Family Practice Vol. 16, No. 1, 18-22
© Oxford University Press 1999
Sources and implications of dissatisfaction among new GPs in the inner-city
United Medical and Dental Schools (UMDS), Department of General Practice, 80 Kennington Road, London SE11 6SP, UK.
Ashworth M and Armstrong D. Sources and implications of dissatisfaction among new GPs in the inner-city. Family Practice 1999; 16: 18–22
Received 3 March 1998; Accepted 7 October 1998.
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Abstract |
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Objectives. We aimed to examine the factors that were most stressful for new principals in inner-city general practice. In addition, given the concerns about retention of new principals, to ascertain whether high perceived stress translated into regret that they had joined their practice and factors that might protect from regret.
Methods. A questionnaire survey, within an inner-city Health Authority. The subjects were 101 GPs appointed as principals between 1992 and 1995.
Results. Eighty-three out of 101 GPs replied. The greatest sources of stress were, in order, patient expectations, fear of complaint, out-of-hours stress and fear of violence. Although these stresses were scored highly, 61% expressed no regret at having joined their practice with just 4% reporting considerable regret. Stress within the partnership and stress arising from patient expectations accounted for 23% of the variation in regret. Holders of the MRCGP were significantly protected against regret; there was no evidence that other factors such as medical positions outside the practice, membership of a young principals support group, fundholding status or training practices offered significant protection against regret.
Conclusion. Despite reported difficulties in recruiting new young principals to the inner-city—and despite their reported high levels of stress—few have regrets about their decision to join their practice. For those who did regret joining their practice, the three principal associations were partnership stress, patient expectations and not possessing the MRCGP. Each of these factors may be amenable to intervention by policies geared to improve GP retention.
Keywords. Dissatisfaction, inner-city practice, new GPs, stress in doctors, young principals..
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Introduction |
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Generation X, it is reported, has finally arrived into British general practice.1 Its arrival brings a new set of values to contrast with the traditional professional emphasis on duty, long-term commitment and authority. The values of the new intake into general practice are reportedly more closely aligned to personal needs such as flexible career paths, including options for part-time work, personal and professional development and something more than merely getting through nine surgeries a week.
Recruiting and retaining young principals with a Generation X outlook—particularly to the stresses of the inner-city—may be much harder than those with a commitment to traditional general practice values.2 In part, this is counterbalanced by a sense that inner-city practice might offer young principals more exciting primary care problems as well as a less traditional professional environment.
Discussing the problems of hospital doctors, Richards3 detailed a ‘long and unedifying’ list of stress factors and concluded that ‘it is not difficult to see why some doctors regret their career choice’. To gain a greater understanding of the stress experienced by new principals and whether this translated into regret that they had joined their practices, a survey was carried out of all GPs appointed by one health authority in inner-city London in the last 4 years. This area, in keeping with many inner-city areas, is characterized by high levels of social deprivation, a young and mobile population together with the problems of homelessness and an influx of refugees. These factors, in turn, place considerable demands on primary care, which also has to respond to the associated greater prevalence of teenage pregnancies, drug abuse, HIV-related illness and other illnesses frequently associated with poorer areas of inner cities. Recruitment had been difficult in this area, with 18 unfilled full-time vacancies at the time of the study, supporting the observation that recruitment is hardest in areas of greatest health need .4
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Methods |
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All 101 GPs appointed as principals between 1992 and 1995 in the inner-city London boroughs of Lambeth, Southwark and Lewisham (the area of the Health Authority) were sent a questionnaire. There are 426 GPs altogether in the area.
The questionnaire was developed following piloting on 20 of the 1991 intake onto the local medical list. It covered basic demographic data and descriptive data about the practice, previous professional experience and current professional activity outside the practice, together with a series of attitudinal questions based on Likert scales. The attitudinal questions asked the new principal to state whether they had any regret at joining their practice and to quantify this on a four-point scale ranging from ‘none at all’ to ‘yes, a bit’ to ‘yes, quite a lot’ to ‘yes, a lot’. This was followed by nine questions on factors that other studies have reported as being particularly stressful.5,6 For example, the question, ‘Is fear of complaint a source of stress to you?’, was scored on the same four-point Likert scale as above. Response rates were increased by follow-up questionnaires to non-responders and invitation to a locally organized conference for new principals.
Data from the questionnaires were coded, entered into a computer and analysed using SPSS for Windows. The relationship between a sense of regret and potential stressors in general practice was explored using multiple regression; personal and practice characteristics predictive of regret were analysed using logistic regression.
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Results |
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Eighty-three out of 101 (82.2%) new principals replied to the questionnaire. Characteristics of the responders and of their practices are summarized in Table 1
. There was no significant difference between the sex of responders and non-responders, although non-responders were older (mean age 38 and 47 years respectively, Mann–Whitney U 263.5, P < 0.001).
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Forty-nine GPs (61%) expressed no regrets at all about becoming a principal in this inner-city health authority and although some regrets were expressed by the other 39%, just three (3.8%) reported this to be a major problem, scoring 3 or 4 on the Likert scale. There was no relationship between age and regret (Spearman correlation coefficient: –0.003). The relationship of regret to other sources of stress and also to personal and professional characteristics of new principals is summarized in Tables 2 and 3
respectively. Reported regret was at a lower level on the Likert scale (mean 1.38) than that for any of the stress factors enquired about.
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In order to determine which of the potential stressors summarized in Table 2
best explained the variation in regret, all were entered into a backward-step multiple regression. Two variables, namely patient expectations and GP partnership stress, were the only two significant relationships and they accounted for 23% of the variation in regret.
Finally, to explore the relationship between expressions of regret and the personal and practice characteristics summarized in Table 3, a logistic regression was carried out using ‘no regret’ and ‘any regret’ as a dichotomized dependent variable. The odds ratios of the six factors entered into the calculation are presented in Table 4. After removing those variables that did not significantly predict regret, only one variable remained in the equation as protective against having regrets, namely possessing the MRCGP (odds ratio 2.09, confidence interval 1.19–3.67).
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Discussion |
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Almost a quarter of principals in this Inner London health authority had joined their practice only within the last four years, reflecting a spate of recent retirements and problems of GP retention in inner cities. Data from this survey painted a picture of these new GPs as having taken a fairly long break before entering practice (average 22 months) and joining a well-developed practice, almost all of which have practice nurses and managers and receive deprivation payments for their patients. Only a small minority of practices were fundholding or training practices. Already, 49% have a paid medical commitment outside the practice; only a third trained within the area and just half possess the MRCGP; not quite a third have the peer support of a young principals' group. However, this sample of GPs reported relatively few regrets about their decision to become a principal in an inner-city area, despite the obvious stressors which they reported.
Altogether, 17% of new principals did not respond to the survey. They were older than those who did not reply, but there were no sex differences between responders and non-responders. This bias in the study toward younger new principals would not have significantly affected the degree of regret, as there was no correlation between regret and age. Nevertheless, it is possible that non-responders would consist of some who were disillusioned with general practice and who would have reported higher levels of regret but who felt unable to participate in a questionnaire survey.
The highest stress scores were for patient expectations, fear of complaint, out-of-hours stress and fear of violence (Table 2). All of these appear to be responses to changes in society at large and may reflect the rising empowerment of patients, a shift in society toward consumerism, the ‘24-hour society’ and the decline in respect for those in positions of responsibility. These findings describing the impact of patient demands are in line with other studies,5 supporting the validity of our questionnaire (the low level of regret also endorses its validity, there being no reason why regret should have been under-reported in a questionnaire sent out by the health authority). New principals are left relatively unprepared by their training to take on the care of the patient as an informed citizen7 and this study highlights the need to adapt training policy to deliver primary care to a new breed of patients.
It requires considerable commitment to take on partnership in general practice—this is the beginning of a long-term relationship with existing partners and patients, often involving heavy financial commitments over many years. But having made this leap of commitment and endured the stress of the early years of partnership, there were few indications that new principals subsequently regretted the decision to join their practice. Reported stress was high but this did not in the main result in regrets about taking on the job. If there were doubts about the staying power of Generation X, this study should dispel the notion that the new intake of principals is unable to cope with stress and rapidly regret their decision to take on partnership. However, the participants were not directly asked whether they were thinking of leaving or considering alternatives, and the single question about regret may not be sufficient to allay anxieties about a retention crisis in inner-city general practice.8 Moreover, by its very nature, this study only provides information of attitudes among those in their first 4 years of practice. Although there was no increase in reported regret with duration of partnership (Table 3), it is possible that regret, and subsequent departures from partnership, are a later phenomenon occurring after the 4-year period observed here. The type of practice itself, large or small, fundholding or training, did not affect the expression of regret (Table 3).
Possession of the MRCGP qualification was a protective factor against subsequent regrets, those with the MRCGP being twice as likely to report that they had no regrets. In itself, the qualification may confer advantages in terms of self-esteem and competence, but it is also possible that the qualification simply indicates a certain type of GP who is more resilient to the problems of inner-city general practice. Holders of the MRCGP are known to be less likely to have complaints upheld against them and to cost defence societies less in litigation claims than do those who do not hold it.9 However, other GP characteristics that might have been expected to offer further professional support, such as outside work commitments or membership of a young principals' group10, did not affect the view of whether the right decision had been made. Using the investment that has arisen within the London Initiative Zone,11 the Health Authority where this study took place has targeted local GPs, offering to finance a 1-year educational programme geared to passing the MRCGP. With just under half of new principals possessing the MRCGP, it would require further study to determine whether boosting this proportion correspondingly increases the protection against regret and increases retention.
Most of the factors producing stress bore no relation to expressions of regret. However, the two variables that did predict regret (using multiple regression analysis) were stress from patient expectations and stress within the partnership. Patient expectations have already been incriminated as the single highest stressor for new principals (Table 2), but unlike most other reported stresses of their professional lives, this factor appears more likely to translate into regret, implying that it is particularly deeply felt and can make the new principal doubt their current appointment. It appears that a strong and supportive partnership protected against regret, perhaps by making the stress of life as a new principal bearable; but finding strife in a partnership rapidly led to disillusionment. The potential for developing partnership as a form of support and buttress against retention problems has not been well documented. Outside interventions to strengthen partnerships are in their infancy, but the importance of strong partnership is not doubted, with one review12 concluding that building healthy partnerships may require an increased role for management consultants in primary care to help with the organization and dynamics of partnership.
Ironically then, despite the reported concerns about a generation-X-style of GP principal, and despite the stresses that have been highlighted within inner-city practice, regrets amongst new principals were few and related more to the traditional values of good working relationships within their partnership and with their patients and the acquisition of a higher professional qualification.
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Acknowledgments |
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We would like to thank Rebecca Scott and Stephen Langford of Lambeth, Southwark and Lewisham health authority for their support of this work and Paul Seed, Department of Public Health, UMDS, London SE1 7EH, for statistical advice. This work was funded by the London Implementation Zone Educational Incentives programme.
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References |
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1 Vaughan C. Career choices for generation X. Br Med J 1995; 311: 525–526.
2 Wilson M, Ball J, Barnett R et al. (Task Group of General Medical Services Committee.) Medical Workforce. London: BMA, 1995.
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8 Review Body on Doctors' and Dentists' Remuneration. Twenty-fifth Report, 1996. London: HMSO, 1996.
9 Gray DP. Assessment at last. Br J Gen Pract 1993; 43: 402–403.[Medline]
10 Edwards PH, O'Toole OB, Pharoah C. Survey of young principal groups in the United Kingdom. J R Coll Gen Pract 1988; 38: 61–63.[Medline]
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Hayward J, Modell M. New incentives for GPs in London. Br Med J 1995; 311: 1314–1315.
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Handysides S. Building an efficient and healthy practice. Br Med J 1994; 308: 179–182.
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