Exploring residents’ perspectives on their professional identity in general practice residency in the Netherlands: a qualitative study

Abstract

Objectives

Educational initiatives in residency may lack alignment with residents’ learning objectives. Furthermore, they may overlook residents’ struggle to find fulfilment in their work. Professional identity formation (PIF) is a conceptual lens through which to explore the alignment of educational initiatives with residents’ learning objectives. Few empirical studies have examined PIF in residency in general. PIF outcomes in general practice (GP) residency, from the perspective of residents, are poorly represented in the current literature. This study aimed to explore residents’ perspectives on their professional identity to inform PIF learning objectives in GP residency.

Design

A qualitative descriptive study using a list of predetermined questions to guide focus group interviews.

Setting

Data collection took place between winter and autumn 2019 at four GP training institutes across the Netherlands.

Participants

92 third (final) year GP residents participated in focus group interviews.

Results

Residents’ overall perspectives hinged on how to negotiate the endlessness of the profession. This endlessness was reported to manifest in four areas, namely, the GP: as an accessible healthcare provider, as a spider in the care-web, providing personalised care and maintaining a work–life balance.

Conclusions

GP residents’ narratives highlighted an increasingly challenging profession and posited the importance of guided negotiation for their PIF. Deploying the concept of subjectification in residents’ guided negotiation of the profession’s endlessness possibly improves the supervisor–resident educational alliance. Furthermore, awareness of issues related to work–life balance and fostering residents’ sense of belonging and collegiality may contribute to improving their well-being and sense of fulfilment in their work.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• A large sample of residents from rural and urban practices was included, the gender ratio of which corresponded with the current average gender diversity score in the Dutch general practice (GP) residency programme.

• The method contributed a rich co-construct of perspectives, and the data were analysed thoroughly using Thick Analysis.

• Focus group interviews are prone to recall and social desirability bias.

• There were no data regarding the ethnic and cultural background of residents which undermines the representativeness and inclusiveness of the results.

• Applicability of the study results could be limited to residents in GP residency programme, which undermines generalisability.

Introduction

Educational initiatives in residency may overlook residents’ increasing struggle to find fulfilment in their work. As stated in the literature, ‘a growing number of residents may feel that residency is just a job’.¹ The educational environment in residency seems to lack alignment with residents’ learning objectives; ‘residents may become frustrated by an environment that does not let them heal or learn as they had hoped’.² In general practice (GP) residency in particular, this struggle may be even more evident given the increasing challenges the profession has been facing, including increasing workload and workforce shortages.^{3 4} These challenges were highlighted by Barnhoorn et al, who demonstrated that GP residents (hereafter referred to as ‘residents’) experience having to negotiate the norms imposed by their supervisors, and even though this negotiation is important for their professional identity formation (PIF), residents experience little opportunity to discuss challenges arising from it.⁵

PIF, the socialisation process through which medical students come to think, feel and act like doctors,^{6 7} has mainly been explored in the setting of undergraduate medical education (UGME). A limited number of studies have examined PIF in postgraduate medical education (PGME), which includes GP residency.58,14 These studies showed that autonomous experiential learning in the workplace, role modelling and the development of bonds of trust between supervisor and resident contributes to PIF. Furthermore, PIF is considered a significant conceptual area, where the focus of education is predominantly on workplace-based learning and the learner.^{15 16} PIF is, therefore, an interesting concept through which to explore the alignment between the residency’s educational programme and the resident’s learning objectives. PIF outcomes in GP residency from the perspective of GP supervisors (hereafter referred to as ‘supervisors’) have previously been explored.¹⁴ For supervisors, a good GP aspires to take ownership of patient care, self-care and the profession in general.¹⁴ However, residents’ perspectives on their professional identity in the context of the increasingly challenging primary healthcare environment have not been fully explored.

Insight into residents’ perspectives on their professional identity could potentially help inform and update the PIF curriculum and learning objectives, thereby promoting residents’ well-being and improving the sense of fulfilment in their work. To deepen understanding of this important area, this qualitative exploratory focus group study aimed to explore GP residents’ perspectives on their professional identity through the lens of the ‘good GP’.

Methods

Study design

We conducted an exploratory study from a constructivist paradigm; the outcome of the study is created by our participants voicing multiple realities and perspectives. We employed the qualitative description design as we wanted to remain close to the data,¹⁷ to construct the outcome collectively.

Procedures

Drawing on the social aspect of PIF as a process that also takes place on the collective level, we conducted focus group interviews with residents in four postgraduate GP training institutes across the Netherlands. The four institutes, Leiden (LUMC), Rotterdam (ErasmusMC), Maastricht (MaastrichtUMC+) and Groningen (UMCG), were selected to achieve a purposeful sample on the base of practice location (urban vs rural) as practice location might influence the socialisation process.¹⁸ A contact person in each institute recruited all residents in their final year to participate in the focus groups. The former yielded 12 groups with 3–13 residents. There were no dropouts, no residents who refused to participate and no repeat interviews. The focus groups were organised during regular group meetings at the training institute and started by informing residents of the research goal, the voluntary nature of the study and confidentiality. All focus group interviews were conducted in person. Residents in each focus group knew each other as they were members of fixed groups who meet weekly to follow theoretical deepening at the training institute. Table 1 describes the focus groups in more detail. The 12 focus groups were moderated by an experienced moderator (PB) between winter and autumn 2019. An observer made field notes and asked clarifying and deepening questions. A list of predetermined questions derived from the prevailing literature on PIF was pilot-tested twice before use⁵ (online supplemental material). The predetermined questions were similar in format to a semistructured interview guide allowing the moderator to probe for more detail encouraging participants to share deeper insights. We analysed residents’ responses to the question ‘What are your views on the good GP?’. The ‘good GP’ is the lens that we used to explore what residents perceive as a successful example of how a GP thinks, feels and acts in the current challenging primary healthcare environment. By using the ‘good GP’, we mainly had an outcome-oriented approach as opposed to a process-oriented approach for which the remaining questions of the focus group interview guide served. The focus group discussions lasted approximately 90 min each and were audio recorded and transcribed verbatim. The transcripts were not returned to participants for comments or corrections. Theoretical sufficiency¹⁹ was achieved after 8 out of the preplanned 12 focus groups. The quotes in the results section were translated into English by MA-S in consensus with PB and IS.

Table 1. Details of the focus groups.

Focus group number/GP institute	Number of participants	Female–male ratio	Date of focus group
1. The Hague I	4	4–0	6 March 2019
2. The Hague II	6	3–3	6 March 2019
3. Groningen I	7	7–0	18 July 2019
4. Groningen II	8	6–2	18 July 2019
5. Leiden I	7	6–1	20 March 2019
6. Leiden II	3	2–1	3 July 2019
7. Leiden III	5	3–2	17 July 2019
8. Leiden IV	6	4–2	21 August 2019
9. Maastricht	9	5–4	17 September 2019
10. Rotterdam I	12	9–3	14 February 2019
11. Rotterdam II	12	9–3	28 March 2019
12. Rotterdam III	13	8–5	23 May 2019

GPgeneral practice

Study context

The Dutch national 3-year GP residency programme consists of workplace-based learning combined with formal training activities. In years 1 and 3, residents learn and work at a practice with a single supervisor. Year 2 consists of rotations in hospitals, nursing homes and psychiatric outpatient clinics. The residents’ working week consists of 4 days of workplace learning and 1 day of theoretical deepening at the GP training institute. Focus groups were conducted with residents in four different residency programme institutes. Each resident had the same supervisor for a minimum of 12 months. This one-to-one continuous relationship is known to result in a less hierarchical workplace culture compared with the hospital setting.²⁰

Similar to the UK, the core of primary care in the Netherlands is that the GP aims for continuity of care and provides a mix of chronic disease management, acute care and child and women’s health management. Also comparable to the UK, GPs in the Netherlands run their own practice, are employed by a practice owner GP, or do locum work. Unlike countries such as France or Australia, the GP in the Netherlands has a gatekeeper function, authorising access to specialty care, hospital care and diagnostic tests at all times.

Reflexivity

MA-S was the primary investigator in this study which was conducted as part of her PhD in Health Professions Education. She was also a GP resident at the time of data analysis and dissertation writing and as such had the position of an ‘insider’ researcher in relation to residents.^{20 21} The interdisciplinary research team consisted of two male GPs (PB and MEN), a male intensivist (WNVM) and a female educationalist (IS), all of whom are experienced educational researchers. IS gave her educational insight to complement the construct of four physicians. PB, an insider in the research field, chairman of the national Professionalism Committee and of the equivalent local body at Leiden university, conducted all 12 focus groups. He had no prior working or supervisory relationships with participants. WNVM is also an insider in the medical education research field, chairman of a local professionalism committee and Professor of Professional Development. The research team had frequent discussions about each other’s perspectives to add nuance to the issues at hand.

Analysis

We applied the principles of Thick Analysis (TA), a systematic cyclic process whereby data are segmented yet remain related to the whole.²² TA involves a reflective activity where researchers creatively engage with the data using constant comparison. MA-S initially made the data manageable by inductively allocating thematic codes to the content of the focus group interviews. The thematic codes mainly consisted of attributes of the ‘good GP’ as named by residents. The thematic codes were discussed with IS and PB following immersion in the data from 6 of the 12 interviews separately by MA-S, IS and PB. Interpretation of each segment showed at this early point that residents describe the ‘good GP’ mainly using causality, occasionally using metaphors and at times using contradiction. As a result and to connect the generated codes, IS, PB and MA-S separately performed causal, metaphor and contradiction analysis for each of the six interviews.²³ MA-S repeated comparable analyses of the remaining six interviews. The generated codes were entered into Excel 2010. Producing overarching codes, tertiary analysis was performed to describe and clarify how the newly generated data segments were related to each other.²³ Participants were not asked to provide feedback on the findings.

We used TA to enhance the depth and breadth of data analysis by creatively combining several methods, allowing for a more comprehensive analysis.²² In addition, despite being systematic, TA appealed to us as being an eclectic operation that motivates researchers’ freedom and creativity.²²

Patient and public involvement

None.

Results

12 focus groups consisting of 92 third-year residents at four GP training institutes across the Netherlands were conducted. 67 (73%)of the residents were female.

For residents, being a ‘good GP’ means being able to negotiate the endlessness of practicing the profession. The perceived endlessness was manifest in four intertwined areas namely, the GP:

1. As an accessible healthcare provider.

2. As a collaborative spider in the care-web.

3. Providing personalised care.

4. Maintaining a work–life balance.

In the following section, we first describe how this endlessness related to each area. Subsequently, we describe how residents think that ‘good GPs’ should deal with the endlessness in each area. Illustrative quotes are marked by each participant’s gender (F/M) and focus group interview number (1–12). Table 2 indicates areas of endlessness discussed in each focus group.

Table 2. Areas of endlessness discussed in each focus group.

Focus group number/GP institute	Areas of endlessness
1. The Hague I	1, 2, 4
2. The Hague II	1, 2, 3
3. Groningen I	1, 2, 4
4. Groningen II	1, 2, 3, 4
5. Leiden I	1, 2, 3
6. Leiden II	1, 2, 4
7. Leiden III	1, 2, 4
8. Leiden IV	1, 2, 3, 4
9. Maastricht	1, 3, 4
10. Rotterdam I	1, 2, 3
11. Rotterdam II	1
12. Rotterdam III	1, 3, 4

GPgeneral practice

To negotiate the endlessness of the profession, GPs need to set boundaries which, in turn, renders constant boundary negotiation inevitable.

without setting boundaries, you’ll find out that your work is never finished, so setting boundaries I think ultimately benefits patient care in the long run. (F9)

To describe the ‘good GP’, residents predominantly used causal relationships, metaphors and contradictions. In causal relationships, the cause was how GPs think, feel and act, and the effect was the reactions of others:

If you’re empathetic, patients will feel at ease to share their concerns freely, so you will be able to reassure them better. (M2)

In addition, residents used metaphors such as ‘winning the war’, ‘setting boundaries’ and ‘finding a balance’ when describing the ‘good GP’. Analysis of the contradictions yielded contradicting statements, demonstrating residents’ internal dilemmas when practicing an endless profession:

If they (patients) want a shoulder to cry on… because not every patient has a shoulder to cry on … But that’s not my role. (F1)

1. The GP as an accessible healthcare provider

The endlessness of practicing the profession was manifest in being a service-oriented first port of call for a patient population with whom the GP has longstanding relationships.

As a generalist, not only do GPs deal with a broad variety of medical and psychosocial issues but also

patients come with the strangest questions. They think: I’ll just start with the GP. (F7)

Furthermore, GPs are service-oriented. Residents elaborated on overwork and patients’ over-reliance on GPs as drawbacks to being service-oriented:

you can also lose yourself in it and people can kind of unconsciously abuse that by starting to call you every day. (F2)

Largely due to their longstanding relationship with patients, GPs struggle with their dedication to stay engaged with their patients’ lives;

I too would love to be a doctor patients praise, but there are boundaries: patients are better off too. (F1)

Some residents enjoy being a generalist;

I am a kind of squirrel who always looks for a new sparkle in things and flies at a lot of things. (F9)

Some residents, however, negotiate the endlessness of being a generalist by setting boundaries to it;

you are not an all-rounder. (F3)

Also, residents figuratively emphasised not being

rescuing angels for every patient (F3),

and stressed the importance of refusing patients non-medical requests.

Setting boundaries around being service-oriented is essential as

GPs already work hard in the nine to ten hours they work. (F8)

Furthermore, ‘good GPs’ maintain a professional distance from patients, which they think preserves the quality of not only healthcare, but also their own well-being;

you can’t sleep with all these patients in your head. (F1)

2. The GP as a collaborative spider in care-web

The endlessness of practicing a profession that is subject to ongoing transformation from a solo to a collective practice and from ‘individual patient responsibility’ towards ‘community-oriented primary care’, manifested in residents’ emphasis on establishing multiple collaborations. The ‘spider’ GP should determine why and with whom to collaborate, and how to shape this collaboration.

You have to win the war together, not only with your patient, but also with the chronic disease practice nurse, your assistants, also the dietician, the physical therapist, and the home care provider. (F7)

To negotiate the endlessness of dealing with collaboration, communication skills are essential;

you do a little bit and communicate that well with the team. (AF1)

Also, good GPs should be able to deal with and accept collaborators’ diversity of perspectives;

you sometimes take the lead, and others leave that to the person who knows more about it than you do. (AF3)

3. The GP providing personalised care

The endlessness also manifested in the myriad ways in which personalised care can be provided. In addition to personalised care around patient-specific characteristics,

I don’t think it’s appropriate to pull out all the stops when a 95-year-old complains of chest pain who gets about everything imaginable (M4),

the ‘good GP’ pursues personalised care in the sense of empathy;

If they (patients) want a shoulder to cry on… because not every patient has a shoulder to cry. (F1)

Also, the ‘good GP’ provides personalised care in the sense of practice organisation;

patients don’t have to call or visit the practice for an answer when e-consultations can offer a solution. (M5)

Residents’ emphasis on the importance of being familiar with their patients’ medical and personal history to provide personalised care also demonstrated the endlessness of practicing the profession;

When I think of a GP I immediately think of someone who knows what’s going on in their patient’s family. (M12)

Residents internally negotiate what belongs to their responsibilities as part of their pursuit of providing personalised care. In her dedication for personalised care, this resident, after ample consideration, embraced the more general task of a caregiver:

a terminally ill man who lived alone at home and had home care, but for all sorts of reasons that didn’t work out well enough. I visited him just around lunch time and he was lying there in his own faeces. I thought: of course that’s not my job, but I can’t leave things like that, can I? So then I picked him and washed him and all that. And yes, I wonder if you would see a surgeon do that. (F8)

4. The GP maintaining a work–life balance

The last area where the endlessness of practicing the profession was manifest concerned residents’ work–life balance. Residents frequently mentioned issues related to their well-being and the many ways it could be compromised. One resident elaborated on their supervisor who compromised his own well-being to provide continuity of care:

patients call him in the night as half of his practice population has his private number. (F1)

In addition, residents must balance multiple responsibilities, whether professional or non-professional;

we have multiple roles, we need to keep a lot of balls in the air. (F1)

By saying

one works now to live and does not live to work (F8)

and

burnout is lurking among GPs (F6),

residents argued that ‘good GPs’ should learn to balance their energy-depleting responsibilities, which are primarily patient care-related, with energy-releasing activities that seem to be possible in personal, ‘free’ time.

To negotiate the endlessness of maintaining a work–life balance, a ‘good GP’ is perceived to set boundaries to work. Furthermore, as residents associated well-being with ‘life’ in the work–life binary, they give precedence to ‘life’ as their well-being was considered a prerequisite for the quality of patient care they can provide.

You yourself are the most important precondition for the care you can provide for your patients. If you are not functioning, the patient has no family doctor. If your head is full or you’re overworked then yeah, you just really do need your brain in this profession. (F7)

Discussion

In this study, focus groups were conducted to understand residents’ perspectives on their professional identity through the lens of the ‘good GP’ to help inform the PIF curriculum and learning objectives. Residents perceived the ‘good GP’ as being able to negotiate the endlessness of practicing the profession. That endlessness was perceived to manifest in four intertwined areas, namely, the GP, as an accessible healthcare provider, as a collaborative spider in the care-web, providing personalised care and maintaining a work–life balance. The essence of the ‘good GP’ was considered to be the ability to negotiate between the various dilemmas that a GP must deal with in relation to these four areas.

In this section, we consecutively attempt to clarify the results presented and compare them to the perspectives of residents and supervisors presented in the literature on PIF, subjectification and well-being.

The endlessness of practicing the profession

Residents appear to be overwhelmed by their profession. This state of being overwhelmed can however provide an interesting educational opportunity giving excellent potential to enhance residents’ PIF. Not addressing this issue might even compromise residents’ PIF when they lose track of ‘who they are’ in the midst of the profession’s endlessness. Supervisors are perceived to have a coaching role in guiding residents through the negotiation of endlessness. They do this by unravelling, the areas in which residents experience endlessness, the relationship between these areas and the ‘who I am’ of the individual resident. The former can be referred to as ‘guided negotiation’, that is to say, residents’ negotiation of the profession’s endlessness that is guided by supervisors. Subjectification, a philosophical concept that advocates approaching a subject with their own freedom and agency,²⁴ could contribute to this guided negotiation. Residents come to think, feel and act as GPs according to the norms and values of the GP professional group through PIF. To compliment residents’ PIF and mitigate their tendency to merely copy their supervisors (particularly when they feel overwhelmed), subjectification grants a voice to residents themselves and facilitates the emergence of the unique individual (subject) behind the resident.¹⁵ According to Biesta, whenever there is a choice to make, learners are in a state of negotiation between the world (norms and values of the professional group) and themselves. The role of the teacher (supervisor) is to support the learner (resident) in finding a middle ground.²⁵ When being overwhelmed by the profession’s endlessness could lead residents to solely copy their supervisors by doing what is most practical, rather than making a choice that aligns with the residents’ own unique identity, guided negotiation can endorse the ability of the resident to reach a middle ground.

The supervisors’ perception of the ‘good GP’

As described earlier, supervisors perceived the ‘good GP’ as one who demonstrates ownership over patient care, self-care and the persistence of the profession.¹⁴ An important item in the ownership of patient care is providing relational continuity of care.²⁶ Also, the essence of ownership over the persistence of the profession from the perspective of supervisors is embodied by becoming a GP partner.¹⁴ In the current study, due to their views on collaboration, residents seemed to view continuity of care, however, as a collective as opposed to an individual responsibility. In our study group, residents’ discourse on the ‘good GP’ does not correlate with supervisors’ advocacy for becoming a GP partner. Instead, residents feel that they are faced with a seemingly endless profession on many levels and that constant negotiation between these levels is inevitable. The former posits questions about the educational alliance between supervisors and residents; residents seem to partially think, feel and act as supervisors ‘socialise’ them to be. The perceived differences in PIF outcomes in GP residency by supervisors and residents respectively may help inform PIF curriculum and learning objectives in GP residency. The sense-making of these differences may centre on the attribution of intent to work towards common goals, for which dialogue is the evident joint starting point. Both residents and supervisors should now embark on this collaborative voyage in the interests of both GP as a profession and in the interests of society in general.

Residents’ well-being

We noted that residents’ concerns about their well-being emerged in their narrative on GPs maintaining a work–life balance. Residents seemed to perceive work-related tasks as energy-depleting and to experience well-being through energy-releasing activities, particularly outside work. The link between setting work boundaries and well-being is long-established. This was demonstrated in a qualitative study carried out more than two decades ago demonstrating that intensive care residents emphasise balancing their professional and personal lives.²⁷ A more recent study showed not only that GP residents experience challenges in negotiating their professional and personal roles but also that there is little room for discussing these challenges with their supervisors.⁵ Residents’ well-being could thus be jeopardised by supervisors who, in their targeting of an ‘end in mind’, might overlook the resident’s need to address issues related to work–life balance within a contemporary, overwhelming, endless profession which makes residents even less likely to raise such issues.

The literature on professional well-being advocates initiatives that highlight the experience of meaning at work, and the connection, not competition, between work and life.^{28 29} To support residents in achieving a sustainable sense of well-being, educational initiatives in residency should thus target the experience of well-being within the working environment. Research in UGME has identified a sense of belonging and collegiality as being protective against burnout and as a contributor to well-being in the workplace.^{30 31} It can be argued that a sense of belonging and collegiality can also play a prominent role in the well-being of GP residents at work due to the context of that work mainly consisting of workplace-based learning alongside various medical, paramedical and administrative personnel. A constructive, nonjudgmental dialogue is essential to foster residents’ feelings of being accepted and valued by others (a sense of belonging)³⁰ and to develop a sense of social resilience through connecting with colleagues in the workplace (collegiality).³⁰ Evidently, supervisors play an indispensable role in addressing residents’ work–life balance-related issues and fostering residents’ sense of belonging and collegiality, which in turn fosters well-being.

Strengths and limitations

To our knowledge, the current study is the first in PGME that has explored residents’ perspectives on their professional identity in the current challenging primary healthcare environment. A large sample of residents from rural and urban practices was included. Moreover, the gender ratio corresponded with the current average gender diversity score in the Dutch GP residency programme. In addition, the method contributed a rich coconstruct of perspectives, and the data were analysed thoroughly using TA. However, there are some limitations. Focus group interviews are prone to recall and social desirability bias. There were no data regarding the ethnic and cultural background of residents, which undermines the representativeness and inclusiveness of the results. In addition, the applicability of the study results could be limited to residents in the GP residency programme which undermines generalisability.

Practical implications

In primary care, negotiation is not confined to the notorious work-–life binary but rather extends to four intertwined areas. To facilitate guided negotiation, this study provides insights into how supervisors should coach residents on how to reflect on their individual, identity-driven negotiation of these areas.

To foster bonds of trust between residents and supervisors and eventually supervisor–resident educational alliance in GP residency (and more generally in PGME), supervisors and faculty should adapt an open and encouraging attitude towards discussing possible differences in the perception of the ‘end in mind’ in GP residency. Fostering bonds of trust between residents and supervisors and enhancing educational alliance is perceived to promote residents’ well-being.

Conclusion

GP residents’ narratives highlight the increasing challenges of their profession. From their perspective, a ‘good GP’ is perceived by residents as someone who is able to negotiate the endlessness of practicing the profession. By deploying the concept of subjectification while guiding residents’ negotiation of the profession’s endlessness, supervisors play a key role in reinforcing residents’ PIF, and thereby in possibly improving supervisor-resident educational alliance. Addressing work–life balance-related issues and fostering residents’ sense of belonging and collegiality could promote their well-being and eventually their sense of fulfilment in their work.

Data availability statement

Data are available upon reasonable request.