their potential choices other than what happens when they step into it themselves) about their GP career choice “[…] he was not only working as a GP, but he was also working as like the obstetrician at the rural hospital and working as the anaesthetist at the rural hospital. So he had lots of lots of different hats. So I guess it sort of showed that a GP doesn’t always have to just be like the GP. Like if you do rural training you can do lots of different things. But even in, I guess metro areas, GPs are doing lots of different roles.” (GP1) Characteristic Frequency Gender Male 10 Female 14 Non-binary/third gender 1 Age, years <30 2 30-34 15 35-39 8 Affiliation ACRRM 1 RACGP 23 Both 1 Rural self-identification (multiple allowed) Rural background 6 Rural medical school term>12 months 7 Rural postgraduate doctor placement>12 months 10 GP training – mostly rural/regional 12 GPs reporting no substantial medical training rural experiences 13 Number of GP jobs held 0 1 1 10 2 7 3 6 4 1 Main GP job location New South Wales 6 Northern Territory 1 Queensland 13 South Australia 1 Victoria 1 Western Australia 2 Metropolitan (MMM1) 16 Regional centre (MMM2) 3 Small rural town (MMM5) 4 Very remote (MMM7) 1 ACRRM = Australian College of Rural and Remote Medicine. MMM = Modified Monash Model (classification). RACGP = Royal Australian College of General Practitioners.
Reasons (multiple usually present) Timing (context) Doctor’s characteristics (context) Exposure (context) Environmental Work experience in GP setting Medical school or pre-vocational, reinforced over time Open to all specialties, haven’t decided on specific specialties Generally positive or neutral clinical experience/s in general practice placement, feeling connection or ‘clicking’ with holistic and individualised person-centred care, and/or a patient demographic, and/or a medical community, and/or rural areas, and/or exemplary generalist clinicians Ruling specialties and medical interests in or out Medical school and pre-vocational experiences Open to all specialties, but is becoming more self-aware of own interests, skills, and capabilities over time – discovers they enjoy a broad variety of medicine and work Experiencing a broad variety of areas of clinical medicine, to the point where they could not choose only one specific specialty to continue in. An ‘aha’ moment often came, realising how different medical areas can be included in GP specialty (with or without training), and GP career could be tailored individually to self Validation and support experienced in the general practice environment Medical school and early pre-vocational Feels vulnerable with lack of skills or knowledge, and is within identity formation as doctor or GP Medical experiences that were more than observation in the general practice setting with GPs and allied health, ‘feeling helpful’ in the general practice setting compared to other specialty placement experiences, and connecting with GP role models who invested in personal relationships and demonstrated in-depth generalism and continuity of care medicine, while showing that their lifestyles allowed family and other interests to be prominent Hospital non-GP specialties perceived as less favourable environment to the individual Pre-vocational Tired, burnt out, frustrated, may have completed 10+ years of university and hospital vocational training by this stage Some exposure to general practice setting
Usually this mechanism was triggered during pre-vocational training which takes place in hospital settings
Hospital administration (which was difficult to appeal to for personal leave and considerations) particularly prompted this conclusionProfessional GP medical work fits their personal medical interests, after comparing GP and hospital non-GP specialties Medical school and pre-vocational Individual prefers to ‘know’ patients over a long period of time through interactional and holistic person-centred care; likes a broad variety of presentations and lesser patient acuity Exploring different specialties’ skills, attributes, personalities, lifestyle, and own medical interests, preferred values and lifestyle through placements and postgraduate doctor training, including the GP specialty GP work setting fits their personality, skills and norms, after comparing GP and hospital non-GP specialties Medical school and pre-vocational Individual wants to privilege family, personal wellbeing, and external goals, not just medical work Observations of specialty trainees and consultants, finding out information from trainees and consultants, and personal experience working within different specialties, including the GP specialty Holds a health system perspective, rather than only privileging their specialty or discipline Registrar and fellow The doctor feels quietly providing value to the healthcare system is important through disease prevention interventions and longitudinal episodic care, rather than easily measurable once-off acute hospital care Experiencing GP work over more than 12 months and realising the value and impact that general practice has on individuals and at a system level Medical status perceived to matter less than personal rewards derived from helping others Medical student to fellow The doctor values being a part of patients’ health progress and lives, enjoys helping others Experiencing GP work in one practice for more than 12 months, having their own patient pool.
Talking about medical status with people external to medical profession.Registrar training takes less time and requirements than other specialties The doctor prefers above factors over other specialties’ perceived benefits and long training programmes; wants to plan life outside medical career within 2–5 years rather than 5–10 years Comparison of non-GP and GP specialty training requirements
Speaking with non-GP and GP registrars and consultantsPrevious medical experience and credentials (including those gained when pursuing other training pathways) are valued and not ‘wasted’ in GP work and can be used still Pre-vocational to fellow The doctor previously began training in or has serious interest in other specialist medical pathways (for example, paediatrics or women’s health) but is interested in pivoting to GP because of incompatibilities in lifestyle, or personal or family goals, and similar reasons Explanation by senior doctors that other medical experience and credentials are beneficial, welcomed, and acknowledged in GP or rural generalist settings Non-professional Work–life balance and personal sustainability is attainable in GP career Medical school to fellow Does not believe medical career should ‘take over’ their lives, believes in the importance of self-care and wellbeing, and is willing to take actions to perform self-care Seeing and knowing GP role models who have built successful and sustainable careers that allow them to be excellent doctors, but also spend time with their families and achieve other goals external to medical career Agreeable or tolerable projected economic and social position as GP Registrar,
fellowNo financial responsibilities (for example, mortgage, family) undertaken during pre-vocational years, willingness to change medical perspectives, considers GP pay sufficient since they have enough patients and Medicare billing competence/understanding Comparison with GP pay and status with non-medical careers, rather than non-specialist careers
Availability of locum GP and emergency department positions as second job for GP registrar period
Understanding and experience in Medicare billing
Supplementary Data
- Yon_10.3399BJGPO.2024.0218_supp.pdf -
Supplementary material is not copyedited or typeset, and is published as supplied by the author(s). The author(s) retain(s) responsibility for its accuracy.
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General practice specialty decision making: a system-level Australian qualitative study
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