More than one-half of those respondents who were not working as GPs had either considered general practice but decided against it, or they had been a GP and quit the profession.
More women (than men) and more young doctors had considered taking up general practice. The most important reasons for doctors not to choose general practice were the administrative burden and the small professional community. The fact that so many of the proposed reasons are highly ranked indicates that the reasons are complex. It is worth noting that 'too many obligations' appears to be a prominent cause for opting out.
Studies have repeatedly shown that GPs have a longer working week than most other doctors (20, 21). In 2018, the average working week for GPs was measured at 56 hours (22). The same study also showed that GPs have more tasks to perform than previously, for example e-consultations, certificates/declarations and dialogue meetings. A report from the Norwegian Directorate of Health shows that each patient has more consultations than was the case before (2). This indicates that the disease pathways to be dealt with in general practice have become more complicated than previously, and that the threshold to attending GPs has been lowered.
Doctors included in this study believe that too many obligations and an excessive administrative burden have contributed to their choice of leaving general practice. Studies from other countries show that the administrative burden imposed on has increased, and that this is perceived as taking time away from patient treatment (19). Tasks that entail longer working hours can be hard to reconcile with the doctors' increasing wish for a better work-life balance (23),(24). A Norwegian study points out the importance of a good work-life balance, with an opportunity to work part-time – especially for women – in order to reduce the risk of work-life stress that may lead to burn-out (24).
The need for more knowledge about the disease pathways and responsibility for standardised patient pathways and follow up from the specialist health service that have been transferred to the primary healthcare service may have been underestimated in the introduction of health service reforms (5). The health enterprise reform and the Coordination Reform, which included expedited transfer of patients from hospitals to the primary healthcare service and expectations for more decentralised treatment (such as standardised pathways for cancer treatment), may have increased the need for professional knowledge and thereby also for good professional communities and networks for GPs (5, 15). Reduced hospitalisation time, higher patient expectations and patients' access to knowledge about medical issues connected to their own health demand an expansion of GPs' knowledge (5, 15). This development highlights the need for a professional community.
In recent years, job satisfaction has declined among the GPs. The main reasons are lack of recognition for a job well done, less freedom to choose methods, heavy responsibility, long working hours and insufficient financial compensation (25). Doctors who opt out of general practice report that the most important factors are the difficulty of being self-employed and the cost of establishing a private practice, while having little access to social rights and benefits. To recruit specialists in general practice, regions in Western Norway have been granted government support for a pilot project for the years 2017–2020, in which doctors are employed in permanent traineeships (specialty registrars in general practice, ALIS). GPs who participate in this project believe that a fixed salary, social security, shorter patient lists and good supervision in this type of position will help increase the recruitment to general practice (26). In our data, we find that 'coincidental factors' are frequently reported as a reason for opting out of general practice by doctors who had considered this possibility, but made another choice. This may reflect a situation where the choice of specialty is governed to a large extent by the opportunities that present themselves during the training period, as well as when and where they appear (27). An opportunity for an ALIS position may thus have a major bearing. While many municipalities struggle to recruit applicants to GP positions (4), the ALIS positions are attracting numerous applicants.
Some studies suggest that more systematic effort should be devoted to improvement measures aiming to cater to the doctors' own health and generate enthusiasm for the profession (28, 29). The suggestions include changes to the distribution of tasks, such as delegating some of the administrative duties to others. Nurses and other auxiliary medical personnel could be given an expanded role in planning and responsibility for prevention, at the doctor's recommendation. To avoid fragmentation and non-transparent distribution of responsibilities this would require careful impact assessments and require considerable coordination (30, 31).
Measures that may help achieve a better work-life balance provide stability in everyday life and are important for a good career in general practice. These issues have been widely discussed in the GPs' own forums and the media in general in recent years (30, 31, 32). Findings in this study provide further knowledge on issues that affect doctors' choice of general practice and their decision to remain in this specialty.