Career intentions and perceptions of general practice on entry to medical school: baseline findings of a longitudinal survey at three UK universities

Background Medical graduates from the universities of Oxford and Cambridge have a lower intention to become GPs compared with other UK medical graduates. It is not clear to what extent this difference is present on admission to medical school. Aim To compare the career intention and influencing factors of students on admission to different UK medical schools. Design & setting First year of a 6-year prospective cohort study of medical students admitted in autumn 2020 to the three East of England medical schools: University of East Anglia (UEA), University of Cambridge (UOC), and Anglia Ruskin University (ARU). Method An online survey instrument was administered at the beginning of the first year. This measured self-reported career interests and various influencing factors, including perceptions of general practice. Results UOC students declared a lower intention to become a doctor, a higher likelihood of choosing careers in pathology and public health, and a much lower likelihood of becoming a GP than students of UEA or ARU (all at P<0.001). In all three schools, the phrases least associated with general practice were 'opportunities for creativity/innovation' and 'research/academic opportunities', whereas the phrases most associated with general practice were 'favourable working hours' and 'flexibility'. However, research/academic opportunities were far more important, and favourable working hours far less important, to UOC students (P<0.001 for both) than to students of UEA or ARU. Conclusion UOC students’ lower intention to become a GP appears to be present on entry to medical school. This may be explained in part by these students placing a higher importance on research/academic opportunities, combined with the widely held perception that GP careers lack these opportunities.


Introduction
There is an imperative on UK medical schools to produce future GPs 1,2 and UK medical schools vary in the proportion of their graduates who enter GP training. 3,4 Historically, the universities of Oxford and Cambridge (collectively termed 'Oxbridge') are the furthest outliers in this regard, with very low numbers of their graduates entering GP training. 5 There is currently a lack of evidence regarding the reasons for this discrepancy, and its investigation may shed further light on factors influencing medical student career choice.
In 2004, Goldacre et al 6 demonstrated that medical students graduating from Oxbridge report significantly lower interest in following a career in general practice compared with those from other UK medical schools, but this study only contained minimal exploration of possible influencing factors. Since then, there have been a number of cross-sectional surveys investigating medical student career preferences and self-reported influencing factors, [7][8][9][10][11] and a few of these 7, 10 have explored the degree to which medical students perceive GP careers as possessing these factors. However, none of these surveys have included measures of intolerance of uncertainty, 12 which is significant, given that problembased learning (PBL) is characterised by a response to uncertainty, 13 and medical schools that employ a PBL approach have been shown to produce more future GPs. 4 Moreover, none of the above studies have explicitly investigated the differences in acceptability of GP careers between Oxbridge students and students at other medical schools. The findings of a recent survey of Oxford medical students 7 suggested that they may not perceive GP careers as offering sufficient potential for status, research opportunity, and financial reward. However, this study did not compare with other medical schools, did not investigate attitudes at admission, and did not include intellectual stimulation or measures of intolerance of uncertainty as possible influencing factors.
While there is some evidence to suggest that level of exposure to primary care in a medical school curriculum is associated with the degree to which it produces future GPs, 3,4,14 Cambridge does not appear to fit this hypothesis, because the amount of time spent on GP placements puts it in the top 20% of medical schools in the country in this regard. 15 The available literature does not fully explore the degree to which differences in career preferences and influencing factors are fixed on admission, nor the degree to which they change over time with exposure to the curriculum. Therefore, a longitudinal survey was designed to compare over time the career drivers and perceptions of Cambridge medical students with those of two other medical schools that also provide high exposure to general practice. This article presents baseline results from the first year of that longitudinal study, principally looking at differences between cohorts shortly after admission to medical school.

Study population
The cohort of medical students who commenced studies at three UK universities in autumn 2020 were included in the survey. These three medical schools are described below.

Measures
The survey was designed to assess students' expressed career intentions, drivers, perceptions, and potential influencing factors as they progress through their course. The items measured were based to a large part on the themes (although not the exact design) of the Royal College of General Practitioners' Destination GP 10 questionnaire, as well as some additional themes.
The questionnaire asked students to rate the following: • the importance they placed on a selection of career factors (using an electronic Likert scale 0-100) • the degree to which they perceived general practice as possessing these factors (using an electronic Likert scale 0-100) • their intention to be a doctor on completing their medical degree • their likelihood of choosing a GP career • their likelihood of choosing each of the following career options: anaesthetics, dermatology, emergency medicine, geriatrics, hospital medicine, obstetrics and gynaecology, paediatrics, pathology, psychiatry, public health, radiology, surgery, a career outside of medicine • how GPs and general practice have been represented in the media in the last 6 months • their experience of general practice as a patient or relative of a patient • their experience on GP placement • the extent to which they have encountered negativity towards general practice from -academics, clinicians, and/or educational trainers (using an electronic Likert scale 0-100) -other medical students (using an electronic Likert scale 0-100) -family and friends (using an electronic Likert scale 0-100) Other than where stated, the scale for all the above was -50 to +50, where 0 = neutral.
Yes/No questions were used to determine whether or not: • so far in the course, they have had a positive role model who happens to be a GP • so far in the course, they have encountered an academic who is a GP • they have attended a student GP society event • they have a friend or family member who is a GP An abbreviated version of the Intolerance of Uncertainty Scale (IUS) 12 was used in the survey, and demographic data were also collected. As this was a longitudinal cohort study, some of the questions were not relevant to students at the beginning of their first year; the responses to those questions were not analysed.

Data analysis
For ease of interpretation of the results, the -50 to +50 scales were recoded into 0-100 (50 becoming the neutral value). The minimum and maximum values as well as the mean, median, standard deviation (SD), and the 25 th and 75 th percentile were used for the continuous variables, and the percentages with the corresponding frequencies were used for the categorical variables. Measurement of intolerance of uncertainty involved calculating the sum score of more than one item. The reliability of these latent scores was evaluated using Cronbach's alpha statistic.
For categorical variables, χ 2 tests were used to investigate the differences between the three schools. For continuous variables, the univariate relationships were examined using one-way analysis of variance (ANOVA) in cases where its assumptions were met; otherwise, the non-parametric alternative of Kruskal-Wallis was applied. The statistic and the corresponding P value of the test were reported, with 0.001 being considered the level of statistical significance.

Results
Sample: size, response rates, and demographic characteristics of responders  Importance of career factors and the degree to which they are associated with general practice Table 2 presents descriptive statistics regarding the degree to which certain phrases were associated with general practice. For each of the three schools, the phrases least associated with general practice were 'opportunities for creativity/innovation' and 'research/academic opportunities' while the phrases most associated with general practice were 'favourable working hours' and 'flexibility'. In general, there were not statistically significant differences between the three schools in the extent to which they associated the different phrases with general practice. The one exception was research/academic opportunities, with students in UEA scoring this lower than the other two schools (F = 6.91, P = 0.001). Table 3 presents the scores for importance of certain career factors. For all three medical schools, the top two career factors rated as the most important were intellectual stimulation and team working. UOC students appeared to rate the importance of some factors quite differently to the UEA and ARU students, whose scores were more closely aligned. UOC students rated intellectual stimulation and research/academic opportunities significantly higher (H(2) = 25.4, P<0.001, and H(2) = 64.07, P<0.001 correspondingly), than those from the other two universities. They also rated flexibility significantly less important (H(2) = 15.13, P<0.001), and favourable working hours much less important (H(2) = 22.50, P<0.001) than those from the other two universities. Figure 1 illustrates differences between the three medical schools in terms of the importance students placed on certain career factors and the degree to which they associated these factors with general practice. It also demonstrates for each school where there is a mismatch between the perceived importance of a factor and its perceived association with general practice. Such mismatches appear to be most evident in the UOC group, especially for research/academic opportunities and favourable working hours.
The maximum for all variables and schools was 100 and it is omitted from the table for space economy. ARU = Anglia Ruskin University. UEA = University of East Anglia. UOC = University of Cambridge. perc. = percentile. SD = standard deviation.

Intolerance of Uncertainty
A score was constructed as a sum of the eight items. The internal consistency of this measure was good in all schools (in UOC the Cronbach's alpha was 0.76, while in ARU and UEA it was 0.79). It was found that intolerance of uncertainty was not significantly different between the three schools (F-test = 2.07, P = 0.13). A summary of the scores for the three medical schools is available in Supplementary  Table S2.
Other potential influencing factors (role models, encountering a GP academic, a GP friend/family member, quality of experience as a patient or relative, experiencing negativity from staff/students/family/ media) There was no statistically significant difference between the three groups in terms of:  Table 4); or • the perceived quality of their experience of general practice as a patient or relative (H(2) = 3.37, P = 0.186) (see Table 4).  Where only two shapes are evident this is because the third is obscured by another which has the same value. Table 4 Media representation of GPs/negativity from staff, students, family and friends/quality of experience of GP as a patient or relative (0 = extremely negatively/ not at all/very negative; 100 = extremely positively/a great deal/very positive) The minimum and the maximum for all variables and schools was 0 and 100 correspondingly, and it is omitted from the table for space economy. *Denotes that ANOVA F test was done for this variable rather than Kruskal-Wallis test as data met its assumptions ARU = Anglia Ruskin University. UEA = University of East Anglia. UOC = University of Cambridge. perc. = percentile. SD = standard deviation.
testing met the threshold for statistical significance (role model χ 2 = 69.78, P = 0.000; GP Academic χ 2 = 94.64, P = 0.000), whether this difference is of true significance is doubtful. This is because, as elaborated on in the discussion, the UOC survey reached a suitable response rate much earlier in the first year than the surveys in the other two schools. This will have resulted in a significantly longer exposure to the curriculum (and thus educators) in the ARU and UEA groups.

Discussion Summary
On entry to medical school, UOC students declare a lower likelihood of choosing a GP career, or indeed any career in medicine, compared with UEA and ARU students. They also declare a higher interest in the following careers: pathology, public health, and careers outside medicine. Perceptions of general practice were broadly similar across the three groups. The phrases most associated with general practice were 'favourable working hours' and 'flexibility', while the phrases least associated with general practice were 'opportunities for creativity/innovation' and 'research/ academic opportunities'. However, UOC students differed significantly from ARU and UEA students in how important these factors were to them. In particular, UOC students rated research/academic opportunities as much more important to them, and favourable working hours as much less important to them, compared with ARU and UEA students. The most obvious mismatches between the perceived importance of a factor and its perceived association with general practice, therefore, appeared to occur in the UOC group, and were related to these two factors ( Figure 1).
In terms of intolerance of uncertainty and the other potential influencing factors that were surveyed, differences between the groups were non-significant.

Strengths and limitations
A limitation of the survey instrument was that only eight out of the 27 questions in the IUS 12 were included. This decision was taken in light of the unfeasible length that the full tool would have added to the questionnaire. While there is a validated 12-item intolerance of uncertainty questionnaire available (IUS-12), 16 many of the questions with most face validity for learners are not contained in the 12-item tool. It was, however, ensured that the eight questions chosen were equally balanced between the two subscales of the 27-point IUS tool ('uncertainty has negative behavioural and selfreferent implications' and 'uncertainty is unfair and spoils everything'). 17 It was also demonstrated statistically that the shortened eight-item tool has good internal consistency. Nevertheless, further work is required to confirm its construct validity with regards to uncertainty in learning and in clinical decision making.
This first survey of the cohort study was purposed to measure student responses on entry to medical school to provide a baseline for future years, before exposure to the curriculum had a chance to take effect. However, after the survey opened on 5 October 2020, UOC, ARU, and UEA took different lengths of time to reach their respective final response rates of 77%, 66%, and 65% (see Supplementary Figure S1 for a graph of cumulative response rates by school). For example, UOC reached 60% by week 1, and ARU reached that level at week 9. UEA reached 40% by week 11 and 60% by week 21. This means that, for example, one-third of UEA responders will have had up to 3 months more exposure to the first-year curriculum before completing the survey. Finally, another limitation of this study may lie in the selection of 0.001 as significance level. Chosen to reduce type I errors resulting from multiple testing, this level could increase the chance of type II errors.

Comparison with existing literature
It is already well documented that graduates of Oxford and Cambridge medical schools have a lower interest in GP careers compared with other UK medical schools. 6 However, this study's results add to the literature by demonstrating that in Cambridge students, this difference appears to be present around the time of admission to medical school, rather than being solely attributable to subsequent influences.
Students' perceptions of the nature of general practice were consistent with the results of previously published surveys. [7][8][9][10] However, this study adds to the literature by comparing perceptions between the three groups. It is revealing to see that all three groups of students viewed general practice similarly for all but one factor (and even with that factor included, UOC was not the outlier). This suggests that Cambridge students' lower interest in GP careers is not due to a different perception of the nature of general practice. Similarly, the data also suggest that this lower interest at admission does not appear to be related to any difference in those influencing factors that could act before medical school such as intolerance of uncertainty, exposure to negativity about general practice, quality of experience as a patient, or having friends or family members who are GPs.
A desire for intellectual stimulation is thought to be a very important factor influencing medical student subspecialty choice. 10,18 The present study's results confirm this by demonstrating that it was the factor that all three groups of students rated most important to them. However, the data suggest that differing importance placed on certain career factors, when combined with commonly held perceptions of general practice, may provide a clue to Cambridge students' lower interest in GP careers (see Figure 1). For example, while all three groups of students perceived general practice as possessing very low research/academic opportunities and highly favourable working hours, UOC students placed much greater importance on the former and much less importance on the latter, compared with students from the other medical schools.

Implications for research and practice
A lower interest in primary care careers of Oxbridge medical students compared with those from other UK medical schools is well documented. 6 However, this study is the first to explore the underlying reasons for this difference. Its findings show that for Cambridge students this difference exists at admission to medical school. The results suggest that this may be explained in part by the greater importance Cambridge students place on having a career with research/academic opportunities, combined with the widely held perception among medical students that general practice offers little in this regard. This adds weight to current calls to raise the profile of academic general practice among certain groups of medical students. 19,20 Current thinking is that increasing the amount of exposure to general practice at medical school and reducing negativity from students, staff, and media is key to increasing medical student interest in GP careers. 3,10,14 However, these findings suggest that further research is required to determine whether such interventions have the desired effect in subgroups of students, such as those at Cambridge who desire a career with research/academic opportunities. Given that the Cambridge curriculum contains a relatively high GP placement content, continuing this longitudinal study should help to answer this question. If the data on exit remain similar to that on entry, it will suggest that Cambridge students, and other similarly profiled students, may be impervious to such interventions without first addressing a broad perception of a lack of research/academic opportunities in primary care.

Funding
The authors received no specific funding for this work.

Ethical approval
Ethical approval was obtained from The University of Cambridge Psychology Research Ethics Committee (ref PRE 2018.097). All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all subjects at the point of clicking on the link to the survey.

Provenance
Freely submitted; externally peer reviewed.