A Realist Evaluation of Theory about Triggers for Doctors Choosing a Generalist or Specialist Medical Career
Abstract
:1. Introduction
2. Materials and Methods
2.1. Design
2.2. The Environment for our Evaluation
2.3. Initial Program Theory
2.3.1. Phase 1: Developing Theory
2.3.2. Phase 2: Refining Theory
3. Results
3.1. Environmental
3.1.1. A Conversion
I was a medical student…. I visited a surgeon… who ended up doing the most comprehensive face transplant in history… after that… I did a student elective in [major city]—plastic surgery—that was quite good, and then I got into the nitty gritty of trying to be a Plastic Surgery Service Registrar.(FM4_Male_Spec)
I just clicked with that department. I really enjoyed the people I worked with. I enjoyed the nature of the work, so that’s how I chose anaesthetics.(TR1_Fem_Spec)
I did a rural health placement here [regional centre] as a student… I wasn’t really interested in GP probably still at that point… but I was really interested in Aboriginal health… I decided to apply for internship up here… then when I was a Resident… I did a PGPPP [general practice rotation] in [remote area]… in a homeland service… which was just incredible.(FR5_Fem_Gen)
3.1.2. Ruling Things in or Out
[as a junior doctor]… it’s just been solidified over time as I’ve done different rotations. And you rule out certain specialties.(TM2_Male_Spec)
[as a junior doctor] I had trouble choosing one specific specialty… I [hoped I] could have that opportunity to practice some primary health, some hospital health in emergency on the wards as well as some anaesthetics and giving me that wide breadth.(TM1_Male_Gen)
3.1.3. Validation and Support
I think the primary motivating factor for psychiatry… was driven partly by what I perceive to be reasonable success and good feedback when I worked in a junior stage. I think I was quite impressionable and so, I was quick to jump…(TR3_Male_Spec)
[When medical student]… I was nursed along and shown what the joys of general practice and long-term care in a community was like.(FR1_Male_Gen)
[When medical student]… individuals who were prepared to take me into their personal and family lives, and not just at clinic… as a person, in my early 20s, that had a big impact on my ideas about the world.(FR6_Fem_Gen)
3.2. Professional
3.2.1. Suits Desired Clinical Practice
I always loved doing critical care, I was always interested in looking after sick patients. I always wanted to work in a hospital environment. That’s just how I felt about it….(FM1_Fem_Spec)
I became interested in anaesthetics when I was in my intern year… I guess I really enjoy the very procedural nature of anaesthetics(TR1_Fem_Spec)
[As a junior doctor]… I can do whole of life care and get in earlier and be the first point of contact rather than just see people when they get to hospital.(FR6_Fem_Gen)
[As a junior doctor]… I was burnt out from the hospital—you see all the sort of pointy end of things there.(FR5_Fem_Gen)
3.2.2. Fit Personality, Skills and Norms
[when a junior doctor] I chose oncology… I guess my communication skills are probably my strongest point and oncology is a specialty where it’s based around communication.(FR8_Male_Spec)
3.2.3. Status and Reward
3.3. Non-Professional
3.3.1. Work-Life Balance and Personal Sustainability
[with partner and children] Oncology … was a specialty that appealed to me…for a bit of a lifestyle—not a lot of after-hours.(FR8_Male_Spec)
[psychiatry] I was very well supported in paediatrics as a PHO, but I looked at how long the training programme was at my age and what I’d have to learn and I, despite their assistance, I didn’t go that way.(FM5_Male_Spec)
[partner planning children, anaesthetics]… a career that I can spend time with my children when I have them and all that, and spend time with my partner… you don’t have inpatients, you don’t have longitudinal care… it doesn’t drain you….(JM1_Fem_Spec)
… my own health and then also the birth of my son, yeah just helped to cement my desire for a more flexible part-time approach to clinical work.(TR3_Fem_Gen)
[GP]… allowed much more flexibility in the training and taking part-time work, for example, which any of the other specialties didn’t allow.(FR4_Male_Gen)
3.3.2. Suits Desired Economic and Social Position
4. Discussion
5. Conclusions
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
References
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Question | Specific Prompts | General Prompts |
---|---|---|
Could we start by you telling me a little about yourself and your career as a doctor? | Things like your current practice location, area of medicine, stage of medical career, and where you did each stage of your medical training? | Could you please expand on that? That is very interesting, could you tell me more? Really, what was that like? Reflecting on that time in X, could you give me a bit more detail about X experience? |
What are the major factors that have influenced your medical career journey to date? | Identify factors that influenced participant’s career decision, current practice location; area of clinical practice; amount of time devoted to clinical medicine; decision-making in the context of family situations, partner employment, incentives, professional support | |
What were the important time points when things happened that determined the current shape of your medical career? | ||
What made these time points important? | ||
What happened at those times and how did they affect your career trajectory? | ||
How much control have you had over how your medical career has turned out? | Things like; going to medical school, internship location, vocational training, geographical location of current clinical practice | |
What are the factors that influenced (gave you more or restricted) that control? | ||
How easy (or realistic) is it to change where you practice (geographically); and also your field of medical practice? | How flexible is a medical career; and does it vary at different times in one’s life? Does it vary by area of medical practice? By where you live (city/country)? | |
Have you considered changing where you practice or your field of medical practice? | ||
Have you had to move from where you were living to pursue a training opportunity, or to meet clinical/professional college requirements? | ||
Did you later return to where you were? | ||
Have you had breaks in practice? | ||
Can you tell me the reasons for those breaks? | ||
What would have made your medical career progression better informed? | ||
What (else) would have improved the way your medical career has progressed? | ||
Before I turn off the recording device, is there anything else you would like to comment on? |
Notation | Definition |
---|---|
J, T or F | junior doctor, trainee or fellow (defined in Table 3) |
R or M | working rurally or metropolitan |
Male or Fem | male or female |
Gen or Spec | Generalist (general practice or public health) or specialist (all others) based on self-reported interest/uptake of a chosen postgraduate field of medicine |
Characteristics | n (%) |
---|---|
Sex | |
Females | 16 (50) |
Males | 16 (50) |
Training stage | |
Junior—yet to start vocational training as registrar (typically PGY 1–5) | 8 (25) |
Trainee—currently enrolled in specialty training (registrar) (typically PGY 3–10). | 10 (31) |
Fellow—completed specialty (registrar) training (typically PGY 6–17) | 14 (44) |
Working rurally | |
Yes | 15 (47) |
No | 17 (53) |
Rural background | |
Yes | 8 (25) |
No | 24 (75) |
Specialty focus | |
Generalist | 12 (38) |
Specialist | 20 (63) |
Outcome | Trigger for Choice (Mechanisms) | Doctor’s Characteristics/Timing of Exposure (Context) | Doctor’s Exposure (Context) |
---|---|---|---|
Specialisation choice (S or G) | ENVIRONMENTAL | ||
A conversion | (S/G) Medical school and reinforced over time | (S) A key focused clinical experience or clicking with a Department or specialist clinician (G) Connecting to a community and/or rural areas and exemplary generalist clinicians | |
Ruling things in (G) or out (S) | (S/G) Mostly postgraduate | (S) Experiencing a range of areas of clinical medicine (G) Experiencing a range of areas of clinical medicine and seeing how these can be linked into generalist practice, with sufficient training | |
Validation and support | (S) Early postgraduate when impressionable (G) Medical school and early postgraduate when impressionable | (S) Getting reinforcing feedback from senior clinician/s, focused clinical skills and endorsement/references for job/training applications (G) Connecting with role models who invest in a personal relationship, demonstrating lifestyle and continuity medicine | |
PROFESSIONAL | |||
Suits desired clinical practice | (S) Mostly postgraduate if do not have a fixed specialty ideation (S) Medical school if have a fixed specialty ideation (G) Mostly postgraduate, burnt out from hospital work | (S) Being intellectually stimulated, enjoying procedural work and working in acute hospital care and comfortable with working in teams (G) Enjoying skills breadth (including procedural and intellectually challenging work), complexity of the ‘whole person’ continuity of care, working independently and making an upstream impact to population health | |
Fits personality, skills and norms | (S) Before medicine, medical school and postgraduate (G) Mostly postgraduate | (S) Having particular attributes—technical or soft skills and desire to align with social and professional norms (G) Comfortable with uncertainty and enjoy problem-solving, innovation, change and challenging social and professional norms | |
Status and reward | (S) Medical school and reinforced over time, desire to optimise professional power and maintain income through market control (G) Medical school and reinforced over time, desire to be useful and maintain income within broader market | (S) Being sensitised that G have inferior skills and observing benefits of being known in tight professional network for doing a key skill well (G) Observing G with excellent skills (recognised by professional title) and remunerated/supported for the range of their skills, working in sustainable models (enough clinical back up), plus benefits of being known in community for doing many things well. | |
NON-PROFESSIONAL | |||
Work-life balance and personal sustainability | (S–M) Mostly postgraduate, partner and older when completed medical school (S–F) Mostly postgraduate, have partner, planning/have children (G–M) Mostly postgraduate, partner and older when completed medical school (G–F) Mostly postgraduate, partner, planning/have children and/or other personal constraints | (S–M) Observing specialty options with controlled working hours and feasible to complete (length, difficulty) (S–F) Observing specialty options with controlled working hours and less job creep into personal life (G–M) Observing shorter times to access/complete training and flexible and part-time work options (G–F) Observing flexible and part-time work options | |
Suits desired economic and social position | (S) Medical school and reinforced over time, desire to gain or uphold social status and financial security relative to familial and social expectations, cost/effort of training and potential remuneration for the working hours involved (G) Medical school and reinforced over time, desire to uphold broader socio-cultural values including important non-professional roles | (S/G) Observe benefits of socio-economic position |
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O’Sullivan, B.; McGrail, M.; Gurney, T.; Martin, P. A Realist Evaluation of Theory about Triggers for Doctors Choosing a Generalist or Specialist Medical Career. Int. J. Environ. Res. Public Health 2020, 17, 8566. https://doi.org/10.3390/ijerph17228566
O’Sullivan B, McGrail M, Gurney T, Martin P. A Realist Evaluation of Theory about Triggers for Doctors Choosing a Generalist or Specialist Medical Career. International Journal of Environmental Research and Public Health. 2020; 17(22):8566. https://doi.org/10.3390/ijerph17228566
Chicago/Turabian StyleO’Sullivan, Belinda, Matthew McGrail, Tiana Gurney, and Priya Martin. 2020. "A Realist Evaluation of Theory about Triggers for Doctors Choosing a Generalist or Specialist Medical Career" International Journal of Environmental Research and Public Health 17, no. 22: 8566. https://doi.org/10.3390/ijerph17228566