Willingness to commute among future physicians: a multicenter cross-sectional survey of German medical students

Willingness to commute among future physicians: a multicenter cross-sectional survey of German... Background: Many countries are faced with a decrease in physicians in non-urban areas. Especially for regions with decreasing populations, temporary solutions like commuting models might be a suitable option. So far, little is known about the willingness to commute among future physicians. Methods: In this multicenter, cross-sectional survey, five years of medical students (8th to 10th semester) from three German universities (Charité Berlin, Halle, Leipzig) were questioned about their willingness to commute to work, the maximum acceptable commute time, and how several job-related factors might enhance the attractiveness of commuting. Results: Altogether 1108 of 1203 (92.1%) students completed the questionnaire. For 55.9% of the participants it was imaginable to commute to a non-urban area in the future. The most important job-related factors that would increase the attractiveness of such a commuting model were remuneration of the commuting time, higher remuneration in general, working self-employed in a joint practice with 2–3 physicians, existence of a specifically qualified “supply assistant”, provision of a home office, good public transport connection, and a driver service. The maximum acceptable commute time was on average 39.0 min (one-way). If the way to work would be a salaried integral part of the normal working time, the participants stated they would accept traveling 51.2 min (one-way). Conclusions: Most future physicians are open-minded regarding models of commuting. The attractiveness of such models can be increased mainly through higher remuneration, reduction of the physicians’ burden, and comfortable modes of transport. Keywords: Physician shortage, Commuting, Non-urban areas, Primary care, General practice Abstract German Hintergrund: Viele Länder stehen vor der Herausforderung eines zunehmenden Ärztemangels in ländlichen Regionen. Insbesondere für Gebiete mit rückläufigen Bevölkerungszahlen könnten Pendelmodelle eine praktikable temporäre Lösung darstellen. Über die Pendelbereitschaft zukünftiger Ärzte ist bisher wenig bekannt. (Continued on next page) * Correspondence: tobias.deutsch@medizin.uni-leipzig.de Johannes Quart and Tobias Deutsch contributed equally to this work. Department of General Practice, Medical Faculty, University of Leipzig, Leipzig, Germany Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Quart et al. Journal of Occupational Medicine and Toxicology (2018) 13:17 Page 2 of 9 (Continued from previous page) Methoden: In dieser multizentrischen Querschnittsstudie wurden fünf Jahrgänge von Medizinstudierenden (8. bis 10. Semester) aus drei Universitäten (Berlin, Halle, Leipzig) zu Ihrer Pendelbereitschaft befragt. Außerdem wurden maximal akzeptable Fahrzeiten und der Einfluss verschiedener Arbeitsbedingungen auf die Attraktivität des Pendelns erhoben. Ergebnisse: Von 1203 Studierenden in den untersuchten Jahrgängen erhielten wir 1108 analysierbare Fragebögen (92.1%). Für 55.9% der Teilnehmer war es vorstellbar, zukünftig in ländliche oder kleinstädtische Regionen zu pendeln. Den stärksten positiven Einfluss auf die Attraktivität eines solchen Pendelmodells hatten eine Vergütung der Fahrzeiten, eine generell höhere Vergütung der Tätigkeit, die Arbeit in einer Gemeinschaftspraxis (2–3 Ärzte), die Entlastung durch qualifizierte „Versorgungsassistenten“, die Bereitstellung eines Home-Office, eine gute Anbindung an öffentliche Verkehrsmittel und ein Fahrservice. Grundsätzlich betrug die maximal akzeptable Fahrzeit (eine Strecke) durchschnittlich 39.0 Minuten. Wäre die Fahrzeit bezahlt und Teil der regulären Arbeitszeit, würden die Teilnehmer durchschnittlich 51.2 Minuten je Strecke akzeptieren. Schlussfolgerung: Die zukünftigen Ärzte stehen Pendelmodellen mehrheitlich offen gegenüber und könnten primär über Vergütung, Reduktion der Arbeitsbelastung und komfortable Beförderungsmöglichkeiten motiviert werden. Background of medical students (8th to 10th semester of altogether 10 There is a decrease in physicians in non-urban areas in semesters plus 2 semesters final clinical year) from three many countries, including Germany [1–3]. Particularly German universities (Charité Berlin, Halle, and Leipzig). the growing shortage of primary care physicians will in- In Leipzig, students completed the questionnaires at the creasingly threaten adequate medical care for an aging beginning of a mandatory geriatric self-experience course population in many regions [4]. The perspective of living in a (10th semester) and prior to the written exam following non-urban area seems to be relatively unattractive for young the lecture series in general practice (8th semester), re- physicians today [5]. The reasons are diverse and include spectively. In Halle, students completed the questionnaires perceptions of demanding working conditions, inadequate at the end of a mandatory two-week general practice payment, limited opportunities for personal and professional clerkship (9th semester). In Berlin, students answered the development, less job opportunities for spouses as well as questionnaire at the beginning of a mandatory general limited educational opportunities for children [2, 6]. Regard- practice seminar (10th semester). less of the medical profession, in Germany there is a general trend towards a concentration of the population in attractive Questionnaire urban regions. Interestingly, although particularly shaped by We used a self-developed questionnaire created by a young adults starting out at their first job, this trend is not multidisciplinary team (general practitioner, general primarily linked to the local availability of jobs [7]. practice resident, psychologist, and economist). To en- Several studies have been conducted to identify factors sure comprehensibility, usability and face validity, the attracting or inhibiting young physicians establishing or questionnaire was pre-tested with two medical students taking over rural doctors’ offices [8]. However, in some in advanced study years (target group). The pre-testing regions the population and thus the supply needs are procedure was oriented towards the qualitative method continuously decreasing, querying the economic viability of concurrent think aloud (CTA) and led to minor ad- of local doctors’ offices in the long run [9]. justments with regard to content and form. Particularly for those regions temporary solutions like Survey participants were questioned about relevant commuting models might be a pragmatic option to fill socio-demographic information, current career preferences, gaps in healthcare availability. So far, little is known their willingness to commute to a non-urban area while liv- about future physicians’ attitudes regarding commuting. ing in an urban environment (as a hypothetical scenario), This study aimed to examine medical students’ willing- and the maximum acceptable commute time (one-way ness to commute in the future, maximum acceptable from home to workplace/ door to door). Furthermore, they distances, and how different job-related factors might were asked to assess how several work-related factors positively influence the willingness to commute. would positively influence their readiness to commute. Methods Statistical analysis Sampling and design Data were analyzed using IBM SPSS Statistics 24 for Between May 2015 and May 2016 we performed a Windows. As N’s may vary due to missing values, frequen- cross-sectional questionnaire-based survey among 5 years cies are presented as % (n /n ). Continuous valid absolute valid Quart et al. Journal of Occupational Medicine and Toxicology (2018) 13:17 Page 3 of 9 variables are presented as mean ± standard deviation (SD). Results Chi-square test was used for group comparisons with re- Out of altogether 1203 students 1114 returned a ques- gard to frequencies. Continuous variables were compared tionnaire. After the exclusion of six only fragmentarily using the Mann-Whitney U test in the case of two groups filled out forms the analyzable sample size was 1108, and the Kruskal-Wallis test in the case of more than two corresponding to a response rate of 92.1%. The partici- groups. Statistical significance was assumed for p <0.05. pants’ age was on average 25.3 ± 3.2 years and 64.4% (714/1108) were women. Detailed sample characteristics Cartographic presentation (isochrones map) are shown in Table 1. For 11.8% (126/1069) of the stu- To illustrate the practical consequences of our results dents, general practice was the currently preferred career regarding the maximum accepted commute times within option. With regard to their future place of residence different scenarios we created a geographical map with 71.1% (779/1096) of the students stated that they could isochrones lines. As a map of Germany would have been imagine to live in a big city, 64.6% (708/1096) could im- too complex, we decided to show the areas of Saxony agine to live in a small town and 42.7% (468/1096) in a potentially covered by commuting. The underlying com- rural area (multiple answers were possible). For 24.5% muting times were nevertheless derived from the whole (269/1096) of the participants living in a big city was the sample (including Halle, Leipzig, and Berlin). As in only option. Germany medical study places are awarded centrally, pri- Regarding whether they can imagine commuting to a marily based on school leaving examinations, students’ rural/small-town area for work while living in a big city places of origin, study places, and later workplaces are (as a hypothetical scenario), 10.4% (115/1106) of the often not the same. Considering this, although focusing participants answered “definitely yes”, 45.5% (503/1106) on the example of Saxony, the use of all data seemed to be “rather yes”, 35.7% (395/1106) “rather no”, and 8.4% (93/ most realistic. We used ISO4APP API [10], a software tool 1106) “definitely no”. Among those who considered a big based on “openstreetmap” [11], which is made available city as their future place of residence 60.7% (472/777) for free under the Open Database License [12]. The iso- could imagine commuting to a rural/small-town area chrones lines were created for the scenario of driving by (“definitely yes” or “rather yes”). Among those who stated car at average daily traffic from the city-center of one of that living in a big city is the only option 44.2% (118/ the three big cities in Saxony with more than 100,000 in- 267) could imagine commuting (“definitely yes” or “ra- habitants (Dresden, Chemnitz, and Leipzig). ther yes”). Based on bivariate comparisons we found no Table 1 Sample characteristics a b Variable valid (N) N (%) Sub-Sample (university, year, course, semester) 1108 Leipzig, 2016, geriatric self-experience course, 10th semester 259 (23.4) Leipzig, 2015, geriatric self-experience course, 10th semester 259 (23.4) Leipzig, 2016, general practice exam, 8th semester 274 (24.7) Berlin, 2015, general practice seminar, 10th semester 159 (14.4) Halle, 2015, two-week general practice clerkship, 9th semester 157 (14.2) Age [mean ± SD] 1103 25.3 ± 2.3 Female gender 1108 714 (64.4) Living in a stable relationship 1089 680 (62.4) Having children 1094 98 (9.0) At least one parent with university degree 1100 837 (76.1) Being a physician’s child 1106 290 (26.2) Family or friends in general practice 1104 341 (30.9) Pre-existing concluded education in a medical occupation 1103 244 (22.1) Mainly grew up in … 1098 ... big city 422 (38.4) … small town 369 (33.6) … rural area 307 (28.0) N’s vary due to missing values Unless otherwise indicated Quart et al. Journal of Occupational Medicine and Toxicology (2018) 13:17 Page 4 of 9 significant associations between the willingness to com- to a future workplace in a non-urban area while living in mute (“definitely/rather yes” vs. “rather/definitely no”) a big city. The most crucial factors that might increase and the variables gender, age, university, stable relation- the attractiveness of commuting were associated with ship, having children, regional background, pre-existing higher remuneration, reduction of the physicians’ bur- concluded education in a medical occupation, and den (e.g. via joint practices or a qualified supply assist- current GP career preference (data not shown). ance), and comfortable modes of transport. Basically, the maximum acceptable commute time (one-way) for the surveyed students was on average Main findings in relation to other studies 39.0 ± 13.3 min (N = 1098). Regarding the scenario of liv- We found no other studies directly addressing the fac- ing in an urban but working in a rural/small-town envir- tors influencing willingness of future physicians to com- onment, the maximum acceptable commute time varied mute to a workplace in a non-urban area while living in depending on different modes of transport and payment a big city. So far, most studies have focused mainly on (Table 2). The participants accepted the longest commute how to convince physicians to settle down in rural areas time if it would be a salaried and integral part of the work- [2, 6, 13–16]. Other studies have examined general ing time (51.2 ± 22.6 min). Based on these time specifica- health aspects of commuting or the commuting behavior tions (basic and longest acceptable time), an exemplary of the whole population without consideration of specific map of Saxony showing areas potentially covered by com- professional subgroups [17–19]. Consequently, our results muting is presented in Fig. 1. are only partially comparable to the existing literature. We found no significant associations between the More than half of our study participants were maximum acceptable commute time (one-way) and the open-minded about commuting to a rural/small town variables gender, age, stable relationship, having children, area (“definitely yes” or “rather yes”). Thus, a substantial pre-existing concluded education in a medical occupation, percentage of future physicians might be convinced, if and current GP career preference (data not shown). How- not to live, then at least to work in non-urban areas if ever, there were significant differences depending on uni- the right measures are taken. For general comparison, it versity (Halle: 35.6 ± 12.1 min, Leipzig: 38.1 ± 12.6 min, can be stated that currently 60% of the German popula- Berlin: 46.6 ± 15.5 min; p < 0.001) and regional back- tion commute (home and workplace in different munici- ground (mainly grew up in big city: 40.9 ± 14.0 min, palities) [18]. Despite several studies implying relations small-town: 38.8 ± 13.7 min, rural area: 36.6 ± 11.5 min; between the willingness to commute and sociodemo- p < 0.001). graphic variables like gender and age [19–21], we found The participants were asked to what extent various no such associations in our data. However, it must be job-related factors would increase the attractiveness of considered that we examined a homogenous age group commuting to a rural/small-town area (scale from 0 = ‘no of students in their mid-twenties, and respective associa- increase’ to 4=‘very strong increase’). The respective results tions might develop later on, when life circumstances are provided in Fig. 2 as relative frequencies (100% bar change after graduation [19]. charts) and in Table 3 as means±SD (overall and depend- In our study the most important factors increasing the ing on gender and current GP career preference). attractiveness of commuting were associated with remu- neration, disburdening the physician, and comfortable Discussion modes of transportation. Previous studies investigating This study shows that more than half of German med- the willingness of physicians to establish a practice or to ical students in an advanced stage of undergraduate live and work in a rural area have also underlined the in- medical education can imagine a scenario of commuting fluence of money [6, 13, 22], flexible working times Table 2 Maximum acceptable commute time to work (one-way) depending on different conditions Maximum acceptable commute time (one-way) if … valid Mean ± SD Quartiles (minutes) N in minutes 25% 50% 75% … I go by car 1084 36.1 ± 12.9 30.0 30.0 45.0 … I go by public transport 1083 40.3 ± 15.2 30.0 40.0 45.0 … I can take part in a car pool 1064 35.5 ± 13.9 30.0 30.0 45.0 … I get picked up by a driver service 1065 39.1 ± 15.6 30.0 30.0 45.0 … time getting to work is paid as working time, additional to it 1075 47.0 ± 18.3 30.0 45.0 60.0 … time getting to work is paid as working time, included into it 1069 51.2 ± 22.6 30.0 50.0 60.0 … time getting to work is utilizable for organizational tasks 1066 43.9 ± 19.0 30.0 45.0 60.0 Quart et al. Journal of Occupational Medicine and Toxicology (2018) 13:17 Page 5 of 9 Fig. 1 Areas potentially covered by commuting in Saxony*. * related to the centers of the cities with more than 100,000 inhabitants (Dresden, Leipzig, Chemnitz) and an accepted time getting to work of 39.0 min. Outer lines show coverage by an increased accepted commute time in case of payment for travel time and integrating it into working time (51.2 min) including part-time work [22–24], the possibility to work working models, single or small joint practices and a dis- in a group practice [6, 13, 25], working as an employee burdening by “supply assistants” than their counterparts [6, 16, 24], and a reduced workload by extended medical favoring other specialties. A current study examining the staff competencies and delegation (“supply assistant”)[3, 24]. preferences of GP trainees regarding practice size and Our results indicate slight but significant gender differ- weekly working hours also found them to be attracted to ences regarding the job-related conditions increasing the work in small shared practices. However, this study attractiveness of commuting. For women, a reduction of found no direct preference to work less hours per week the workload through alternative working arrangements as long as salary is appropriate for the workload [27]. (part-time, job-sharing, joint practice, working as employee, Among the participants of our study the acceptable home-office) as well as possibilities to avoid daily car driv- commute time was on average 39 min. A survey from ing (through pick up service or car pool) seem to be more 2010 among German general practice residents found attractive than for men. This may be seen in line with a that 72% would accept up to 30 min, but only 13% up to previous study on young physicians’ decision to establish a 60 min one way [6]. For the whole German working practice that has also shown job cooperation possibilities, population it has been shown that about 47% have a way reduced workload and good reconciliation of work and to work of 10 to 30 min and about 22% a way of 30 to family to be more important to female physicians [26]. 60 min [28]. Our results indicate regional differences in Furthermore, we found that students interested in a the acceptable commute time depending on the university GP career were significantly more attracted by part-time attended (Halle<Leipzig<Berlin). Considering the Quart et al. Journal of Occupational Medicine and Toxicology (2018) 13:17 Page 6 of 9 Fig. 2 Influence of several job-related conditions on the attractiveness of commuting to a rural/small-town area (100% bar chart) significantly different size of these cities it may be as- working models (flexible working times, part-time work, sumed that students in Berlin are simply used to longer joint practices, job sharing, home office) as well as redu- commute times. This is supported by data of the German cing the physicians’ workload (e.g. through support by federal statistical office indicating longer commute times specifically qualified medical staff with extended compe- among people living in conurbations [28]. tencies). Furthermore, our results emphasize the import- Since a nationwide map would have been hard to read, ance of paying adequately for commute time and we chose Saxony as an example to illustrate areas poten- providing comfortable transportation options. Further tially covered by the accepted commute times found in our research is needed to verify the possibly higher ac- study. Furthermore, a current report of the Saxon federal ceptance of commuting in comparison to conven- government provides sufficient and detailed comparative tional “live-and-work” models and to identify more data concerning regional medical care supply problems [9]. factors that might increase willingness to commute. Altogether, our map indicates that not every Saxon region Additionally, it would be interesting to replicate our would be able to cover healthcare supply needs via com- survey among residents and young medical specialists. muting models. Interestingly, the areas not covered are currently those with the biggest difficulties [9]. Strengths and limitations This study addresses a rarely studied, innovative topic of Implications for practice and further research potential practical relevance regarding the future med- To attract young physicians to commute to non-urban ical supply in non-urban areas. Medical undergraduates areas, the respective working conditions should be modi- in advanced study years constitute a relevant target fied to ensure good remuneration and minimalized loss of group – the future physicians. The sufficient sample size, leisure time. The focus should be particularly on tailored the very good response rate and the inclusion of three Quart et al. Journal of Occupational Medicine and Toxicology (2018) 13:17 Page 7 of 9 Table 3 Influence of several job-related conditions on the attractiveness of commuting to a rural/small-town area – differences due to gender and general practice career preference Potential influence factor Students’ assessment of the increase of the attractiveness of commuting (0 = no increase, + 1 = slight increase, + 2 = medium increase, + 3 = strong increase, + 4 = very strong increase) All Male Female p* GP career Others p* preferred Mean ± SD Mean ± SD Mean ± SD Mean ± SD Mean ± SD Working time To work full-time 0.9 ± 1.3 1.1 ± 1.4 0.8 ± 1.2 0.003 1.0 ± 1.3 1.0 ± 1.3 0.882 To work full-time, but compressed to 3½ days 1.8 ± 1.4 1.8 ± 1.4 1.8 ± 1.4 0.984 2.1 ± 1.4 1.8 ± 1.4 0.044 per week To work part-time (less working days per week) 1.9 ± 1.3 1.6 ± 1.3 2.0 ± 1.3 < 0.001 2.2 ± 1.3 1.8 ± 1.3 0.005 To work part-time (reduced daily working time) 1.4 ± 1.3 1.1 ± 1.2 1.5 ± 1.3 < 0.001 1.9 ± 1.4 1.3 ± 1.3 < 0.001 Job sharing with colleagues (2 days per week rural, 1.9 ± 1.4 1.8 ± 1.3 2.0 ± 1.3 0.002 2.0 ± 1.5 2.0 ± 1.3 0.954 3 days in big city) Existence of an adequate accommodation option 1.2 ± 1.3 1.4 ± 1.3 1.2 ± 1.3 0.012 1.2 ± 1.3 1.2 ± 1.3 0.723 Defined time limit for the job (e.g. 5 years) 1.2 ± 1.2 1.2 ± 1.2 1.2 ± 1.2 0.915 1.1 ± 1.2 1.2 ± 1.2 0.243 Remuneration Time getting to work is paid as working time, 2.9 ± 1.1 2.9 ± 1.1 2.9 ± 1.1 0.876 2.9 ± 1.2 2.9 ± 1.1 0.683 additional to it Time getting to work is paid as working time, 2.9 ± 1.1 2.9 ± 1.2 3.0 ± 1.1 0.266 3.0 ± 1.1 2.9 ± 1.1 0.334 included into it Time getting to work is utilizable for organizational tasks 1.8 ± 1.3 1.9 ± 1.2 1.7 ± 1.3 0.048 1.9 ± 1.3 1.8 ± 1.2 0.174 Remuneration is significantly higher than in the big city 2.8 ± 1.1 2.8 ± 1.2 2.8 ± 1.1 0.647 2.9 ± 1.1 2.8 ± 1.1 0.436 Mode of transport Getting to work by using own car 1.6 ± 1.4 1.7 ± 1.4 1.6 ± 1.4 0.352 1.6 ± 1.4 1.6 ± 1.4 0.903 Good public transport connection 2.1 ± 1.3 2.1 ± 1.3 2.2 ± 1.3 0.223 2.2 ± 1.3 2.1 ± 1.3 0.539 Organization of a car pool 1.4 ± 1.2 1.3 ± 1.2 1.5 ± 1.2 0.017 1.4 ± 1.2 1.4 ± 1.2 0.611 A driver service is picking me up (from the doorstep 2.0 ± 1.5 1.9 ± 1.5 2.1 ± 1.5 0.020 1.8 ± 1.6 2.0 ± 1.5 0.149 to work, and back) Assuming the consideration of working office-based: legal structure and organization Working self-employed in a single practice 1.4 ± 1.3 1.5 ± 1.4 1.3 ± 1.3 0.024 1.8 ± 1.4 1.3 ± 1.3 < 0.001 Working self-employed in a joint practice 2.3 ± 1.2 2.0 ± 1.2 2.4 ± 1.1 < 0.001 2.7 ± 1.2 2.2 ± 1.2 < 0.001 (2–3 physicians) Working self-employed in a joint practice 1.7 ± 1.2 1.6 ± 1.2 1.8 ± 1.2 0.014 1.8 ± 1.3 1.7 ± 1.2 0.337 (4–6 physicians) Working as an employee of another physician 1.1 ± 1.1 0.8 ± 1.0 1.2 ± 1.2 < 0.001 1.4 ± 1.3 1.0 ± 1.1 0.002 (office-based) Working as an employee of an institution, e.g. 1.0 ± 1.1 0.9 ± 1.1 1.1 ± 1.1 0.003 1.4 ± 1.3 0.9 ± 1.1 < 0.001 municipality or KV Working as an employee of a medical employer, 1.5 ± 1.2 1.2 ± 1.1 1.6 ± 1.2 < 0.001 1.6 ± 1.3 1.5 ± 1.2 0.432 e.g. hospital or medical service center Mobile surgery (installed in a ‘surgery-bus’, continuous 0.8 ± 1.1 0.7 ± 1.0 0.8 ± 1.1 0.749 1.2 ± 1.3 0.7 ± 1.0 < 0.001 care for several municipalities on different days) Provision of a home-office to be able to do some work 2.1 ± 1.3 1.9 ± 1.2 2.2 ± 1.3 < 0.001 2.4 ± 1.2 2.1 ± 1.3 0.022 at home (e.g. organizational tasks) Existence of a specifically qualified „supply assistant“, 2.2 ± 1.2 2.1 ± 1.2 2.2 ± 1.2 0.010 2.6 ± 1.2 2.1 ± 1.2 < 0.001 disburdening the physician regarding delegable tasks Home visit patients were, if possible, picked up by a 1.6 ± 1.3 1.6 ± 1.3 1.5 ± 1.3 0.245 1.6 ± 1.3 1.6 ± 1.3 0.926 driver service and brought to me KV Kassenärztliche Vereinigung = Association of Statutory Health Insurance Physicians * p-values < 0.05 are highlighted in bold Quart et al. Journal of Occupational Medicine and Toxicology (2018) 13:17 Page 8 of 9 different universities support the representativeness of Authors’ contributions JQ contributed to the conception and design of the study, the collection, the results. As a validated instrument fitting to our re- analysis, interpretation, and visualization of the data, and was the main search questions and the target group was not available, contributor regarding the initial draft of the manuscript. TD contributed to we used a self-developed questionnaire. This might be the conception and methodology of the study, and supported data analysis and interpretation, as well as writing the manuscript. SC contributed to data discussed as a possible limitation. However, the thor- interpretation, and critically commented and revised the manuscript. SD ough development by an experienced multidisciplinary contributed to data collection, and critically commented and revised the team and the pre-testing of the questionnaire ensure at manuscript. TF initiated and supervised the study, contributed to conception and data interpretation, and revised the manuscript. All authors read and least face validity. Another limitation might result from approved the final version of the manuscript. the fact that we asked medical students about a topic that becomes really relevant only after graduation. It Ethics approval and consent to participate According to the regulations of the ethics committee of the Leipzig Medical can’t be excluded that some of the participants’ percep- Faculty and the Model Professional Code for Physicians an explicit ethical tions might alter when life circumstances are changing. approval was deemed unnecessary for this study. After being informed Furthermore, it should be considered that the list of about the study, all participants completed this anonymous survey on a voluntary basis (informed consent). conditions potentially influencing the attractiveness of commuting examined in our study is probably not ex- Competing interests haustive (e.g. we did not ask for participation in medical The authors declare that they have no competing interests. emergency services). The focus of this study was on the students’ general open-mindedness regarding models of Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published commuting to a non-urban workplace while living in a maps and institutional affiliations. big city. We didn’t discuss extensively how many stu- dents in our sample might decide to have their future Author details Department of General Practice, Medical Faculty, University of Leipzig, place of residence in non-urban regions. As these sce- Leipzig, Germany. Institute of General Practice and Family Medicine, narios cannot be considered as completely independent, 3 Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany. Institute of this should be kept in mind when interpreting our re- General Practice, Charité-Universitätsmedizin Berlin, Berlin, Germany. sults. Finally, it should be mentioned that, due to tech- Received: 27 November 2017 Accepted: 16 May 2018 nical restrictions, our cartographic presentation is based on very limited presuppositions (using a car, starting at References the city center, average traffic). Consequently, geograph- 1. Dussault G, Franceschini MC. Not enough there, too many here: ical conclusions should be drawn with respective care. understanding geographical imbalances in the distribution of the health workforce. Hum Resour Health. 4:12. https://doi.org/10.1186/1478-4491-4-12. 2. Grobler L, Marais BJ, Mabunda S. 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Health Aff (Millwood). reduction of the physicians’ burden (e.g. joint practice, 2008;27:w232–41. https://doi.org/10.1377/hlthaff.27.3.w232. specifically qualified supply assistance), as well as the 5. Gibis B, Heinz A, Jacob R, Muller C-H. The career expectations of medical students: findings of a nationwide survey in Germany. Deutsches Ärzteblatt provision of comfortable modes of transport. Regions fur- international. 2012;109:327–32. https://doi.org/10.3238/arztebl.2012.0327. ther from big cities (approximately more than 1 h) may 6. Steinhäuser J, Annan N, Roos M, Szecsenyi J, Joos S. Lösungsansatze gegen not be able to close gaps in medical care supply through den Allgemeinarztmangel auf dem Land–Ergebnisse einer Online-Befragung unter Ärzten in Weiterbildung. Dtsch Med Wochenschr. 2011;136:1715–9. commuting models. https://doi.org/10.1055/s-0031-1272576. 7. Empirica ag. Schwarmverhalten in Sachsen – eine Untersuchung zu Acknowledgements Umfang, Ursache, Nachhaltigkeit und Folgen der neuen Wanderungsmuster. The authors want to thank Prof. Dr. Andreas Klement (Halle), Prof. Dr. Christoph Berlin: Sächsische Aufbaubank, Verband der Wohnungs- und Heintze (Berlin), the “Stiftung Perspektive Hausarzt” (Foundation Perspective General Immobilienwirtschaft in Sachsen, Verband sächsischer Practitioner) as well as the “Sächsischer Hausärzteverband” (Saxon Association of Wohnungsgenossenschaften; 2016. Family Physicians) for supporting this study. 8. Langer A, Ewert T, Hollederer A, Geuter G. Literaturüberblick über niederlassungsfördernde und -hemmende Faktoren bei Ärzten in Deutschland Funding und daraus abgeleitete Handlungsoptionen für Kommunen. Gesundh ökon This study was primarily financed with own funds. A small financial support Qual manag. 2015;20:11–8. https://doi.org/10.1055/s-0033-1356303. was provided by the “Stiftung Perspektive Hausarzt” (Foundation Perspective 9. Versorgungs- und Arztbedarf in Sachsen: Kurzbericht Gutachten zur General Practitioner). Entwicklung des ambulanten Versorgungs- und Arztbedarfs in Sachsen. Dresden: Sächsisches Staatsministerium für Soziales und Verbraucherschutz; Availability of data and materials 2016. The datasets used for the current study are available from the corresponding 10. ISO4APP API. https://www.iso4app.net. Accessed 26 Feb 2017. author on reasonable request. 11. Geofabrik Openstreetmap. http://download.geofabrik.de. Accessed 26 Feb 2017. Quart et al. Journal of Occupational Medicine and Toxicology (2018) 13:17 Page 9 of 9 12. Open Data Commons. Open Database License (ODbL) v1.0. http:// opendatacommons.org/licenses/odbl/1.0/. Accessed 26 Feb 2017. 13. Holte JH, Kjaer T, Abelsen B, Olsen JA. The impact of pecuniary and non- pecuniary incentives for attracting young doctors to rural general practice. Soc Sci Med. 2015;128:1–9. https://doi.org/10.1016/j.socscimed.2014.12.022. 14. Roick C, Heider D, Gunther OH, Kurstein B, Riedel-Heller SG, Konig HH. Was ist künftigen Hausärzten bei der Niederlassungsentscheidung wichtig? Ergebnisse einer postalischen Befragung junger Ärzte in Deutschland. Gesundheitswesen (Bundesverband der Ärzte des Öffentlichen Gesundheitsdienstes (Germany)). 2012;74:12–20. https://doi.org/10.1055/s-0030-1268448. 15. Schmacke N. Ärztemangel: Viele Fragen werden noch nicht diskutiert. Gesundheit und Gesellschaft : G + G. 2006;6:18–25. 16. Laurence CO, Williamson V, Sumner KE, Fleming J. “Latte rural”: the tangible and intangible factors important in the choice of a rural practice by recent GP graduates. Rural Remote Health. 2010;10:1316. 17. Lindstrom M. Means of transportation to work and overweight and obesity: a population-based study in southern Sweden. Prev Med. 2008;46:22–8. https://doi.org/10.1016/j.ypmed.2007.07.012. 18. Bundesinstituts für Bau-, Stadt- und Raumforschung (BBSR). Immer mehr Menschen pendeln zur Arbeit. 2017. http://www.bbsr.bund.de/BBSR/DE/ Home/Topthemen/2017-pendeln.html. Accessed 5 Apr 2017. 19. Pfaff S. Pendeln oder umziehen? Ursachen und Folgen berufsbedingter räumlicher Mobilität in Deutschland. Karlsruhe: KIT-Bibliothek; 2013. 20. Eckey H-F, Kosfeld R, Türck M. Pendelbereitschaft von Arbeitnehmern in Deutschland: willingness to commute of employees in Germany. Raumforschung und Raumordnung : RuR. 2007;65:5–14. 21. Ruppenthal S, Lück D. Jeder fünfte Erwerbstätige ist aus beruflichen Gründen mobil : berufsbedingte räumliche Mobilität im Vergleich. Informationsdienst Soziale Indikatoren. 2009:1–5. 22. Scott A, Witt J, Humphreys J, Joyce C, Kalb G, Jeon S-H, McGrail M. Getting doctors into the bush: general practitioners' preferences for rural location. Soc Sci Med. 2013;96:33–44. https://doi.org/10.1016/j.socscimed.2013.07.002. 23. Kearns R, Myers J, Adair V, Coster H, Coster G. What makes ‘place’ attractive to overseas-trained doctors in rural New Zealand? Health Soc Care Community. 2006;14:532–40. https://doi.org/10.1111/j.1365-2524.2006.00641.x. 24. Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen. Bedarfsgerechte Versorgung: Perspektiven für ländliche Regionen und ausgewählte Leistungsbereiche. Köln: Bundesanzeiger Verlag; 2014. 25. Höppner K, Maarse JAM. Planung und Sicherung der hausärztlichen Versorgung in den Niederlanden. Gesundheit und Gesellschaft : G + G. 2003;3:21–31. 26. Stengler K, Heider D, Roick C, Gunther OH, Riedel-Heller S, Konig H-H. Weiterbildungsziel und Niederlassungsentscheidung bei zukunftigen Facharztinnen und Facharzten in Deutschland. Eine genderspezifische Analyse Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2012;55:121–8. https://doi.org/10.1007/s00103-011-1397-8. 27. Pedersen LB, Gyrd-Hansen D. Preference for practice: a Danish study on young doctors' choice of general practice using a discrete choice experiment. Eur J Health Econ. 2014;15:611–21. https://doi.org/10.1007/s10198-013-0500-5. 28. Berufspendler: Infrastruktur wichtiger als Benzinpreis: STATmagazin: Arbeitsmarkt. Wiesbaden: Statistisches Bundesamt; 2014. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Occupational Medicine and Toxicology Springer Journals

Willingness to commute among future physicians: a multicenter cross-sectional survey of German medical students

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Medicine & Public Health; Occupational Medicine/Industrial Medicine; Pharmacology/Toxicology; Public Health
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Abstract

Background: Many countries are faced with a decrease in physicians in non-urban areas. Especially for regions with decreasing populations, temporary solutions like commuting models might be a suitable option. So far, little is known about the willingness to commute among future physicians. Methods: In this multicenter, cross-sectional survey, five years of medical students (8th to 10th semester) from three German universities (Charité Berlin, Halle, Leipzig) were questioned about their willingness to commute to work, the maximum acceptable commute time, and how several job-related factors might enhance the attractiveness of commuting. Results: Altogether 1108 of 1203 (92.1%) students completed the questionnaire. For 55.9% of the participants it was imaginable to commute to a non-urban area in the future. The most important job-related factors that would increase the attractiveness of such a commuting model were remuneration of the commuting time, higher remuneration in general, working self-employed in a joint practice with 2–3 physicians, existence of a specifically qualified “supply assistant”, provision of a home office, good public transport connection, and a driver service. The maximum acceptable commute time was on average 39.0 min (one-way). If the way to work would be a salaried integral part of the normal working time, the participants stated they would accept traveling 51.2 min (one-way). Conclusions: Most future physicians are open-minded regarding models of commuting. The attractiveness of such models can be increased mainly through higher remuneration, reduction of the physicians’ burden, and comfortable modes of transport. Keywords: Physician shortage, Commuting, Non-urban areas, Primary care, General practice Abstract German Hintergrund: Viele Länder stehen vor der Herausforderung eines zunehmenden Ärztemangels in ländlichen Regionen. Insbesondere für Gebiete mit rückläufigen Bevölkerungszahlen könnten Pendelmodelle eine praktikable temporäre Lösung darstellen. Über die Pendelbereitschaft zukünftiger Ärzte ist bisher wenig bekannt. (Continued on next page) * Correspondence: tobias.deutsch@medizin.uni-leipzig.de Johannes Quart and Tobias Deutsch contributed equally to this work. Department of General Practice, Medical Faculty, University of Leipzig, Leipzig, Germany Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Quart et al. Journal of Occupational Medicine and Toxicology (2018) 13:17 Page 2 of 9 (Continued from previous page) Methoden: In dieser multizentrischen Querschnittsstudie wurden fünf Jahrgänge von Medizinstudierenden (8. bis 10. Semester) aus drei Universitäten (Berlin, Halle, Leipzig) zu Ihrer Pendelbereitschaft befragt. Außerdem wurden maximal akzeptable Fahrzeiten und der Einfluss verschiedener Arbeitsbedingungen auf die Attraktivität des Pendelns erhoben. Ergebnisse: Von 1203 Studierenden in den untersuchten Jahrgängen erhielten wir 1108 analysierbare Fragebögen (92.1%). Für 55.9% der Teilnehmer war es vorstellbar, zukünftig in ländliche oder kleinstädtische Regionen zu pendeln. Den stärksten positiven Einfluss auf die Attraktivität eines solchen Pendelmodells hatten eine Vergütung der Fahrzeiten, eine generell höhere Vergütung der Tätigkeit, die Arbeit in einer Gemeinschaftspraxis (2–3 Ärzte), die Entlastung durch qualifizierte „Versorgungsassistenten“, die Bereitstellung eines Home-Office, eine gute Anbindung an öffentliche Verkehrsmittel und ein Fahrservice. Grundsätzlich betrug die maximal akzeptable Fahrzeit (eine Strecke) durchschnittlich 39.0 Minuten. Wäre die Fahrzeit bezahlt und Teil der regulären Arbeitszeit, würden die Teilnehmer durchschnittlich 51.2 Minuten je Strecke akzeptieren. Schlussfolgerung: Die zukünftigen Ärzte stehen Pendelmodellen mehrheitlich offen gegenüber und könnten primär über Vergütung, Reduktion der Arbeitsbelastung und komfortable Beförderungsmöglichkeiten motiviert werden. Background of medical students (8th to 10th semester of altogether 10 There is a decrease in physicians in non-urban areas in semesters plus 2 semesters final clinical year) from three many countries, including Germany [1–3]. Particularly German universities (Charité Berlin, Halle, and Leipzig). the growing shortage of primary care physicians will in- In Leipzig, students completed the questionnaires at the creasingly threaten adequate medical care for an aging beginning of a mandatory geriatric self-experience course population in many regions [4]. The perspective of living in a (10th semester) and prior to the written exam following non-urban area seems to be relatively unattractive for young the lecture series in general practice (8th semester), re- physicians today [5]. The reasons are diverse and include spectively. In Halle, students completed the questionnaires perceptions of demanding working conditions, inadequate at the end of a mandatory two-week general practice payment, limited opportunities for personal and professional clerkship (9th semester). In Berlin, students answered the development, less job opportunities for spouses as well as questionnaire at the beginning of a mandatory general limited educational opportunities for children [2, 6]. Regard- practice seminar (10th semester). less of the medical profession, in Germany there is a general trend towards a concentration of the population in attractive Questionnaire urban regions. Interestingly, although particularly shaped by We used a self-developed questionnaire created by a young adults starting out at their first job, this trend is not multidisciplinary team (general practitioner, general primarily linked to the local availability of jobs [7]. practice resident, psychologist, and economist). To en- Several studies have been conducted to identify factors sure comprehensibility, usability and face validity, the attracting or inhibiting young physicians establishing or questionnaire was pre-tested with two medical students taking over rural doctors’ offices [8]. However, in some in advanced study years (target group). The pre-testing regions the population and thus the supply needs are procedure was oriented towards the qualitative method continuously decreasing, querying the economic viability of concurrent think aloud (CTA) and led to minor ad- of local doctors’ offices in the long run [9]. justments with regard to content and form. Particularly for those regions temporary solutions like Survey participants were questioned about relevant commuting models might be a pragmatic option to fill socio-demographic information, current career preferences, gaps in healthcare availability. So far, little is known their willingness to commute to a non-urban area while liv- about future physicians’ attitudes regarding commuting. ing in an urban environment (as a hypothetical scenario), This study aimed to examine medical students’ willing- and the maximum acceptable commute time (one-way ness to commute in the future, maximum acceptable from home to workplace/ door to door). Furthermore, they distances, and how different job-related factors might were asked to assess how several work-related factors positively influence the willingness to commute. would positively influence their readiness to commute. Methods Statistical analysis Sampling and design Data were analyzed using IBM SPSS Statistics 24 for Between May 2015 and May 2016 we performed a Windows. As N’s may vary due to missing values, frequen- cross-sectional questionnaire-based survey among 5 years cies are presented as % (n /n ). Continuous valid absolute valid Quart et al. Journal of Occupational Medicine and Toxicology (2018) 13:17 Page 3 of 9 variables are presented as mean ± standard deviation (SD). Results Chi-square test was used for group comparisons with re- Out of altogether 1203 students 1114 returned a ques- gard to frequencies. Continuous variables were compared tionnaire. After the exclusion of six only fragmentarily using the Mann-Whitney U test in the case of two groups filled out forms the analyzable sample size was 1108, and the Kruskal-Wallis test in the case of more than two corresponding to a response rate of 92.1%. The partici- groups. Statistical significance was assumed for p <0.05. pants’ age was on average 25.3 ± 3.2 years and 64.4% (714/1108) were women. Detailed sample characteristics Cartographic presentation (isochrones map) are shown in Table 1. For 11.8% (126/1069) of the stu- To illustrate the practical consequences of our results dents, general practice was the currently preferred career regarding the maximum accepted commute times within option. With regard to their future place of residence different scenarios we created a geographical map with 71.1% (779/1096) of the students stated that they could isochrones lines. As a map of Germany would have been imagine to live in a big city, 64.6% (708/1096) could im- too complex, we decided to show the areas of Saxony agine to live in a small town and 42.7% (468/1096) in a potentially covered by commuting. The underlying com- rural area (multiple answers were possible). For 24.5% muting times were nevertheless derived from the whole (269/1096) of the participants living in a big city was the sample (including Halle, Leipzig, and Berlin). As in only option. Germany medical study places are awarded centrally, pri- Regarding whether they can imagine commuting to a marily based on school leaving examinations, students’ rural/small-town area for work while living in a big city places of origin, study places, and later workplaces are (as a hypothetical scenario), 10.4% (115/1106) of the often not the same. Considering this, although focusing participants answered “definitely yes”, 45.5% (503/1106) on the example of Saxony, the use of all data seemed to be “rather yes”, 35.7% (395/1106) “rather no”, and 8.4% (93/ most realistic. We used ISO4APP API [10], a software tool 1106) “definitely no”. Among those who considered a big based on “openstreetmap” [11], which is made available city as their future place of residence 60.7% (472/777) for free under the Open Database License [12]. The iso- could imagine commuting to a rural/small-town area chrones lines were created for the scenario of driving by (“definitely yes” or “rather yes”). Among those who stated car at average daily traffic from the city-center of one of that living in a big city is the only option 44.2% (118/ the three big cities in Saxony with more than 100,000 in- 267) could imagine commuting (“definitely yes” or “ra- habitants (Dresden, Chemnitz, and Leipzig). ther yes”). Based on bivariate comparisons we found no Table 1 Sample characteristics a b Variable valid (N) N (%) Sub-Sample (university, year, course, semester) 1108 Leipzig, 2016, geriatric self-experience course, 10th semester 259 (23.4) Leipzig, 2015, geriatric self-experience course, 10th semester 259 (23.4) Leipzig, 2016, general practice exam, 8th semester 274 (24.7) Berlin, 2015, general practice seminar, 10th semester 159 (14.4) Halle, 2015, two-week general practice clerkship, 9th semester 157 (14.2) Age [mean ± SD] 1103 25.3 ± 2.3 Female gender 1108 714 (64.4) Living in a stable relationship 1089 680 (62.4) Having children 1094 98 (9.0) At least one parent with university degree 1100 837 (76.1) Being a physician’s child 1106 290 (26.2) Family or friends in general practice 1104 341 (30.9) Pre-existing concluded education in a medical occupation 1103 244 (22.1) Mainly grew up in … 1098 ... big city 422 (38.4) … small town 369 (33.6) … rural area 307 (28.0) N’s vary due to missing values Unless otherwise indicated Quart et al. Journal of Occupational Medicine and Toxicology (2018) 13:17 Page 4 of 9 significant associations between the willingness to com- to a future workplace in a non-urban area while living in mute (“definitely/rather yes” vs. “rather/definitely no”) a big city. The most crucial factors that might increase and the variables gender, age, university, stable relation- the attractiveness of commuting were associated with ship, having children, regional background, pre-existing higher remuneration, reduction of the physicians’ bur- concluded education in a medical occupation, and den (e.g. via joint practices or a qualified supply assist- current GP career preference (data not shown). ance), and comfortable modes of transport. Basically, the maximum acceptable commute time (one-way) for the surveyed students was on average Main findings in relation to other studies 39.0 ± 13.3 min (N = 1098). Regarding the scenario of liv- We found no other studies directly addressing the fac- ing in an urban but working in a rural/small-town envir- tors influencing willingness of future physicians to com- onment, the maximum acceptable commute time varied mute to a workplace in a non-urban area while living in depending on different modes of transport and payment a big city. So far, most studies have focused mainly on (Table 2). The participants accepted the longest commute how to convince physicians to settle down in rural areas time if it would be a salaried and integral part of the work- [2, 6, 13–16]. Other studies have examined general ing time (51.2 ± 22.6 min). Based on these time specifica- health aspects of commuting or the commuting behavior tions (basic and longest acceptable time), an exemplary of the whole population without consideration of specific map of Saxony showing areas potentially covered by com- professional subgroups [17–19]. Consequently, our results muting is presented in Fig. 1. are only partially comparable to the existing literature. We found no significant associations between the More than half of our study participants were maximum acceptable commute time (one-way) and the open-minded about commuting to a rural/small town variables gender, age, stable relationship, having children, area (“definitely yes” or “rather yes”). Thus, a substantial pre-existing concluded education in a medical occupation, percentage of future physicians might be convinced, if and current GP career preference (data not shown). How- not to live, then at least to work in non-urban areas if ever, there were significant differences depending on uni- the right measures are taken. For general comparison, it versity (Halle: 35.6 ± 12.1 min, Leipzig: 38.1 ± 12.6 min, can be stated that currently 60% of the German popula- Berlin: 46.6 ± 15.5 min; p < 0.001) and regional back- tion commute (home and workplace in different munici- ground (mainly grew up in big city: 40.9 ± 14.0 min, palities) [18]. Despite several studies implying relations small-town: 38.8 ± 13.7 min, rural area: 36.6 ± 11.5 min; between the willingness to commute and sociodemo- p < 0.001). graphic variables like gender and age [19–21], we found The participants were asked to what extent various no such associations in our data. However, it must be job-related factors would increase the attractiveness of considered that we examined a homogenous age group commuting to a rural/small-town area (scale from 0 = ‘no of students in their mid-twenties, and respective associa- increase’ to 4=‘very strong increase’). The respective results tions might develop later on, when life circumstances are provided in Fig. 2 as relative frequencies (100% bar change after graduation [19]. charts) and in Table 3 as means±SD (overall and depend- In our study the most important factors increasing the ing on gender and current GP career preference). attractiveness of commuting were associated with remu- neration, disburdening the physician, and comfortable Discussion modes of transportation. Previous studies investigating This study shows that more than half of German med- the willingness of physicians to establish a practice or to ical students in an advanced stage of undergraduate live and work in a rural area have also underlined the in- medical education can imagine a scenario of commuting fluence of money [6, 13, 22], flexible working times Table 2 Maximum acceptable commute time to work (one-way) depending on different conditions Maximum acceptable commute time (one-way) if … valid Mean ± SD Quartiles (minutes) N in minutes 25% 50% 75% … I go by car 1084 36.1 ± 12.9 30.0 30.0 45.0 … I go by public transport 1083 40.3 ± 15.2 30.0 40.0 45.0 … I can take part in a car pool 1064 35.5 ± 13.9 30.0 30.0 45.0 … I get picked up by a driver service 1065 39.1 ± 15.6 30.0 30.0 45.0 … time getting to work is paid as working time, additional to it 1075 47.0 ± 18.3 30.0 45.0 60.0 … time getting to work is paid as working time, included into it 1069 51.2 ± 22.6 30.0 50.0 60.0 … time getting to work is utilizable for organizational tasks 1066 43.9 ± 19.0 30.0 45.0 60.0 Quart et al. Journal of Occupational Medicine and Toxicology (2018) 13:17 Page 5 of 9 Fig. 1 Areas potentially covered by commuting in Saxony*. * related to the centers of the cities with more than 100,000 inhabitants (Dresden, Leipzig, Chemnitz) and an accepted time getting to work of 39.0 min. Outer lines show coverage by an increased accepted commute time in case of payment for travel time and integrating it into working time (51.2 min) including part-time work [22–24], the possibility to work working models, single or small joint practices and a dis- in a group practice [6, 13, 25], working as an employee burdening by “supply assistants” than their counterparts [6, 16, 24], and a reduced workload by extended medical favoring other specialties. A current study examining the staff competencies and delegation (“supply assistant”)[3, 24]. preferences of GP trainees regarding practice size and Our results indicate slight but significant gender differ- weekly working hours also found them to be attracted to ences regarding the job-related conditions increasing the work in small shared practices. However, this study attractiveness of commuting. For women, a reduction of found no direct preference to work less hours per week the workload through alternative working arrangements as long as salary is appropriate for the workload [27]. (part-time, job-sharing, joint practice, working as employee, Among the participants of our study the acceptable home-office) as well as possibilities to avoid daily car driv- commute time was on average 39 min. A survey from ing (through pick up service or car pool) seem to be more 2010 among German general practice residents found attractive than for men. This may be seen in line with a that 72% would accept up to 30 min, but only 13% up to previous study on young physicians’ decision to establish a 60 min one way [6]. For the whole German working practice that has also shown job cooperation possibilities, population it has been shown that about 47% have a way reduced workload and good reconciliation of work and to work of 10 to 30 min and about 22% a way of 30 to family to be more important to female physicians [26]. 60 min [28]. Our results indicate regional differences in Furthermore, we found that students interested in a the acceptable commute time depending on the university GP career were significantly more attracted by part-time attended (Halle<Leipzig<Berlin). Considering the Quart et al. Journal of Occupational Medicine and Toxicology (2018) 13:17 Page 6 of 9 Fig. 2 Influence of several job-related conditions on the attractiveness of commuting to a rural/small-town area (100% bar chart) significantly different size of these cities it may be as- working models (flexible working times, part-time work, sumed that students in Berlin are simply used to longer joint practices, job sharing, home office) as well as redu- commute times. This is supported by data of the German cing the physicians’ workload (e.g. through support by federal statistical office indicating longer commute times specifically qualified medical staff with extended compe- among people living in conurbations [28]. tencies). Furthermore, our results emphasize the import- Since a nationwide map would have been hard to read, ance of paying adequately for commute time and we chose Saxony as an example to illustrate areas poten- providing comfortable transportation options. Further tially covered by the accepted commute times found in our research is needed to verify the possibly higher ac- study. Furthermore, a current report of the Saxon federal ceptance of commuting in comparison to conven- government provides sufficient and detailed comparative tional “live-and-work” models and to identify more data concerning regional medical care supply problems [9]. factors that might increase willingness to commute. Altogether, our map indicates that not every Saxon region Additionally, it would be interesting to replicate our would be able to cover healthcare supply needs via com- survey among residents and young medical specialists. muting models. Interestingly, the areas not covered are currently those with the biggest difficulties [9]. Strengths and limitations This study addresses a rarely studied, innovative topic of Implications for practice and further research potential practical relevance regarding the future med- To attract young physicians to commute to non-urban ical supply in non-urban areas. Medical undergraduates areas, the respective working conditions should be modi- in advanced study years constitute a relevant target fied to ensure good remuneration and minimalized loss of group – the future physicians. The sufficient sample size, leisure time. The focus should be particularly on tailored the very good response rate and the inclusion of three Quart et al. Journal of Occupational Medicine and Toxicology (2018) 13:17 Page 7 of 9 Table 3 Influence of several job-related conditions on the attractiveness of commuting to a rural/small-town area – differences due to gender and general practice career preference Potential influence factor Students’ assessment of the increase of the attractiveness of commuting (0 = no increase, + 1 = slight increase, + 2 = medium increase, + 3 = strong increase, + 4 = very strong increase) All Male Female p* GP career Others p* preferred Mean ± SD Mean ± SD Mean ± SD Mean ± SD Mean ± SD Working time To work full-time 0.9 ± 1.3 1.1 ± 1.4 0.8 ± 1.2 0.003 1.0 ± 1.3 1.0 ± 1.3 0.882 To work full-time, but compressed to 3½ days 1.8 ± 1.4 1.8 ± 1.4 1.8 ± 1.4 0.984 2.1 ± 1.4 1.8 ± 1.4 0.044 per week To work part-time (less working days per week) 1.9 ± 1.3 1.6 ± 1.3 2.0 ± 1.3 < 0.001 2.2 ± 1.3 1.8 ± 1.3 0.005 To work part-time (reduced daily working time) 1.4 ± 1.3 1.1 ± 1.2 1.5 ± 1.3 < 0.001 1.9 ± 1.4 1.3 ± 1.3 < 0.001 Job sharing with colleagues (2 days per week rural, 1.9 ± 1.4 1.8 ± 1.3 2.0 ± 1.3 0.002 2.0 ± 1.5 2.0 ± 1.3 0.954 3 days in big city) Existence of an adequate accommodation option 1.2 ± 1.3 1.4 ± 1.3 1.2 ± 1.3 0.012 1.2 ± 1.3 1.2 ± 1.3 0.723 Defined time limit for the job (e.g. 5 years) 1.2 ± 1.2 1.2 ± 1.2 1.2 ± 1.2 0.915 1.1 ± 1.2 1.2 ± 1.2 0.243 Remuneration Time getting to work is paid as working time, 2.9 ± 1.1 2.9 ± 1.1 2.9 ± 1.1 0.876 2.9 ± 1.2 2.9 ± 1.1 0.683 additional to it Time getting to work is paid as working time, 2.9 ± 1.1 2.9 ± 1.2 3.0 ± 1.1 0.266 3.0 ± 1.1 2.9 ± 1.1 0.334 included into it Time getting to work is utilizable for organizational tasks 1.8 ± 1.3 1.9 ± 1.2 1.7 ± 1.3 0.048 1.9 ± 1.3 1.8 ± 1.2 0.174 Remuneration is significantly higher than in the big city 2.8 ± 1.1 2.8 ± 1.2 2.8 ± 1.1 0.647 2.9 ± 1.1 2.8 ± 1.1 0.436 Mode of transport Getting to work by using own car 1.6 ± 1.4 1.7 ± 1.4 1.6 ± 1.4 0.352 1.6 ± 1.4 1.6 ± 1.4 0.903 Good public transport connection 2.1 ± 1.3 2.1 ± 1.3 2.2 ± 1.3 0.223 2.2 ± 1.3 2.1 ± 1.3 0.539 Organization of a car pool 1.4 ± 1.2 1.3 ± 1.2 1.5 ± 1.2 0.017 1.4 ± 1.2 1.4 ± 1.2 0.611 A driver service is picking me up (from the doorstep 2.0 ± 1.5 1.9 ± 1.5 2.1 ± 1.5 0.020 1.8 ± 1.6 2.0 ± 1.5 0.149 to work, and back) Assuming the consideration of working office-based: legal structure and organization Working self-employed in a single practice 1.4 ± 1.3 1.5 ± 1.4 1.3 ± 1.3 0.024 1.8 ± 1.4 1.3 ± 1.3 < 0.001 Working self-employed in a joint practice 2.3 ± 1.2 2.0 ± 1.2 2.4 ± 1.1 < 0.001 2.7 ± 1.2 2.2 ± 1.2 < 0.001 (2–3 physicians) Working self-employed in a joint practice 1.7 ± 1.2 1.6 ± 1.2 1.8 ± 1.2 0.014 1.8 ± 1.3 1.7 ± 1.2 0.337 (4–6 physicians) Working as an employee of another physician 1.1 ± 1.1 0.8 ± 1.0 1.2 ± 1.2 < 0.001 1.4 ± 1.3 1.0 ± 1.1 0.002 (office-based) Working as an employee of an institution, e.g. 1.0 ± 1.1 0.9 ± 1.1 1.1 ± 1.1 0.003 1.4 ± 1.3 0.9 ± 1.1 < 0.001 municipality or KV Working as an employee of a medical employer, 1.5 ± 1.2 1.2 ± 1.1 1.6 ± 1.2 < 0.001 1.6 ± 1.3 1.5 ± 1.2 0.432 e.g. hospital or medical service center Mobile surgery (installed in a ‘surgery-bus’, continuous 0.8 ± 1.1 0.7 ± 1.0 0.8 ± 1.1 0.749 1.2 ± 1.3 0.7 ± 1.0 < 0.001 care for several municipalities on different days) Provision of a home-office to be able to do some work 2.1 ± 1.3 1.9 ± 1.2 2.2 ± 1.3 < 0.001 2.4 ± 1.2 2.1 ± 1.3 0.022 at home (e.g. organizational tasks) Existence of a specifically qualified „supply assistant“, 2.2 ± 1.2 2.1 ± 1.2 2.2 ± 1.2 0.010 2.6 ± 1.2 2.1 ± 1.2 < 0.001 disburdening the physician regarding delegable tasks Home visit patients were, if possible, picked up by a 1.6 ± 1.3 1.6 ± 1.3 1.5 ± 1.3 0.245 1.6 ± 1.3 1.6 ± 1.3 0.926 driver service and brought to me KV Kassenärztliche Vereinigung = Association of Statutory Health Insurance Physicians * p-values < 0.05 are highlighted in bold Quart et al. Journal of Occupational Medicine and Toxicology (2018) 13:17 Page 8 of 9 different universities support the representativeness of Authors’ contributions JQ contributed to the conception and design of the study, the collection, the results. As a validated instrument fitting to our re- analysis, interpretation, and visualization of the data, and was the main search questions and the target group was not available, contributor regarding the initial draft of the manuscript. TD contributed to we used a self-developed questionnaire. This might be the conception and methodology of the study, and supported data analysis and interpretation, as well as writing the manuscript. SC contributed to data discussed as a possible limitation. However, the thor- interpretation, and critically commented and revised the manuscript. SD ough development by an experienced multidisciplinary contributed to data collection, and critically commented and revised the team and the pre-testing of the questionnaire ensure at manuscript. TF initiated and supervised the study, contributed to conception and data interpretation, and revised the manuscript. All authors read and least face validity. Another limitation might result from approved the final version of the manuscript. the fact that we asked medical students about a topic that becomes really relevant only after graduation. It Ethics approval and consent to participate According to the regulations of the ethics committee of the Leipzig Medical can’t be excluded that some of the participants’ percep- Faculty and the Model Professional Code for Physicians an explicit ethical tions might alter when life circumstances are changing. approval was deemed unnecessary for this study. After being informed Furthermore, it should be considered that the list of about the study, all participants completed this anonymous survey on a voluntary basis (informed consent). conditions potentially influencing the attractiveness of commuting examined in our study is probably not ex- Competing interests haustive (e.g. we did not ask for participation in medical The authors declare that they have no competing interests. emergency services). The focus of this study was on the students’ general open-mindedness regarding models of Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published commuting to a non-urban workplace while living in a maps and institutional affiliations. big city. We didn’t discuss extensively how many stu- dents in our sample might decide to have their future Author details Department of General Practice, Medical Faculty, University of Leipzig, place of residence in non-urban regions. As these sce- Leipzig, Germany. Institute of General Practice and Family Medicine, narios cannot be considered as completely independent, 3 Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany. Institute of this should be kept in mind when interpreting our re- General Practice, Charité-Universitätsmedizin Berlin, Berlin, Germany. sults. Finally, it should be mentioned that, due to tech- Received: 27 November 2017 Accepted: 16 May 2018 nical restrictions, our cartographic presentation is based on very limited presuppositions (using a car, starting at References the city center, average traffic). Consequently, geograph- 1. Dussault G, Franceschini MC. Not enough there, too many here: ical conclusions should be drawn with respective care. understanding geographical imbalances in the distribution of the health workforce. Hum Resour Health. 4:12. https://doi.org/10.1186/1478-4491-4-12. 2. Grobler L, Marais BJ, Mabunda S. Interventions for increasing the proportion Conclusion of health professionals practising in rural and other underserved areas. Many future physicians are open-minded regarding Cochrane Database Syst Rev. 2015:CD005314. https://doi.org/10.1002/ 14651858.CD005314.pub3. models of commuting to non-urban areas. There are sev- 3. Ono T, Schoenstein M, Buchan J. Geographic Imbalances in Doctor Supply eral possibilities to moderately increase the attractiveness and Policy Responses. OECD Health Working Papers, No. 69. Paris: OECD of such models through customized working conditions, Publishing; 2014. https://doi.org/10.1787/5jz5sq5ls1wl-en 4. Colwill JM, Cultice JM, Kruse RL. Will generalist physician supply meet particularly with regard to remuneration, working time, a demands of an increasing and aging population? 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Journal of Occupational Medicine and ToxicologySpringer Journals

Published: May 29, 2018

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