Which positive factors determine the GP satisfaction in clinical practice? A systematic literature review

Relevant studies were identified by systematic research in the databases Pubmed, Embase and Cochrane. The search was limited to articles published between 1 January, 2000 and 31 December, 2014. The year 2000 was set as the search start year as a turning point for the vision of GP with international work being initiated on its definition (and the WONCA definition being introduced in 2002) [1]. Practice and work organisation in general practice have been changed in many countries in the past decade, which might have a strong influence on job satisfaction. Four researches worked independantely with a merging of their results at each search and inclusion steps.

The database-specific search included the following algorithm for Pubmed: ((“Family Practice” [Majr] OR “General Practitioners” [Majr] OR “Physicians, Family” [Majr]) AND (“Career Choice” [Majr] OR “Career Mobility” [Majr])) AND hasabstract[text] AND (“2000/01/01” [PDAT]: “2014/12/31” [PDAT]) and ((“Family Practice” [Majr] OR “General Practitioners” [Majr]) OR “Physicians, Family” [Majr]) AND “Job satisfaction” [Majr] AND hasabstract[text] AND (“2000/01/01”[PDAT]: “2014/12/31”[PDAT]). Those equations were adapted for Cochrane and Embase according to their own specifications.

“Job satisfaction” was chosen by the research team because it was the best possible MESH term to describe positive factors at work. The use of a MESH term was efficient, because it included all possible synonyms.

In addition to the database search, grey literature was identified by the EGPRN’s national representatives. National teams (eight countries) were asked to provide grey literature citations, using the same keywords or known from experience. These were assessed by the national representatives and included in the review by consensus. Finally the bibliographies of all the included articles were checked in order to find additional references [11].

Four independent researchers screened eligible articles based on title and abstract. Articles were considered relevant if the main focus was on positive factors related to General Practice. Only publications in English, Dutch, German and French were included. Abstracts were excluded if they were not reported in a structured way acoording to the IMRaD format (ie lacking a formal introduction, method result and discussion format), or if they only described a research protocol. Research articles performed in settings less relevant for the European context were also excluded such as studies undertaken in non-industrialised countries. The studies concerning other specialities were excluded because our review focused on GP. The review did not select the articles focusing on negative factors, or specific populations. Specific points raised by why students and trainees are attracted to General Practice were not explored in this review but are being addressed in additional on-going work.

Next, two research teams (French and Belgian) performed a full-text screening on the content and quality of all eligible articles. Because of the large heterogeneity in the types of studies, we assessed the quality of the articles with the criteria described in Table 1. To be included, the article had to score “yes” on every question. This quality appraisal form was adapted from the quality appraisal form of the CASP [12, 13].

Differences of opinion at each step (screening and inclusion) were dealt with by discussion between the two researchers and, where there was a lack of consensus, the whole study group was consulted.

Two researchers analysed the data from the included articles using a mixed method synthesis in which the findings of qualitative and quantitative studies were aggregated at the study level [14]. Results were pooled and anonymised at each step of the data extraction. A thematic analysis process was employed with the intention of capturing any issue relevant to the research question. These relevant issues were labelled and subsequently organised into subthemes and overarching themes. For the qualitative studies, the relevant results were the issues described in the research. For quantitative questionnaire based studies on GP satisfaction with different issues related to GP, only the items for which the mean satisfaction score was 60 % or above were included. (Different scales were used, so we recalculated this as a percentage of the total).

The initial search in the different databases produced 458 different articles. Based on the abstracts, 104 full-text articles were eligible for further assessment and, ultimately, 17 articles were included in the review [15‐31]. The full process is described in the PRISMA flow chart (Fig. 1).

All included studies were published in the English language. Six of the 17 studies were conducted in Canada, four in Australia, two in the USA, two in Germany, one in New Zealand, one in the United Kingdom and one in Switzerland.

Of these 17 selected publications, 11 were cross-sectional questionnaire studies; five used qualitative methods and one was a quantitative comparative study.

Additional file 1 provides an overview of the studies included in the review.

The research team collected 157 factors related to GP job satisfaction. Those factors were classified into 13 subthemes, which could be grouped into three overarching themes of issues supporting GPs satisfaction in their profession. First there are general profession related themes, applicable to many professions. A second group of issues is specific to a General Practice setting. Finally a third group is related to professional life and personal issues.

Those three groups of themes are described in Additional file 2.

Some topics found in the literature were not specific to General Practice, and could be found in other medical professions as well as in non-medical jobs. We described them under two subthemes: “workload, income and the balance between them” and “getting responsibility and recognition for your work”.

We grouped the specific GP related factors into nine sub–themes described below. Some of these aspects of satisfaction could be found in other professions, but these factors are more specific for the medical profession.

Successful medical management of patients and the subsequent feelings of being competent were associated with a higher degree of satisfaction. In a Scottish qualitative study, GPs derived the greatest satisfaction from consultations where GPs perceived that they personally had contributed to a successful outcome for the patient [27].

Freedom to choose the workplace and work organisation was one of the most relevant topics found in the literature, addressed in 13 articles. GPs wanted to have the freedom to choose their work method [16, 19, 22], their payment method [22], and have flexible working hours [18]. GPs need this freedom in order to have job satisfaction [24]. In a qualitative study, an American GP said: “It’s a way of having independence and doing what I want” [26].

Vocational choice; being able to be the kind of doctor you want to be: is an important sub-theme in being satisfied with your work as a GP. Six studies stated that the GP’s own personality and personal values played an important role. Values can differ between GPs. If their job were fully compatible with their temperament and personal values, then GPs were more satisfied. Some chose to be a “traditional family doctor” [21]. The mission for most GPs was to help people. “The goal of practice is to meet people’s needs, take care of them and do the best you can” [26].

The theme of GPs’ physical health, gender or age were assessed in the literature. A good health is associated with GP satisfaction. Not smoking and not being overweight is correlated with greater GP satisfaction. “Older age, being female and having good health behavior has a positive effect on job satisfaction” [16].

Intellectual stimulation to use abilities; continual professional development: This is one of the most studied aspects of satisfaction. Twelve articles in the review refered to the intellectuel aspect of the profession as a positive factor. GPs appreciated the intellectual challenge, and necessary skills that their GP work offered them. “The intellectual and practical challenge to solve and assist with people’s medical problems” [25]. “Doing a wider range of procedures was associated with higher overall job satisfaction” [24].

Nine articles described the influence of community on GPs’ job satisfaction. The community was important, especially in rural areas: “Rural medical education is important for students from a rural background with a desire to work in a rural practice” [29].

An important factor influencing career choice was the influence of the family or domestic circumtances [31]. GPs’ families wanted access to community services and leisure facilities.

One of the results of this literature review is a broad overview of the positive factors which keep GPs in their clinical practice. This comprehensive view on satisfaction factors cannot be found by reading the individual articles. Most research on GP satisfaction was undertaken in a particular context, with small numbers, and with a focused research question on specific aspects. Merging all those factors provides a broader perspective on the topic. This richness of data has been obtained using a broad selection of articles.

The major part of the literature focused heavily on the material working condition of GPs. These studies were almost exclusively based on surveys which used declarative questionnaires, such as the Warr-Cook-Wall job satisfaction scale, which is not specific to General Practice [33]. These questionnaires did not examine in depth the aspects GPs might find satisfying in their profession. The data from the qualitative studies were very relevant. Qualitative studies allow a deeper investigation into the specific aspects of General Practice. However their research question sometimes focused on a particular context.

Confounding factors or interpretation bias could come from differences between social health systems and linguistic understanding. This bias was limited by working with an international research team, containing GPs from diverse cultures, and regular users of different health systems. During the screening of the research, different ways to estimate GP satisfaction were found. Some of the studies asked, “Why are you satisfied?” or “Which policies would lead to an improvement in GP satisfaction?” The research group decided to keep the various question forms although this could have caused confusion bias.

These results are of interest because most of the policies which tried to increase the GP workforce were based on non-specific professional aspects. This literature review opens up new possibilities for increasing the GP workforce by referring to specific activities within General Practice.

The literature review draws up a description of the General Practitioner who is satisfied in his/her work. Satisfied GPs are professionals who can keep a reasonable workload balance, which provides sufficient income and who are free to organise their work and determine how they work. Satisfied GPs are sufficiently challenged in their work and feel competent and useful. They have opportunities to broaden their tasks such as being involved in teaching or academic work. They wish to preserve their own healthand value good relationships with their patients and other professionals and live in an environment/community which appeals to them and to their family. These results will be transmitted to stakeholders of each of the participating countries, to be used in discussions with policy makers on the future of General Practice. This literature review provides new opportunities to improve health systems in OECD countries by referring to the satisfaction factors. To improve the strength of health work, a policy must promote a balance between work and income for GPs. It must take advantage of the skills of GPs, give them responsibilities and strengthen their image in the society. Policy makers now have a broad view of which factors constitute job satisfaction for GPs and could integrate them into their policies to increase the workforce.

This literature review showed numerous factors related to job satisfaction among GPs which are not widely explored elsewhere. Qualitative surveys seem important in the identification of these factors. Therefore, as the next step, the research team is committed to looking at these factors using a qualitative approach, with interviews and focus group discussions with GPs.