General practice prestige: understanding medical students’ perceptions – a repeated cross-sectional study

Abstract

Introduction

A global shortage of general practitioners (GPs) is partly due to the limited number of medical students interested in working in the field. Prestige is one of several factors influencing choice of medical specialty. This study examined medical students’ perceptions of the prestige attached to working in general practice and how their career intentions evolved at medical school.

Methods

A repeated cross-sectional survey was conducted among students at the Medical University of Graz between 2018 and 2023. Data were collected at six time-points in every academic year. Prestige was assessed using items from a questionnaire developed to assess medical students’ attitudes towards general practice. Factor scores were calculated and compared between time-points and between changes in career aspirations.

Results

The number of students aspiring to become a GP increased at medical school (1.1% vs. 4.5%; p < 0.001), while the number of undecided students decreased (67.2% vs. 62.4%, p < 0.001). Students initially considered general practice to be more prestigious (0.47 ± 0.86) than later in their studies (0.23 ± 0.96; p < 0.001). Students uninterested in working in general practice rated prestige lower than interested students (0.19, 95%CI: 0.12–0.26 vs. 0.62, 95% CI 0.42–0.81; p = 0.002) and undecided students (0.35, 95% CI 0.32–0.39; p < 0.001). By the end of medical school, more students considered general practice to have a poor reputation relative to other specialties (p < 0.001), similar to political decision-makers (p < 0.001), but considered a high reputation among patients and society as a whole (p < 0.001).

Conclusion

These findings highlight the need for positive educational experiences and stronger recognition of general practice within the medical community.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-08894-5.

Introduction

A shortage of general practitioners (GPs) is an international phenomenon [1]. High rates of retirement [1] and difficulties attracting young doctors have significantly exacerbated the problem [2].

Recent studies, including two in Austria, have shown that only three to four% of medical students are interested in becoming a GP [3, 4]. In the literature, such factors as higher age, parental status, positive evaluation of the content of the work, organizational aspects and prestige are found to influence whether students choose to become a GP [3, 5–7]. In the present study, prestige is understood as students’ perceived image of general practice relative to other medical specialties, including both professional status and income-related perceptions. In terms of prestige, medical students often imagine general practice to be mundane, repetitive and less intellectually demanding than other medical specialties [5–7]. Students do not think GPs are highly regarded in the field of medicine [8] and this perceived lack of respect deters them from opting for a career in general practice [9]. In a UK study, for example, 63% of medical students asked to rate the status of GPs and non-GP specialists believed that general practice had a lower status, 31% thought there was no difference and no one thought GPs enjoyed a higher status than non-GP specialists [10]. General practice is seen at the bottom of the medical hierarchy, offers fewer career opportunities and attracts less ambitious doctors [11]. These results indicate that lack of prestige bears substantial responsibility for the shortage of general practitioners.

Not only students, but also medical specialists partly evaluate the status of GPs negatively. In a qualitative study conducted in 2006, such medical specialists said that although they did not consider their work to be more important than that of GPs, they had observed a negative attitude towards GPs among their peers. They also felt that GPs considered them to have a higher status. A substantial difference in perceived status was found: specialists felt they could teach GPs, but GPs could not teach them [12].

As around half of the students in Austria are undecided on their choice of career when they begin their studies [3, 4], and there is a clear shortage of GPs, especially in rural areas [1], role models and curricula should attempt to positively reinforce students’ views on general practice. Chellappah and Garnham [13] describe that the perceptions and values of students’ clinical role models appear to be communicated implicitly to and adopted by them, resulting in students’ perceptions of general practice being most influenced by the GPs they come into contact with at medical school [14]. The implementation of general practice in the curricula of medical schools can thus have a positive influence on attitudes towards general practice as a career choice [5, 7, 15–19]. Studies have shown that the earlier and more frequently medical students are exposed to explicit general practice content, both mandatorily and voluntarily, the more likely they are to choose a career in the field later on [20, 21]. In addition, Stigler et al. have published a comprehensive catalog of measures aimed at combatting the shortage of GPs, and university training is an important part of the solution [19].

Since prestige appears to play an important role in students’ choice of career path, and both role models and the curriculum can influence their views on the prestige attached to a specific medical field, this study focused on the attitudes of medical students towards general practice and the development of their views on prestige over the course of their medical education. We additionally investigated how the opinions of students that were undecided when they began their studies changed during their studies.

Methods

The manuscript was written in accordance with the STROBE guideline [22] and the corresponding checklist (see Additional file 1). This study further develops the findings of the original investigation conducted by Avian et al. [3].

This study was originally designed as a longitudinal survey following one cohort of medical students across predefined stages in their curriculum. However, participation across all survey time-points was highly incomplete: no participant responded at all six time-points, and only one participant contributed data at five time-points. Most students participated at only one or two time-points. Consequently, the number of within-person repeated observations was insufficient for valid longitudinal modelling. Therefore, the data were analysed and are reported as repeated cross-sectional samples at each time-point.

Study population

This survey was open to all medical students at the Medical University of Graz (MUG) and covered one six-year course from 2018 to and 2023. A total of 2063 students started studying during this period. Surveys were conducted at six specific time-points, corresponding to distinct stages in their studies. The MUG curriculum is modular in structure, and teaching mainly takes place in interdisciplinary and topic-specific modules. Each subject is taught by a specialist in that subject. After completing all the modules, the program culminates in the Clinical Practical Year (CPY). The CPY consists of compulsory subjects and an elective subject. The required subjects are surgery and perioperative studies, general medicine, psychiatry, pediatrics and adolescent medicine, internal medicine and neurology. Students can choose the elective subject according to their interests.

The survey was first carried out during the compulsory introductory lecture in the first week of the first academic year (time-point: INTRO). Subsequent surveys took place following completion of the compulsory module PMXVI (Social, Family, and Preventive Medicine; time-point: PMXVI) in the third year, and again after PMXXIII (Sensory Organs and Their Diseases I and General Practice; time-point: PM XXIII) in the fifth year. Additionally, students that selected the elective module SSM40 (a specialized study module in general practice), which may be undertaken voluntarily in the second phase of medical studies (between the fourth and fifth academic years), completed the survey upon its conclusion. In the third phase, corresponding to the sixth and final year of medical school, the questionnaire was administered both prior to (time-point: pre-CPY) and following the Clinical Practical Year (time-point: post-CPY). These time-points were based on the involvement of lecturers at the Institute of General Practice and Evidence-Based Health Services Research in the respective modules, as this facilitated the distribution and collection of questionnaires. Prior to the Covid-19 pandemic, the survey was administered as a paper-pencil questionnaire. Questionnaires were distributed and collected by the lecturers at the Institute of General Practice and Evidence-Based Health Services Research, with strict respect for the preservation of students’ anonymity. In response to the pandemic, the survey was conducted in an online format. Students could access the online questionnaire upon completion of the courses. Students were informed about the study and gave their consent by answering the survey. Participation was voluntary, and no incentives were provided for completion.

Questionnaire

To evaluate the perceived prestige the scale “image and income compared to other medical specialists” from a published questionnaire developed to assess medical students’ attitudes towards general practice was used [3]. This scale consists of six items, covers aspects relating to income, prestige and career opportunities, and shows an internal consistency of Cronbach’s alpha α = 0.80. The level of agreement was provided on a five-point Likert-type response scale. Initial evaluation of the questionnaire adopted an Item Response Theory approach and a Graded Response Model was used to estimate item parameters. These item parameters were therefore used to calculate scale scores and resulted in scores on a logit-scale that were generally between − 3 and + 3. A further three items from the published questionnaire that were not assigned to a specific scale were also used. These items assessed what students imagined other groups of people (patients, colleagues from other disciplines, political decision makers) thought about general practice [3]. Students were also asked whether they wanted to become a GP, did not want to become a GP, were undecided, or did not know what they wanted to become. The last two categories were collapsed into the category “undecided students” because both groups consist of students who have not yet made a decision. Although these two groups may differ in certain aspects, no further differentiation was made, as this was not the focus of the present study.

Statistics

Looking on the whole response pattern only 0.7% (n = 32) of the responses have duplicates. Since the number is small (< 1%) and it cannot be ruled out that these could be at least partly unique students, no data records were deleted. Baseline characteristics are presented as median and interquartile range (IQR) or absolute counts and percentages, as appropriate. Factor scores for the scale “image and income compared to other medical specialists” were calculated using item parameters taken from the published questionnaire [3]. The scores and career aspirations at each time-point were then compared (GP vs. not GP vs. undecided) using a General Linear Model. Although some students participated at multiple time-points, repeated participation was sparse and uneven across time-points. Therefore, longitudinal modelling was not feasible, and time-points were considered independently in this model. The chi-square test was used to compare single-item responses according to sex and time-point. Since the SSM 40 general practice module is an elective, it can be assumed that students taking this module would differ from other students in their attitudes towards general practice. The results for this module are therefore presented separately.

Results

The questionnaire was completed 4,878 times between 2018 and 2023. Overall, 4,179 (85.6%) responses were submitted at identifiable time-points, ranging from 1256 following the introductory lecture to 263 following the compulsory ‘General Practice elective’). Students generally only filled out the questionnaire once (2828 responses, 58.0%), while a further 30.4% (n = 1484 responses, n = 742 students) responded twice, 7.5% (n = 366 responses, n = 122 students) three times, 1.5% (n = 72 responses n = 18 students) four times and 0.1% (n = 5 responses, n = 1 students) five times. Of the responses, 2.5% (n = 123 responses) could not be clearly assigned to a student. Over half of the questionnaires were submitted by female students (54.8%, n = 2672 responses). The average age ranged from 20 (19–22) at the time of the introductory lecture to 26 (25–27) at the end of the mandatory clerkship (Table 1). Overall, 2.8% (n = 131) of students wanted to become a GP, 30.6% (n = 1493) did not want to become a GP, 64.5% (n = 3149) were undecided and 2.1% (n = 105) did not answer this item. Career aspirations were similar in female and male students (GP: 2.6% vs. 2.9% / n = 68 vs. n = 62; not GP: 30.0% vs. 33.0% / n = 786 vs. n = 704; undecided: 67.4% vs. 64.1% / n = 1769 vs. n = 1370; χ²_(2,4759) = 5.73,; p = 0.057).

Table 1.

Socio-demographic parameters of all medical students (time of survey: 2018–2023)

		All responses (n = 4,878)
Sex
	Female	2672 (54.8%)
	Male	2189 (44.9%)
	Missing	17 (0.3%)
Age
	Introductory lecture (INTRO)	1178
	Compulsory module 3rd year (PM XVI)	1256
	Compulsory module 5th year (PM XXIII)	886
	Compulsory ‘General Practice’ elective (SSM 40)	263
	Pre-CPY	525
	Post-CPY	770

At the beginning of their studies, 1.1% (n = 13) of students wanted to become a GP, 31.7% (n = 368) did not want to become a GP and 67.2% (n = 779) were undecided. By the end, the number of students wanting to become a GP had risen to 4.5% (n = 33), while 33.5% (n = 246) did not, and 62.0% (n = 455) were undecided (χ²_(10,4773) = 159.8, p < 0.001).

At the beginning of their studies, students rated general practice as more prestigious (0.47 ± 0.86) than later on, with the lowest rating being given pre-CPY (0.23 ± 0.96; p < 0.001).

The individual items in the prestige scale revealed that ratings throughout the period were less favorable to general practice for (1) income compared to other specialists (p < 0.001), (2) a GP is a second-class doctor (p < 0.001), and (3) fewer additional services can be billed (p < 0.001). Students rated career opportunities for non-GP specialties more favorably at the beginning of their studies (p < 0.001).

Students not wanting to become a GP (n = 1307) rated the prestige attached to general practice significantly lower than students wanting to (n = 106) (0.19, 95%CI: 0.12–0.26 vs. 0.62, 95% CI 0.42–0.81; p = 0.002), and undecided students (n = 2818) (0.35, 95% CI 0.32–0.39; p < 0.001). Students wanting to become a GP did not differ significantly from undecided students in their assessment of prestige (p = 0.197).

Students’ assessment of the reputation of GPs among non-GP specialists in other fields (χ²_{(8,4799 )} = 111.7, p < 0.001), patients and society (χ²_(8,4793) = 34.1, p < 0.001), and political decision-makers (χ²_(8,4793) = 146.6, p < 0.001) depended on the stage of their studies (Fig. 1). At the end of the CPY, more students believed general practice had a poor reputation (response: no) among non-GP specialists than at the beginning of their studies (“no” responses: INTRO 45.8.% (n = 537), post-CPY 62.4% (n = 553); “yes” responses: INTRO 15.8% (n = 185), post-CPY 17.0% (n = 151); Fig. 1A).

Fig. 1.

Answer to the item: Do you think that GPs have a high reputation among the following groups of people: colleagues from other disciplines (A), patients (B), and political decision-makers (C)

Furthermore, over the course of their university studies, more students believed that general medicine has a good reputation among patients/society (“yes” responses: INTRO 86.8% / n = 1017, post-CPY 93.4% / n = 829; “no” responses: INTRO 6.8% / n = 80, post-CPY 3.7% / n = 33; Fig. 1B). In contrast, more students thought general practice had a poor reputation among political decision-makers at the end of their studies than at the beginning (“yes” responses: INTRO 24.7% / n = 288, post-CPY 18.8% / n = 166; “no” responses: INTRO 31.1% / n = 363, post-CPY 55.0% / n = 486; Fig. 1C).

Students’ career aspirations changed during the course of their studies (χ²_(10,4773) = 159.8, p < 0.001), with only 1.1% (n = 13) wanting to become a GP at the beginning, but 4.5% (n = 33) by the end. Likewise, the number of students that were still undecided was higher at the beginning of their studies (67.2%; n = 779) than at the end (62.4%; n = 455) (Fig. 2).

Fig. 2.

Career aspirations of medical students at different time-points during their studies

SSM 40

Only a small number of the students that attended the elective module SSM 40 were uninterested in becoming a GP (11.9%; n = 31). At all other time-points, between 28.3% (PM XVI; n = 349) and 35.8% (PM XXIII; n = 314) of students did not want to become a GP. The number of students wanting to become a GP (5.0%; n = 13) corresponded to that at other time-points [between 1.1% / n = 13 (INTRO) and 7.3% / n = 44 (pre-CPY)], while the number that were undecided (83.2%; n = 217) was higher than at other time-points [between 57.1% / n = 346 (pre-CPY) and 70.5% / n = 871 (PM XVI)]. Furthermore, these students were the only ones that did not report a lower overall rating of the prestige attached to general practice than at the first assessment (INTRO). Among the students that attended the elective module SSM 40, the number that reckoned GPs had a high reputation among non-GP specialists was lower (11.1%; n = 29) than at other points in time [15.1% / n = 189 (PM XVI) to 17.3% / n = 107 (pre-CPY)]. In contrast, the number of students that thought GPs enjoyed a good reputation among patients (95.0%; n = 249), was higher than at other time-points [86.8% / n = 1017 (INTRO) to 93.4% / n = 829 (post-CPY].

Discussion

Our six-year survey showed that while the prestige attached to general practice declined over the course of students’ studies, the number of students wanting to become a GP was higher at the end than at the beginning of their studies. This apparent paradox suggests that students’ career decisions may increasingly be guided by intrinsic motivations and lifestyle considerations, even when the perceived prestige of a specialty declines. The number of students that could imagine becoming a GP but were still undecided was higher at the beginning than at the end of their studies, but remained high throughout medical school.

Similar results have been found in longitudinal studies, with interest and intention to work in primary care increasing over the course of students´ studies [23–25]. One study found that the number of students intending to opt for general practice appeared to decrease over time. Nonetheless, many students remained uncertain about their career intentions throughout medical school [26].

Most of the students that attended the SSM40 module could imagine becoming a GP but were still undecided. Medical students choose electives to gain a better understanding of the specialty before choosing a career [27]. One study indicated that undecided students changed their career choice after attending an elective in radiology, but most said the elective had no effect on their career choice [28]. An elective internship in general practice in the final year of medical school appears to have the potential to change perceptions about general practice among students that are still undecided [29]. Furthermore, medical teachers can also influence perceptions [29]. If society at large is to exert an influence on career choices, the role played by electives and medical teachers on undecided medical students should be taken into account.

One factor that is negatively associated with primary care career intentions is prestige [4, 23, 24]. Students felt that non-GP specialists had a negative impression of GPs, a view they thought worsened over time. The highest percentage of students taking this view was found among those students that had taken the compulsory elective “General Practice”. It is interesting that those with the greatest interest in becoming GPs also had the most negative opinions of the attitudes towards general practice of non-GP specialists. At the same time, students in this group had the most positive views about how patients and society as a whole viewed general practice. A study in Spain also found that only 20% of students assigned a high status to general practice [30].

Students are much more likely to choose to pursue a career in a specific medical discipline if they consider the chosen field to possess a positive image, not only in the eyes of society and patients, but also in the eyes of doctors working in another medical discipline. One study that investigated how students’ views matched up with their choice of specialty emphasized how difficult it is to attract students to a specialty that they think is not considered generally appealing [6]. Programs included in the medical curriculum must include more than simple internships, as it is extremely important that GPs show that they have a positive self-image. This was apparently not the case in our survey group, as it was precisely the group that had most contact with GPs during their studies that had the most negative views on how GPs are regarded by their colleagues. It may be possible that this view was conveyed to students by the GPs themselves, even if they felt that patients and society had a very positive attitude towards them.

Our study shows that general practice has a poor image among other medical disciplines, which is an impression that appears to be communicated by GPs themselves. Nevertheless, the reputation of general practice among patients and society in general is very high. Although not explicitly taught, the attitude that the specialty of general practice is somehow inferior to others pervades the medical world and naturally influences students’ perceptions [11]. This should be countered by raising the confidence of GPs already working in the field and communicating this openly to students and other physicians. Curricula and faculty development initiatives could provide opportunities to address prestige-related perceptions by fostering reflective discussions on professional roles, supporting positive role models, and increasing the visibility of the intellectual and societal contributions of general practice.

An important step towards improving the image of general practitioners among medical professionals as a whole was undoubtedly the introduction of the professional title of specialist in general practice, which took place in Austria on 1 January 2025 [31]. While the effects of this change cannot yet be assessed, formal equality of status in the professional title may also improve the image among medical professionals as a whole. Studies have shown that a comprehensive approach that emphasizes attractive characteristics and role models will encourage more people to specialize in general practice [32].

It is also worth mentioning that recognition of the importance of general practice in the health care system is much more widespread in countries where primary care is well established [33]. These aspects are not frequently addressed and communicating them during career programs would be a valuable enhancement. In the last couple of years, the MUG has established and promoted programs that concentrate on increasing the attractiveness of general practice (https://allgemeinmedizin.medunigraz.at/lehre).

It is necessary that future research looks closely at undecided students and what features of the medical curriculum and what social factors most influence career decisions. Furthermore, it should be investigated whether the introduction of the professional title of specialist in general practice encourages students to choose it as a specialty.

Limitations

One limitation of this study is that it was only conducted among medical students at the Medical University of Graz, Austria. As healthcare systems and the structure of medical studies vary depending on country, the results may therefore not be fully applicable outside this context.

In addition, we were not able to determine changes in students´ perceptions of general practice over the course of the study because too few students participated at all the time-points. Consequently, the repeated cross-sectional design limits the ability to draw causal or developmental inferences.

Furthermore, we had to change from a paper-pencil to an online format due to the Covid-19 pandemic, which may have discouraged some students that had initially participated from continuing to do so. The change in survey mode may also have influenced response behavior, for example with regard to social desirability or response completeness. Views on prestige and career aspirations may also have been influenced by the pandemic.

Potential non-response bias and the over- or underrepresentation of specific student subgroups may have influenced our results and should be taken into account when interpreting the findings.

Despite these limitations, our study provides valuable insights into medical students’ perceptions of general practice. These findings highlight the need for positive educational experiences and stronger recognition of general practice within the medical community.

Abbreviations

CPY

Clinical practical year

GP

General practitioner

MUG

Medical University of Graz

Authors’ contributions

USK, AS, SP and AA made contributions to the conception and design of the work.USK, SP and AM conducted data collections.AA analysed and interpreted the data.LP and USK drafted the first version of the manuscript, which was critically revised by AS, AA, AM and SP.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

According to national laws (§ 30. (1) Universitätsgesetz 2002), ethical approval was not necessary as completion of the survey implied consent.

The study was conducted in accordance with the ethical standards of the Declaration of Helsinki. Prior to participation, all students received information about the study’s purpose, procedures, and the voluntary nature of their involvement. Informed consent was obtained implicitly, as participants chose to complete the survey after being provided with this information. All data were collected anonymously and treated confidentially.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.