Interventions to attract medical students to a career in primary health care services in the European Union and peripheral countries: a scoping review

Abstract

Background

In the European Union and peripheral countries, the availability of physicians working in primary health care services (PHCS) varies greatly and all countries report shortages and difficulties in recruiting more. The broad consensus that giving access to PHCS to all is a policy priority, reinforced by the lessons learned during the COVID-19 pandemic, implies that a sufficient fit-for-purpose workforce is available. This article focuses on physicians and reports on what countries have done, and with what success, to attract more medical students to a career in PHCS.

Methods

We conducted a scoping review of articles in PubMed and Cochrane Library, and of grey literature in websites of international agencies, think-tanks, international non-governmental organizations, and European Commission-funded projects, published between January 2018 and February 2024.

Results

The search retrieved 1,143 records, of which 45 were eligible for the scoping review; 25 focused on medical students. The documents report interventions in 12 countries, 14 by individual education institutions, mostly in the form of exposure of diverse duration to general/family practice in the medical curriculum (specific modules, residencies, rotations, placements, mentorship), and 11 policy interventions at national level, such as increases in the number of training places for primary health care (PHC) specialties and improvement of working conditions.

Conclusion

Accessible PHCS require the availability of a fit-for-purpose workforce of multiprofessional teams, in which specially trained physicians play a central role. To address shortages, many countries increased training opportunities, a necessary step, but not sufficient. More students must accept to opt for a PHC specialty, in a context of competition with other fields of practice also in need of more students, such as public health, geriatrics, or mental health. Success requires the collaboration of numerous actors, including professional councils and organizations, and regulation bodies that specialists tend to dominate. By making PHCS a political and policy priority, decision-makers can help make attraction more effective, but to do so, they need access to convincing evidence and information on good practices that only research can produce.

Introduction

Ever since the International Conference on Primary Health Care in Alma-Ata (1978) issued a Declaration calling for “urgent and effective national and international action to develop and implement primary health care” [1], countries of the world have struggled to recruit enough health workers to respond to this objective. European Union (EU) and peripheral countries (European Free Trade Association—EFTA members, United Kingdom—UK and EU candidate countries) are no exception; all report a persistent insufficient supply of personnel available to work in primary health care services (PHCS). In many countries, the density of family doctors/general practitioners (GPs) has diminished relatively to populations and to specialists in the last 25 years.

In October 2018, participants at the “Global Conference on Primary Health Care: from Alma-Ata towards universal health coverage and the Sustainable Development Goals” [2] agreed that “the time is now to invest in building and training a sustainable and multidisciplinary primary health care team”. In Europe, the proportion of GPs and family physicians in the medical profession varies considerably and generally remains low, in spite of most countries having increased their total production of physicians [3]; all countries report shortages and difficulties in recruiting and retaining staff in PHCS, and therefore specific targeted interventions are needed to scale-up the PHC medical workforce. The proportion of GPs or family doctors respective to specialists and to population diminished in spite of efforts to increase the number of training slots. For example, in Bulgaria, the proportion of generalists was 13.4% of all physicians in 2021, well below the EU average of 22%, down from 16.5% in 2011 [4]. In Malta, it was 24.3% in 2012, and 19.5% in 2021 [5], and in Spain, it was lower in 2021 than in 2018 (21% vs 22%) [6]. In France, the density of GPs of 1.5 per 1,000 population in 2012 was 1.4 in 2021 [7]. In most countries, available positions in PHCS remain unfilled, with the consequence that access to a GP or to a family physician is limited, like in Portugal, where 16% of the population do not have such access even though they are entitled to it [8].

There are four ways to bring more physicians, nurses and other professionals to work in PHCS: (1) attracting and training more new entrants in the profession; (2) retaining active practitioners for the full duration of a normal career, including by facilitating the return to work after a career break, for family, health or other reasons; (3) retraining specialists—for example, those who change their career path as they come close to retirement—and, (4) international recruitment. This article addresses the necessary conditions of the success of the first strategy, focusing on the attraction of medical students to general or family practice. Here, attraction refers to the process and actions to bring students to choose primary health care (PHC) as a career path.

To cope with shortages, some countries, typically the high-income ones, rely on international recruitment: for instance, the number of foreign-trained medical doctors entering the medical register in Ireland, Norway and Switzerland in 2019 was greater than that of domestic graduates, though not all work in PHCS [3].

There is no dearth of recommendations by health professional associations, international agencies (World Health Organization—WHO, World Bank, Organisation for Economic Co-operation and Development—OECD), as well as by practitioners and researchers on how to make work in PHCS more attractive, as is documented in a European Observatory on Health Systems and Policies on “How to increase the attractiveness of primary care for medical students and primary care physicians” [9]. This Brief surveyed the peer-reviewed literature on the topic up to 2018. Since then, the COVID-19 pandemic has highlighted the weaknesses of PHCS as a first line of defence against a health shock, in part due to shortages of personnel, an issue that acquired more visibility on the political and the policy agendas, at least temporarily. Adding to pre-existing shortages, during the pandemic, there was an excess mortality and morbidity of doctors and other front-line health and care workers, and many decided to leave clinical work, even the health labour market altogether. It is therefore worth looking more closely at what countries have done, and with what success, to attract more medical students to the choice of PHCS as their area of work.

This justified that we conducted a scoping review of the literature since 2018, asking what interventions did countries implement to attract medical students to choose to train for work in PHCS and what has been their effectiveness. This article presents the results of that review that focuses on the attraction of medical students.

Methods

We performed the scoping review in accordance with the methodological recommendations of Arksey and O’Malley [10] that include: (1) the identification of the research question(s); (2) the identification of potentially relevant documents; (3) the selection of documents for analysis; (4) data charting; and (5) summary and report of the results.

Research questions

The original review addressed two complementary questions: (1) What interventions have countries implemented to attract medical and nursing students, and practising doctors and nurses to studies and a career in PHCS? (2) What has been the effectiveness of these interventions? The protocol is available at https://osf.io/ba3fk. For the purpose of this article, the first question is reduced to “What interventions have countries implemented to attract medical students to studies and a career in PHCS?”.

Identification of relevant studies

We used the PICo (Participant, Intervention/Phenomenon of Interest, Context) search tool [11] (Additional file 1) to structure the review.

Information sources

The electronic databases and websites searched included: PubMed, Cochrane Library, international agencies and organizations, think-tanks and International non-governmental organizations, and European funded projects websites. Box 1 includes the list of information sources searched in the original review. We also did reverse citation searches of the key documents identified and publications included in the final assessment phase.

Box 1. sources searched: reference bases, websites

• Electronic databases: PubMed and Cochrane Library.

• International organizations: World Health Organization (Headquarters and Regional Office for Europe), European Commission, European Observatory on Health Systems and Policies, Organisation for Economic Co-operation and Development and World Bank.

• Think-tanks and International non-governmental organizations: The Training for Health Equity Network (THEnet), Health Foundation, Nuffield Trust and King’s Fund.

• European professional associations/organizations: WONCA Europe, European Nursing Council, European Federation of Nurses Associations, European Board for Accreditation of Continuing Education for Health Professionals, European Council of Medical Orders, Association for Medical Education in Europe, European Forum of National Nursing and Midwifery Associations, European Specialist Nurses Organisation, European Health Management Association, European Medical Students’ Association, Union of General Practitioners, European Federation of Nurse Educators, Union of General Practitioners, European Federation of Salaried Doctors, European Federation of Internal Medicine and European Junior Doctors.

• European funded projects: AHEAD (Action for Health and Equity: Addressing medical Deserts), OASES (Promoting evidence-based reforms on medical deserts), Route-HW (A Roadmap OUT of mEdical deserts into supportive Health WorkForce initiatives and policies) and TASHI (Empowering EU health policies on Task SHIfting).

Search

The search strategy covered peer-reviewed articles and technical and political documents published between January 2018 and February 2024 in English, French, Italian, Portuguese, and Spanish. Most search terms were according to the controlled health vocabulary MeSH (Medical Subject Headings). We included relevant words not captured in the keyword search as free terms. The search strategy conducted from 4th January to 13th February 2024 is described in Additional file 2.

Document selection

Selection of sources of evidence and Eligibility criteria

The EndNote [12] software served to collect, organize and manage references retrieved from searches and remove duplicates. Data eligibility was established using Rayyan [13]. One reviewer carried out the literature search in the databases, and two reviewers did the search of the websites. They then applied eligibility and exclusion criteria (Table 1) to the abstracts. When eligibility criteria were met, two reviewers did a full-text analysis of the selected documents; these resolved any discrepancies through consensus. Figure 1 describes the inclusion process as recommended by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [14].

Table 1 Eligibility criteria

Fig. 1

PRISMA flow diagram

Data charting process

Selected documents were randomly divided among two reviewers for data extraction, Reviewers used an Excel spreadsheet adapted from the data extraction instrument from the Joanna Briggs Institute (JBI) Manual of Evidence Syntheses [15].

Data items

The following data items were extracted: bibliographic information (author, title, year), study design, professional category and sample size if applicable, country, interventions (type and information such as level, location, sector and actors involved) and results, according to the data extraction instrument (Additional file 3).

Synthesis of results

We presented the results in a narrative way, and summarize the characteristics of the included documents using descriptive statistics. We grouped the findings in each specific intervention domain of the intervention and outcome. For each outcome, we summarized the type of study and method in selected studies, the context of the intervention, and the results. We also discussed the body of evidence for each intervention domain, the type of intervention, and the outcome.

Results

Selection of sources of evidence

The initial search identified 1,143 records, of which 45 were eligible for the scoping review; 25 focused on medical students (excluded records are available in Additional file 4). Figure 1 summarizes the results in line with the PRISMA-ScR reporting tool [16].

Documents included in the review

Characteristics of sources of evidence

The characteristics of the included sources of evidence are reported in Table 2. Of the 25 documents reviewed in this article, 14 are articles and 11 are technical and policy documents, all written in English. Eight articles present qualitative studies based on interviews, questionnaires and focus group, and four are cross-sectional studies. The documents report four interventions in Germany, three each in England, Estonia, France and Ireland, two each in Scotland and Switzerland and one each in Belgium, Greece, Italy, Slovakia and Türkiye. Interventions identified fall in two groups: by individual education institutions (N = 14) and policy interventions at national level (N = 11). These targeted undergraduate (N = 11) and postgraduate (N = 14) medical students. In 16 documents, the results of the intervention are available.

Table 2 Documents included in the review

Table 2. Documents included in the review.

Results of individual sources of evidence

Interventions by individual education institutions

There have been education interventions in six countries, reported in 14 documents. Interventions at undergraduate level in Germany include introducing an extracurricular longitudinal teaching project, called ‘Leipziger Kompetenzpfad Allgemeinmedizin’ (‘Leipzig Competency Pathway for General Practice’—LeiKA), that provides mentoring and networking [25], and the inclusion of a workshop on physicians’ earning opportunities, workload and job satisfaction as part of a mandatory general practice clerkship [26]. Other interventions are the creation of a longitudinal integrated clerkship (18 weeks) in an Irish university [28], and, in England, a near-peer teaching model (senior learners mentoring more junior learners) [38] and doubling to 4 weeks of exposure to general practice (with 4 weeks module for 4th-year medical students at Nottingham University) [40].

In England, interventions at regional level consisted of exposure to general practice in the first year of the two-year Foundation Programme that follows undergraduate medical studies [39]. In the Canton of Bern, in Switzerland, there are new postgraduate curricula and longitudinal internships, supported by a ten-year state-funded vocational training programme [36]. At national level, the state has invested, since 2000, in Institutes for PHC that introduced various curriculum changes to attract more students to PHC, including an expanded GP training module (Praxis Assistenz) that places trainees in GP offices for 6–12 months [35]. In France, postgraduate general practice residents alternate clinical training in hospitals and in PHC settings, in principle, under the supervision of a GP trainer (Maître de stage). However, not all settings have staff trained to provide that supervision [21].

As regards results of these interventions, the German LeiKA and the workshops on general practice initiatives have had a positive influence on students’ views of working as a GP, but no discernable impact on choosing a career in PHCS [25, 26]. In England, increased exposure to general practice with innovative, paired, career tutorials and exposure in the first year of the two-year Foundation Programme augmented the likelihood of considering a career as a GP [38,39,40]. In Switzerland, longer, part-time internships and training modules on general practice were associated with higher rates of choosing a career in PHCS [35, 36]. In France, a study of the density of GPs in all the country’s municipalities showed that, for the years 2018–2021, it had augmented by 1.36% where postgraduate students had done their residency in general practice under supervision [21].

Some documents reported interventions that had the objective to attract students to practise in underserved areas, such as rural, remote, poor urban or with marginalized populations. Even if it was not explicit, these would principally target future GPs or family physicians. The Martin Luther University Halle-Wittenberg and the University of Leipzig introduced the MiLaMed [23] (“Central German Concept for the Longitudinal Integration of Rural Medical Training Content and Experience in Medical Studies”, [https://www.milamed.de]) that includes adding “rural” content in the compulsory and elective parts of the curriculum, supplementary online teaching and support during rural placements in four target regions. Also, a study describes how students in three German medical faculties—Erlangen, Würzburg and Regensburg—undergo a practical year in a rural general practice before choosing a specialty [24]. In Scotland, in 2016, the University of Dundee School of Medicine piloted a 40-week Longitudinal and Comprehensive Integrated Internship for Year 4 students in rural areas [32]. Moreover, in Scotland, a “Targeted Enhanced Recruitment Scheme”, offered a financial incentive (£20,000) to GP trainees accepting a targeted post, typically in a rural area or an urban one with a history of difficulty of recruitment [33]. In Ireland, the North Dublin City General Practitioner Training Programme (NDCGP) is designed to train future GPs to work in areas of deprivation and with marginalized groups [27]. The NDCGP was the most successful, as almost all participants eventually chose to pursue a career as a GP in an underserved area [27]. German MiLaMed [23] and the Scottish Long Comprehensive Longitudinal Integrated Clerkship [32] had a positive effect on intentions to continue training in general practice [23] and reporting of positive feelings about eventually working in PHCS [32]. Scotland’s financial incentive scheme had a low impact on the choice of a targeted posting [33]. The North Dublin specific training programme was more successful as almost all participants eventually chose to pursue a career as a GP in an underserved area [27].

National policy interventions

There have been policy interventions in eight countries, reported in 11 documents. The most common policy intervention is increasing the number of places for residencies in general practice or family medicine, as occurred in Belgium, Estonia, France, Ireland, and Italy [17, 18, 20, 22, 29, 30]. France also increased the period of general practice residency by one additional year of postgraduate training in ambulatory care settings, preferably in underserved areas) [22]. In 2020, Estonia implemented a national reform of medical specialty training to make it more flexible and to offer part-time options [19]. This is expected to augment the number of GPs, though not at a sufficient level to meet the projected [18, 20].

Slovakia created a residency programme for GPs including training in outpatient facilities during undergraduate medical studies [34]. Türkiye used a mix of interventions to increase enrolment in medical schools in general and in postgraduate family medicine programmes in particular. It also re-trained PHC doctors to recertify as family doctors [37]. Greece has introduced a new compensation system to attract more physicians to PHC. In education, innovations include the offer of a family medicine module in the basic curriculum, now available in 75% of universities and a pilot programme of training periods in general practice to help undergraduate students make “informed decisions” about their choice of a specialty [31]. Only the combination of interventions in Türkiye showed results with an increase in the number of family physicians [37]. Increases in the number of residency places implemented in Belgium, Italy, Ireland and France [17, 22, 29, 30], are too recent to show results.

Discussion

Summary of evidence

In spite of the abundant advocacy in favour of increasing the PHC workforce, out of the 45 countries listed in the selection criteria, only 12 report interventions. There are probably more who have intervened, but their interventions are not documented in the peer-reviewed literature or otherwise. The most frequent interventions are the initiative of individual or groups of education institutions, with no explicit link with a national health workforce policy. The latter are typical to increase the number of places in general or family practice programmes, with a view to attract more graduates to underserved areas, like rural, remote or poor urban ones. Such measure does not mechanically augment the number of students; indeed, it is common that some places remain vacant, like in Portugal [41] (585 vacant places out of 978 in 2023) and in Spain [42] (224 vacancies in 2022–2023), hence the need for additional measures of attraction. Many countries added modalities of increased exposure to work in PHCS, such as new modules in the curriculum, extended periods of residency, rotations or clerkships in PHC settings and access to mentorship. The results of a number of these interventions are not available, due to their recent implementation.

The post-2018 literature does not present major differences from the literature of previous years reviewed by Kroezen, Rajan and Richardson [9]. The volume of interventions is similarly low and there are few examples of countries using a mix of interventions, rather than single ones. There were changes to the traditional medical curriculum (more compulsory and elective primary healthcare contents, longer clerkships), but also rural doctor quota (“Landarztquote” introduced in Germany's federal states) [43], the creation of “interest groups” offering activities such as readings by family physicians, newsletters and conferences [44], and student-run free clinics, three interventions not mentioned in our review.

In our search for literature, we found a number of articles on factors or reasons that influence medical students to choose (or not) PHCS as an area of future practice. This literature is important to inform the design of interventions whose effectiveness may depend on its alignment with the perceptions of students. Out of 11 articles addressing that issue, four surveyed students in German-speaking Switzerland, three in the UK, two in Norway, one in multiple countries (N = 8), and one was a literature review. Participants were medical students at different stages of their education: one in their first-year, five at the end of their studies and three over a continuing period of four years. One study included doctors who had quit general practice and another one was an analysis of active practitioners’ reasons for choosing to be a GP. Methods included questionnaires, face-to-face interviews, focus groups and, in one instance, the analysis of diaries written over a period of ten months. Surveys were limited to one to four schools of medicine and to samples of respondents of between 4 (study of diaries) and 262. This literature mentions a broad set of reasons for not choosing, or in one case, for quitting general practice. These include: value of community-based work and social status of general practice perceived as low; observation of the pressures under which GPs work; lack of exposure to academic role models and of primary care-based research opportunities [45]; loneliness of working in general practice [46]; lack of visibility of results of one’s actions, as is possible in acute care; image of GPs passively sitting at their desk or in meetings contrary to perceptions of being an active care provider; perception of a GP career as default; entry to GP training perceived as having little or no competition; gender stereotyping of career choices, hospital doctors using mistakes made by GPs as material for a teaching session; and perpetuating the sense that GPs were intellectually inferior [47]. Doctors who abandoned general practice reported that they did so because of too many obligations, an excessive administrative burden, the difficulty of being self-employed, and the cost of establishing a private practice [48]. Positive reasons mentioned by students for choosing PHC practice include quality of teaching and of clerkships in general practice, access to positive role models, positive placement experience, diversity of work, feelings of being able to contribute and rewarding and continuous relationships with patients. Additionally, factors like personality characteristics (interest in people’s lives, a strong ability to cope with different situations and patients, open-mindedness, curiosity) [46, 49], sex (women tend to be more attracted by PHC practice) or the rural origin of students [49], and support for work-life balance.

As expected, all articles in our review concluded that educators and planners should take into consideration their findings, even though they had a limited external validity. Like Kroezen, Rajan and Richardson [9], we conclude to the need for more evidence on the effectiveness of interventions to inform the policy process. In fact, the literature surveyed up to 2018 includes studies that tend to be descriptive, with little information on what works and why and what does not work and why. The literature in our review presents the same characteristics.

The absence of solid evidence does not mean that policy-makers should not act. Many recommendations, such as implementing multifaceted interventions that take into account the aspirations and expectations of future practitioners, exposing students to family practice, improving professional recognition, or offering better career prospects have enough face validity to guide policy development. Yet, the question policy-makers, planners, educators and other stakeholders ask is “how to design and implement these recommendations?”. For example, the recommendation to expose students to PHCS work may be consensual [50], but it does not respond to practical issues such as type of exposure (placements, residency, rotations, participation in research on PHCS, mentorship), duration, stage of the education process, trainers/supervisors and their qualifications, and what costs. All recommendations raise similar practical questions, hence the need for evaluative research on the various dimensions of interventions, e.g. design, process of implementation and results. Lessons learned from such evaluations will be context-specific, but they will have a high informative value and offer guidance in the PHC workforce planning process.

Limitations

This review focused on only one professional category, an obvious limitation knowing that the delivery of PHCS requires the collaboration of various categories of providers working as multiprofessional teams of nurses, pharmacists, nutritionists, rehabilitation professionals, and others. It focuses only on one type of intervention to augment the availability of PHCS and does not discuss others, such as scaling-up the productivity of PHC teams by expanding the functions of nurses, pharmacists and others [51] and by increasing the use of communication tools like teleconsulting. There is a potential publication bias linked to the choice of databases. Due to language limitations to English, French, Italian, Portuguese, and Spanish, the review has likely missed publications in other languages, such as from Germany or Norway, two countries that have been active in addressing health workforce problems. The limited number of interventions reviewed and the lack of evaluative studies imply that we cannot draw firm conclusions on the effectiveness of interventions, let alone on their replicability.

Conclusion

To make PHCS accessible to all requires the availability of a fit-for-purpose workforce of multiprofessional teams, in which specially trained physicians play a central role. At present, all countries surveyed in our review report shortages of GPs or family physicians. Opening more training opportunities is a necessary step towards reducing these shortages, but it is not sufficient; more students must accept to opt for a PHC specialty. The attraction of more students is a major challenge for planners, educators and leaders of professional organizations as it faces the competition of hospital specialties and of other fields of practice also in need of more students, such as public health, geriatrics, rehabilitation, or mental health. Successful strategies of attraction require the collaboration of numerous actors, including professional councils and organizations, and of regulation bodies that specialists tend to dominate. More than advocacy, the COVID-19 pandemic provided real-life arguments for the need of more responsive PHCS, and for a more numerous and better prepared workforce to deliver them. Decision-makers are more likely to make the PHCS workforce stronger a political and policy priority, they need access to convincing evidence and information on good practices that only research can produce. In Europe, the “Joint Actions” supported by the European Commission offer an example of multi-country collaborative research. A joint action on how countries are strengthening the PHC workforce could map what countries currently do to, their successes and failures and draw lessons that can augment the probability of effectiveness of future attraction strategies covering all components of the PHC workforce.