Background:

Australia is facing a critical shortage of GPs, with an estimated shortfall of 11,000 GPs by 2032.1 Only 13% of junior doctors are now choosing General Practice as a specialty, leaving many training places unfilled. 30% of GPs are intending to retire within the next 5 years.2 There is some evidence that female GPs are reducing their clinical work and planning to retire at higher rates than their male colleagues. 3 If we are to retain their expertise and capacity in the workforce, we need to better understand the threats that are driving their decision making.

GP Wellbeing:

GPs report declining job satisfaction, unsustainable workloads and increasing financial stress. Complex regulatory changes and increasing administrative requirements are particularly damaging because GPs feel unable to meet the bureaucratic and regulatory requirements of a “good” doctor. In the UK, GPs have faced increasingly negative press, portrayed as “clinically incompetent and morally deficient”.5 “While journalists and columnists are portraying themselves as the patients' champion” writes one author, “they need to realise that these relentless attacks have a much deeper impact. They can demoralise GPs to the point that they dread going to work or hasten their decision to leave the profession.” 6

Fear of regulation is increasing. 2 GPs report high rates of moral distress, feeling unable to protect patients from harm in a healthcare system under increasing strain. 2 There has also been an increase in occupational violence, that disproportionately affect women GPs, leaving them feeling physically and psychologically unsafe. 4

Internationally, rates of burnout, depression and abuse continue to rise. A survey of 10 high income countries by the Commonwealth fund in 2022 shows over 50% of older physicians in most countries reported they would stop seeing patients within the next three years, leaving a primary care workforce made up of younger, more stressed, and burned-out GPs.

The RACGP in its annual survey of GPs concurs, suggesting over 70% of Australian GPs are burned out with only 40% now recommending their profession to junior doctors. 2

Gender In General Practice:

In Australia, female GPs have longer consultations, and a greater proportion of their work involves managing patients with mental illness and complex chronic disease. 7 Short consultations are incentivised in Medicare, which means women GPs are financially disadvantaged for doing increasingly complex care. Recent policy changes have worsened this divide. 8 GPs have one of the highest gender pay gaps in healthcare. Based on taxable income, the pay gap is currently around 40% which explains why female GPs cite financial stress as a major concern. 3,9

Mayson and Bardoel 10 in their qualitative study of female GPs outline the community expectations of women, and how this affects the work that they do. Healthcare is characterised as a caring profession, but “lady doctors” are assumed to care as a vocation, in which they have innate capacity and find personally fulfilling. They are seen as the best source of time and empathy. 10 Mayson & Bardoel describe female GP work as “slow, complex, and emotionally intensive medicine”. They describe seven key characteristics of female GP work.

-              Physically and emotionally demanding part-time work, with a “second shift” of physical and emotional labour at home.

-              Poorly remunerated and invisible labour, with gendered remuneration structures

-              Wanting to practice high quality, slower medicine

-              Trading off income for flexibility

-              Internalised and external assumptions from health professionals and community characterising female GPs as expert in particular forms of caring, including treating psychological trauma.

-              Pressure from patients to donate time and reduce fees

-              Portfolio careers, incorporating jobs with non-clinical or procedural elements with better pay

It is therefore understandable that women GPs have differing needs to their male colleagues, and their decision making around leaving the profession also differ.

Turning Points in GP Wellbeing

In Australia, there are several recent “turning points” that have had clear impacts on GP wellbeing. One was the decision not to consider GPs “frontline workers” in the COVID vaccination program, a government decision that highlighted for many GPs the sense that were not valued. 16 Regulation has also been seen as a serious threat to wellbeing. Doctors with mental health issues are particularly vulnerable, and describe serious failings in the regulatory process, worsening their health and in many cases, truncating their career even when they have no negative findings against them. 17  There are undoubtedly other important moments in recent years that have been critical to GP health and wellbeing.

Conclusion:

Female GPs constitute a particularly vulnerable workforce with multiple systemic barriers to sustaining a psychologically safe, financially viable and personally fulfilling career. With rising rates of mental illness and complex chronic disease in the community, the burden of care on women GPs is increasing exponentially. Sustaining this critical workforce will require a deeper understanding of their contemporary needs, and the threats to their wellbeing. There is clearly a need to "rehumanise" the system. 17-18  Women GPs who are retiring are critical informants in this endeavour.

Aims:

• To explore the reasons why Australian female GPs choose to retire from clinical General Practice

• To identify personal and professional threats to wellbeing that influence their decision to retire

• To explore the perceptions of Australian female GPs on potential interventions to address wellbeing and workforce retention

Methodology:

This study uses a narrative approach, examining turning points in the narratives of female GPs associated with their decision to retire from clinical practice. Narrative approaches draw attention to how people create meaning out of their experiences. 11 It is a dynamic process, where meanings are made known to self (reflexivity) and others (reflection). 12 Narrative method is a constructive activity, where partial and incomplete components are woven into a story that has meaning at a particular point in time. 13 These meanings are co-constructed with the researchers and form the basis for understanding what is important in a particular context. 14 We are grounding our methodology in critical theory, deliberately foregrounding intersectional disprivilege and hidden narratives. We are taking a constructivist position, co-creating shared understanding with our participants, and deliberately seeking out difference to enrich our findings. 15

Wellbeing measures: 

Wellbeing is a complex construct with multiple perspectives. We have chosen to use a typology of wellbeing summarised in the following table. This typology represents a synthesis of common themes from 99 wellbeing measures, and allows us to construct a framework for early analysis.  11

Recruitment

 The study will recruit female GPs who expect to either retire or reduce their General Practice workload by at least 50% in the next five years, or female GPs who already have retired or reduced their General Practice workload by at least 50% in the past five years.

We will recruit a diverse sample of participants from a variety of geographical and professional contexts through professional networks, newsletters and social media for the survey. At the conclusion of the survey, participants will be asked if they consent to participate in an interview. We will then use a theoretical sampling technique to choose a maximum variation sampling for interview.

Methods:

Participants will be asked to complete a survey (appendix 1) which focuses on four key questions:

1.         What influenced you to choose General Practice as a career?

2.         What sustained you during your GP career?

3.         What influenced your decision to retire?

4.         What (if anything) would influence you to consider returning to General Practice?

These four questions will be explored in semi-structured interviews. We are aiming to interview at least 15 participants, although we will continue interviews until we reach theoretical saturation. Interview participants will be able to contribute written submissions if they wish to, and these will supplement the interview data. 

The survey includes questions that explore the changes to GP wellbeing and how this has influenced career work decisions. Participants will then be offered a semi-structured interview which will explore their decision-making and identify the critical “turning points” in their thinking. “Turning points” have been extensively used in the study of professional identity formation. In this case, they are being used to explore shifts away from their professional identities. After analysis of the written and interview data, Dr Erin Walsh will create storyboards to represent their decision making.

We are using qualitative narrative methodology for analysis. We will be looking for individual, professional, political and cumulative turning points that involve wellbeing, and cause changes in a GP’s perspective on their career and their personal and professional identity.

Likely outcomes and benefits:

GPs invest considerable personal resources into their careers. Being a GP is a large part of their identity. Workload reduction and/or retirement is not an easy decision. By analysing key turning points in the narratives of women GPs we can identify wellbeing threats to this group and begin to craft potential interventions to retain this critical workforce.

Dissemination and research translation

We have decided that alongside more traditional dissemination strategies, such as conference presentations and publications in an appropriate journal, we will also be using three less common strategies for research translation.

1.         Dr Erin Walsh will be synthesising our qualitative findings into storyboards, demonstrating common narrative elements that characterise GP decision making.

2.         We are planning to use these storyboards to ground our analysis, but also to develop communications for policy makers involved in workforce planning and policy

3.         We will be also be writing for a more general audience.

Merit and integrity

We believe that the study design matches the research focus, and that the research is achievable within the given timeframe. We are confident that this is an under-researched  area of practice, and therefore will contribute meaningfully to professional discourse.

Autonomy and respect

We need to ensure participants have clear communication around the study, and the way in which their data will be used so they are able to freely consent, not consent or withdraw. Granting them the right to choose their interviewer may assist with this, as they will be able to remain anonymous. Sharing the visual representation of their decision making involves them in decisions around how their data is interpreted and used.

Beneficence/non-maleficence

We will carefully manage risk using macro-ethical strategies (including details of support organisations on our research documentation) and micro-ethical strategies (pausing or ceasing the interviews if participants become distressed). We believe that the telling of stories and synthesising narratives is a positive benefit for most people, and provided they are informed of the risks and likely benefits, they are capable of making an informed decision about the personal benefit-risk balance.

Justice

This study focusses on women GPs, a group whose voices are less obvious in senior policy environments. They experience significant policy misogyny, with very high gender pay gaps, and are leaving in greater numbers than their male colleagues. Apart from getting their voices into the discourse, it is also important that we adopt a theoretical sampling strategy, recruiting for maximum diversity so that intersectional disprivilege is recognised and represented. We will be seeking out participants from the International Medical Graduate, Aboriginal and Torres Strait Islander and LGBTIQA+ communities.

None of the researchers have a significant conflict of interest.

Financial support:

This project has received a $40 000 RACGP Wellbeing grant.

References

1.                          Cornerstone Health Pty Ltd. General Practitioner Workforce in Australia.  2022.

2.              Royal Australian College of General Practitioners. Health of the Nation.  accessed 15 April 24. 2023.

3.              Australian Government Department of Health and Aged Care. National Health Workforce Dataset, https://hwd.health.gov.au/resources/information/nhwds.html (2024, accessed 28/4/2024 2024).

4.              Olsson C, Toropova A, Jensen I and Björklund C. Sexual harassment, bullying, burnout and organisational support during the COVID-19 pandemic in Swedish medical faculty – a survey study. Studies in Higher Education: 1-13. DOI: 10.1080/03075079.2024.2340055.

5.              Barry E and Greenhalgh T. General practice in UK newspapers: an empirical analysis of over 400 articles. British journal of general practice 2019; 69: e146-e153.

6.              Martin M. Media attacks on GPs threaten the doctor-patient relationship. BMJ 2021; 374: n2236. DOI: 10.1136/bmj.n2236.

7.              Britt H, Bhasale A, Miles DA, et al. The sex of the general practitioner: a comparison of characteristics, patients, and medical conditions managed. Medical care 1996; 34: 403-415.

8.              Australian Government Department of Health and Aged Care. MBS Online, https://www.mbsonline.gov.au/ (2024, accessed 28/4/2024 2024).

9.              Australian Tax Office. Individuals statistics, Australian Government (2024).

10.           Mayson S and Bardoel A. Sustaining a career in general practice: Embodied work, inequality regimes, and turnover intentions of women working in general practice. Gender, Work & Organization 2021; 28: 1133-1151.

11.           Linton M-J, Dieppe P and Medina-Lara A. Review of 99 self-report measures for assessing well-being in adults: exploring dimensions of well-being and developments over time. BMJ open 2016; 6: e010641.

12.           Lincoln YS and Denzin NK. Turning points in qualitative research: Tying knots in a handkerchief. Rowman Altamira, 2003.

13.           Clandinin DJ and Connelly FM. Narrative inquiry: Experience and story in qualitative research. John Wiley & Sons, 2004.

14.           Morrison C, Willis J, Crosswell L and Gibson A. Turning points in narratives of research design: Research innovation stimulating unique responses to existing challenges for beginning rural teachers. Journal of Educational Enquiry 2014; 13: 3-17.

15.           Cole ER and Stewart AJ. Narratives and numbers: Feminist multiple methods research. Handbook of feminist research: Theory and praxis 2012: 368-387.

16.           Diana N, Nick G, Christiane K, et al. Determinants of well-being and their interconnections in Australian general practitioners: a qualitative study. BMJ Open 2022; 12: e058616. DOI: 10.1136/bmjopen-2021-058616.

17.           Bradfield OM, Spittal MJ and Bismark MM. “I’m Really Glad that You’re Doing this Research”. Qualitative Research Involving Doctors With Lived Experience of Mental Health or Substance Use Challenges in Australia and Aotearoa New Zealand. International Journal of Qualitative Methods 2023; 22: 16094069231182874. DOI: 10.1177/16094069231182874.

18. Lancet T. Physician burnout: the need to rehumanise health systems. 2019, p. 1591.