Many countries are training more doctors than ever before, but a major goal is achieving enough generalists working in fields like general practice (GP) and public health compared with narrow specialty fields [1
]. Achieving a critical mass of generalists is important as they support delivery of integrated, preventative and primary care services across a wide range of community needs, at lower cost, for increased life expectancy [2
]. Although preventive and primary care services are universally needed, many countries are facing declining general practice numbers [6
]. Current trends are producing an overabundance of non-GP specialists who focus on targeted populations or body systems, potentially increasing the geographic centralisation (city practitioners), fragmentation and inefficiencies of healthcare. A more generalist workforce could be realised if the levers underpinning the choice to become a generalist or specialist doctor, were better understood.
The existing evidence of specialty choice is limited to countries where there are strong markets for specialist services, including Australia, the United Kingdom (UK), the United States of America (USA), Canada, Germany and Japan. Some is based on medical student intentions [8
], somewhat unreliable for informing actual choice. Other material explores preferences of junior (pre-registrar) doctors [15
] or trainees (registrars/residents enrolled in postgraduate vocational training) along with qualified fellows (generalist/specialist) [22
]. However, this evidence is largely analysed by influential factors, not specifically about how these factors are activated (including for whom and when various choices might fire), which would better inform the design of interventions to produce generalists, across the long medical training pathway.
The literature highlights that choosing a specialty is a complex process with a number of identified correlates. One national survey of trainees suggested choice of a particular specialty was stimulated by intrinsic
—appraisal of skills against specialty; intellectual content; interest in helping people; and extrinsic
factors—work culture; flexible working hours and; hours of work [26
]. Compared with other specialties, general practice trainees showed a higher regard for helping people and fitting their work to domestic circumstances [26
]. General practice is also attractive because of lifestyle, continuity of care, procedural skills and work opportunities [15
]. Primary care role models and experiences may facilitate uptake of general practice [15
], although scant studies suggest general practice may have lower professional status compared with focused specialties [15
]. Higher professional status is attributed to specialty fields like surgery that give a clear professional identity and tight network of inherent socio-economic capital [28
Particular specialties may also be attractive to young and emerging doctors because of their pro-social attributes, like teamwork and caring, which reinforce expected values, norms and cultures [28
]. Equally technical attributes may be a drawcard. Cardiology [25
], surgery, obstetrics and gynaecology, ophthalmology, anaesthesia and emergency medicine, were attractive because of technical skills and procedural work [26
Financial reward and medical student debt may also affect the choice to be a generalist or specialist, though the evidence is mixed. A review suggested higher medical student debt may lead to pursuing higher paying specialties in countries like the USA [29
], although other USA [29
] and Australian research [32
] contradicts this.
Demographics may equally overlay choice patterns. Females show differentiated considerations of work-life balance and part-time work options when choosing specialties [11
]. Females are widely demonstrated to be more likely to work in general practice, which has more flexible work options [33
]. Males of older age at medical school graduation may also choose general practice to fit with the rest of their lives [32
]. Apart from gender, other factors may ‘prime the pump’ for choosing to be a generalist or specialist, such as ethnic, family and community background as well as personal experiences, but these are under-researched.
There is minimal research specifically dichotomised to generalist or specialist choice, which accounts for the temporal dimensions impacting choice-making. Only one longitudinal study in the UK suggests general practice interest may increase over time following graduation (18% to 33%), 81% noting this related to achieving particular work conditions and 44% to fit domestic circumstances [33
]. Otherwise, the decision-making process regardless of specialty is known to be multi-staged [20
] and emergent [22
In summary, complex dynamic patterns are likely to underpin specialty choices but there is minimal theory about how the choice to be a generalist or specialist doctor occurs which accounts for doctor’s characteristics and their experiences over time. We aimed to develop theory about what works for whom, when and in what contexts, to yield choice to become a generalist or specialist doctor.
This is the first known study to develop theory about choosing a generalist or specialist medical career. The decision-making patterns revolved around eight mechanisms of environmental, professional and non-professional domains. These may contribute in proximal, intermediate and final ways [35
], to achieving a generalist or specialist doctor, depending on the doctor’s characteristics including their attributes, values and desires and how these intersect with their exposures over time.
The final theory reinforces, with some degree of nuance, elements of the original hypothesis about how choice is made, through the theory of reciprocal determinism. This includes depicting that personal cognitive, social/environmental components and conditioning plays a strong role in generalist or specialist choice [38
]. Various CMO configurations have the potential to work in synchrony and nudge towards a tipping point of choice to be a generalist or specialist doctor, particularly where these may intersect and build momentum over time. No one CMO configuration within the theory is considered causal, but together these configurations contribute to the emergence of generalist or specialist choice.
Some triggers were stronger for some doctors than others. But our findings provide an understanding of a full range of ways that choice-making can be affected. This includes the context of the doctor and timing by which choice is triggered, whereby our findings have the potential to holistically inform education, training and workforce strategies for better uptake of generalist doctors and the distribution of rural doctors [7
Although we present this theory as driving the outcome (positive direction), it can also produce negative outcomes, if patterns of generalist decision-making are suppressed, or insufficient triggers are mounted. Thus, the theory may have greatest utility if used to design holistic policies and programs that promote multiple pro-generalist decision patterns and dampen many of the pro-specialist ones.
Our initial theory was strengthened by drawing on empirical evidence from recent graduates (all of whom at chosen specialty) across a spread of specialties, genders and locations. By then gaining further input from experts spanning different medical schools, career stages and disciplines, enabled the findings and perspectives of individuals to be refined and expanded, supporting greater generalisability of the final theory. This builds on existing research showing specialty choice is multi-level [26
] and multi-staged [20
], by uniquely depicting the timing of various program, social-economic and cultural normative influences on driving to a generalist or specialist outcome.
The findings identify that exposures for choosing a generalist career such as connecting ‘to a community
’ and ‘role models
’, may require recurrent investment (including in medical program design) and be strong and frequent enough to override stimuli leading to specialist choice. This includes reducing the potential that some pro-specialist triggers could fire including doctors being converted by ‘key focused clinical experiences
’ with specialist departments in hospitals. Other research shows the value of community general practice placements for pre-registrar doctors during internship (additional knowledge and skills) [58
]. Planned and regular rotations to non-hospital settings, including in rural areas, with exemplary skilled generalists, who showcase innovative practice, ‘problem-solving
’ and procedural aspects of their work have the potential to stimulate generalist career interest. Students and junior doctors may also be inspired if they observe the status of generalist doctors in the community, respected for their confidence and competence in a range of situations. This needs to be powerful enough to override potential professional derision of generalists by specialists who are seeking to maintain professional power and market control [15
Our findings also depict that choosing to be a generalist also relies on getting ‘enough experience
’ of different forms of clinical medicine to ‘rule things in
’. This differs from the perception that generalist doctors take this path because they aren’t sure about what to do (path of least resistance). On the contrary, generalists are likely to choose this deliberately ‘ruling in
’ a package of skills areas that form a complementary clinical practice model that is remunerated, recognised, sustainable and allows them to focus on upstream health improvement [59
]. Conceptualising viable generalist practice models may take longer for junior doctors than understanding work in more homogenous areas like hospital specialist fields that have a clear professional identity. This may underpin the need for a longer pathway and more deliberate exposure to potential models in areas of interest, to stimulate a generalist choice.
Several elements of theory relate to contemporary challenges. In many countries, more doctors are emerging from postgraduate medical degrees, having incurred more time and cost to achieve two degrees to qualify as a doctor than those from undergraduate systems. Our theory might suggest that older graduates may be more likely to drive towards choosing particular specialty fields or generalist practice, based on two factors: interest in a rapid transition to independent practice (shorter training times and relative ease of training) and to manage work-life balance (leisure, children or other constraints like illness). The tipping point for this group to nominate to a specialty field is that some of these fields enable controlled hours (noted from our research, as psychiatry, anaesthetics and oncology). For this reason, a generalist choice cannot rely on controlled working hours and flexible conditions alone to attract doctors. Instead it requires multi-level strategies including emphasising the gains of organised training pathways to rapid independent practice and promoting of the gains for choosing a generalist career, such as community recognition for ‘doing many things well’. This could be strongly promoted as part of messaging within national campaigns.
Although specialists may claim legitimacy based on their lengthy professional training, expert status and certainty in one area, it may be important to counter this with evidence of generalist competence [48
], trust and credibility [60
] and the reward generalists may experience from contributing to social (not just professional) goals. This may be important for breaking down the assumed professional hierarchies and levels of reward enabled in specialist roles [28
]. Further a structural issue to address, is reducing the gap in earnings between specialists and generalists [52
As hours of medical work are trending down (average fall of 3.4 h per week 1999–2009 in Australia) [61
], advertising generalist work through access to shorter training time frames, flexible and part-time work tailored to trainee needs (including gender-specific flexibility and maternity leave) and sustainable practice models (minimising burnout) continues to be relevant. This issue is increasingly pressing as females (wanting to build careers around children) are making up the bulk of emerging medical school graduates in many countries [62
Finally, our findings also suggest that generalists may be achieved by enrolling more students into medicine who have wider values and social interests based on family, culture and community, as the basis of their identity (status), over would-be-doctors motivated by professional identity and socio-economic gain [28
]. Given that values and expectations are established within a socio-cultural context of family, ethnicity, religion and community, it may be relevant to consider these as important covariates that can affect generalist workforce outcomes.
Our study has limitations. Although we used a 2-phase process to build and refine our theory, it is possible that some elements of theory were missed. This is unlikely given that the cross-university cross-career stage experts in phase 2 largely supported the phase 1 theory, expanding only to two new patterns of decision-making that were cross-validated. Relying on phase 1 interviews across a broad single university early career cohort means there is some potential for sample and recall bias. However, participants were working independently of the university when interviewed and easily recalled their career choice process, whether generalist or specialist and, being blinded to the research question, provided genuine reflections.
The theory we propose is based on medicine in Australia and needs to be refined and validated for other disciplines, countries or career stages. This is particularly because in some countries like America and Canada, the timing of generalist or specialist career choice may occur earlier as part of filling particular pre-set generalist or specialist programs in medical schools that articulate with resident programs, which does not occur in Australia.
In our theory socio-cultural and familial influences mostly featured in relation to affecting pre-set personality, norms and skill as well as the desire for social and economic position relative to other values, but their role and timing of socio-cultural and familial influences may vary in different training sub-systems, countries and cultures. As it was based on a dichotomous outcome, out theory may also require further differentiation for choosing specific specialties and sub-specialties of medical work, including exploring whether this theory applies to further differentiating choice to be a more general (e.g., general surgeon, or more focused sub-specialist e.g., paediatric cardiologist.