Career satisfaction of German human genetics residents

Introduction

Physician shortages in Germany, an issue that has been particularly challenging for rural areas and small disciplines, have become an increasing concern in health care as well as among health scholars and policy makers in the last years. In this context a focus was placed on the career satisfaction of residents and the conditions of specialty training reflecting the increasing importance of the resource “clinician.” In 2009 the German Medical Association first conducted a survey among German residents to determine the quality of specialist training in Germany assuming a correlation between the quality of specialist training and motivation for leaving medical care and moving into other professions. To ensure comprehensive and high-quality patient care, not only a sufficient number of medical graduates, but also their satisfaction in the course of their careers is important [1]. So far, specific data on the subjective assessment of specialist training in human genetics have not been available. We therefore conducted a survey to obtain data on the quality of specialist training and on factors influencing career satisfaction and life satisfaction among human genetics residents in Germany.

Methods

For the development of our questionnaire, we adapted validated questionnaires from the literature described below. In expert rounds with three members of the “Junge Humangenetik,” the forum for young doctors and scientists of the German professional society for human genetics (GfH e. V.), further items were added to the questionnaire regarding sociodemographic variables, variables concerning the institution of residency training and variables concerning the personal professional life and residency in general. The complete questionnaire can be obtained from the corresponding author. After an initial pre-test stage 59 items were chosen for the final questionnaire. In addition, the submission of free text answers was available for certain topics. The online questionnaire was realized using SoSci Survey (Leiner, D. J. (2019). SoSci Survey (Version 3.1.06) [computer software]; available at https://www.soscisurvey.de) and made available to participants at https://webext.mh-hannover.de/soscisurvey/humangenetik2020/. Data were collected anonymously and stored on a server of the Hannover Medical School.

By using the publicly available databases of the 17 state medical associations in Germany we identified 71 institutions employing doctors who are entitled to further specialist training. In each institution one physician (to avoid multiple feedback) was sent an e-mail and informed about the planned survey and asked to provide feedback on whether and how many residents were employed in the institution. In a second step those institutions who had provided feedback were sent the link for the online questionnaire and asked to redirect it to their residents. In addition, we used the mailing list of the “Junge Humangenetik” to distribute the link for the survey. The survey was available for 10 weeks from January to March 2021. Two reminder e-mails were sent.

Results

Discussion

Recent years have brought a substantial increase in genetic knowledge that goes hand in hand with an increasing demand for genetic services and genetic counselling. The number of specialist doctors for human genetics in Germany is currently around 360 [7]. The need for genetic counselling in Germany can be estimated at some 100,000 consultations per year, considering that more than 25,000 patients per year are newly diagnosed with a hereditary cancer, around 47,000 children per year are born with a genetic condition or a malformation, more than 3 million people are affected by a rare genetic disease and 8,500 invasive prenatal examinations are carried out each year, with a subsequent need for genetic counselling and the resulting need of care for family members at risk [8]. The estimated current need for care can already hardly be met with the existing number of specialists today. Due to advantages in genetic knowledge and the increase in therapeutic options, the need for genetic services and counselling will increase dramatically in the next years, which makes it even more important to regard residents as a valuable resource that will ensure human genetics care in Germany in the future. A cornerstone for securing a high standard of specialist care in human genetics is a high-quality specialist training. However, satisfaction with one’s own career is at least as important in order to prevent migration to other disciplines or to other professions.

As early as 1989 Schwartz et al. identified a “controllable lifestyle” (CL) as a new factor in career choice by medical students, for both women and men. Specialties featuring a CL, i. e. control of work hours, work load and work–life balance, included, among others, anaesthesiology, pathology and radiology, whereas specialties like surgery, internal medicine, paediatrics or obstetrics–gynaecology were defined as non-CL specialties. It was observed that the percentage of top medical students in the USA (i. e. those who were able to obtain the specialty of their choice) entering CL specialties had significantly increased over the last decade [9]. This trend has been confirmed in recent years, also outside the USA. Residents place more emphasis on work–life balance when selecting their specialty and prefer CL specialties over non-CL specialties. Furthermore, residents are more likely to change their choice of specialty, contrary to their professional interest, because of social reasons [10]. The increasing feminization of medicine requires innovative and flexible working time models and part-time career options that enable shared care work in the family. In this context human genetics can be regarded as a CL specialty.

Consistent with the existing studies our survey also shows a high level of overall career satisfaction among human genetics residents in Germany. The largest survey in Germany concerning career satisfaction of medical residents has been conducted by van den Bussche et al., evaluating longitudinal data of initially over 1,000 German medical residents. In their study gender and parental status significantly influenced career satisfaction, with female residents with children showing a significantly lower career satisfaction than their male colleagues with or without children, a finding consistent with other studies measuring career satisfaction among residents [1], [11], [12]. In our survey, women with children had lower scores with regard to achieving their professional goals and to their perceived progress in their professional life compared to women without children. In contrast, no significant differences were found between men with and men without children. This may be explained by the fact that women still carry a main part of care work. Apart from this, neither parental status, nor gender, nor working part time had a significant effect on career satisfaction. In the German health care system specialist care is provided in both the inpatient and outpatient sectors. For human genetics this means that specialist training can be completed in academic institutions belonging to university hospitals or private practice/medical care centres that offer medical care within the framework of statutory health insurance accredited medical care. In our cohort 65 % of residents received their specialist training at an academic institution and 35 % in private practice/medical care centres. The site of the specialist training had no influence on career satisfaction. It can be speculated that most institutions of our cohort try to install working and career conditions which meet the above-mentioned needs of residents regarding gender equality and reconciliation of family and career, a fact that should be brought into sharper focus when recruiting young residents.

However, the fact that there is a significant difference in research activities between male and female residents, even if this does not seem to have an impact on career satisfaction, should warrant attention. The unequal distribution could not be explained by an unequal distribution of male and female residents with regard to the site of specialist training, assuming that research mainly takes place at academic institutions. In academic institutions more males than females participate in research, as well as more male residents with children than female residents with children. Interestingly, at academic institutions, 80 % of women and 77 % of men have doctorates, so the starting conditions for research are the same, so the women are lost somewhere down the line. Since research activities are a prerequisite for further career progression, this unequal distribution can lead to an unequal recruitment of men and women for leadership positions further down the line. The institutions should investigate potential structural reasons that hamper female residents’ research activities and promote research activities of female residents e. g. by the implementation of programmes for the support of female researchers, mentoring programmes, adapted working time models or networking programmes.

Consistent with previous studies [1], in our model the highest influence on career satisfaction came from the occupational self-efficacy expectations, meaning confidence in the own professional capability. There is a complex relationship between occupational self-efficacy expectations, perceived workload, perceived stress and burnout prevalence, with residents with lower occupational self-efficacy expectations exhibiting higher levels of stress [13]. Overall burnout syndrome prevalence among human residents has been shown to be around 35.7 % [14]. Studies generally show that burnout is associated with an increased workload and that a higher career satisfaction is consistently associated with less burnout [15], [16], [17]. Lower occupational self-efficacy expectations and burnout influence specialty choice already at the stage of medical students [18]. In this context it seems positive that the perceived subjective workload was generally moderate in our cohort, with lowest item scores for the subjective frustration. No correlation between career satisfaction and workload could be observed. However, it also shows that the foundations for a high level of occupational self-efficacy expectations must already be laid in medical school by teaching skills for the successful practice of medicine and by establishing prevention strategies for unrealistic occupational self-efficacy expectations and burnout. In the years of residency, it is up to the doctor and the institution responsible for the specialty training to ensure that there is an appropriate balance between the resident’s existing skills and the transfer of responsibility.

In recent years, it has been increasingly recognized that the individual teacher has a significant influence on learning success and the acquisition of competences [19]. As shown by Buxel, the satisfaction with the specialty training situation, working atmosphere, workload and leadership style greatly influence general job satisfaction [20]. Overall appreciation of leadership, guidance of residents during training, specific instructions and communication skills positively influence job satisfaction, highlighting the impact of the supervisors’ behaviour [21]. In short, it depends on the teacher. This fact has been recognized in the new regulations for specialty training issued by the state medical associations of Germany in 2020 linking the entitlement for specialty training with participation in “train the trainer” courses issued by the medical associations. The importance of evaluating the quality of the specialist training and the doctors entitled to specialty training has long been recognized and is an existing standard in countries like the USA [5]. Especially in smaller institutions, this is rarely carried out despite the existence of validated measurement instruments such as those of Prien et al. because anonymity is not given in the survey and negative effects on the relationship between the doctor entitled to the specialty training and the resident are feared [5]. However, also in line with previous studies [1], our survey shows a significant correlation between the excellence of the doctor entitled to the specialist training and residents’ career satisfaction. The residency institutions and the doctors entitled to the specialist training must be aware of the responsibility and take measures to constantly ensure a permanent good quality of specialist training.

Residents’ assessment of their own professional prospects and the prospects of the subject are consistently positive. However, the results of the survey show that the human genetics community in general and their respective professional societies have two tasks to fulfil: First human genetics as a specialty must be firmly anchored in the consciousness of other medical colleagues and the general population. Secondly, at the political level, conditions must be created to give residents a long-term perspective in the subject. The existing requirement planning guideline not only stands in the way of adequate care; it also leads to the absurd situation that, despite increasing demand for genetic services, not all residents may be able to obtain the authorization to treat statutory health insurance patients by the Association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung) after passing the specialist examination and could thus be forced to migrate to other disciplines or professions.

Conclusion

Career satisfaction of German human genetics residents is generally high and mainly influenced by life satisfaction, occupational self-efficacy expectations and quality of the specialist training. In contrast to other specialties career satisfaction seems to be independent from gender or parental status even though male residents were significantly more often involved in research activities. In order to keep human genetics residents in the specialty, measures that enable balanced professional and care work as well as continuous improvement of specialist education, e. g. through the implementation of structured curricula and continuing education of the doctors entitled to specialist training, are of great importance.