Sample characteristics and descriptive results
In total, we conducted 20 interviews. Participant characteristics are shown in Table 1. Most participants were recruited from our MA cohort study (n = 14). The interviews had a mean duration of 38.1 min ranging from 23 to 66 min. We interviewed 18 female participants and two male participants with a median age of 44.5 years ranging from 26 to 64 years. The participants had worked as a MA for a median of 22 years (min-max: 5–41 years) and the median number of months since the last exit from the MA profession was 40.5 (min-max: 10–132 months). The majority would somewhat to fully recommend the professional training as a MA to (young) people (n = 14), but more than half of the interviewed former MA would rather not or certainly not choose the MA profession again if they had to make that decision again (n = 11) (see Table 2). All of the participants reported that a return to the MA profession was unlikely or very unlikely.
The decision-making process: changing priorities and barriers to quitting
Entrance into the MA profession
Participants described that their decision to take up professional MA training was often based on first-hand experiences with the profession through internships as a student or after graduating from high school, based on pragmatic reasons (e.g., a workplace close to one’s home, doing any kind of vocational training) or perceived as a coincidence (i.e., “it turned out that way”). Expectations prior to the training were to work in a medical profession, to work closely with people and to carry out administrative work. Some former MA remembered not having any expectations, which was often attributed to their young age and thus their inexperience at the start of training.
Barriers to quitting
Many former MA expressed that they enjoyed working as a MA, because of their personal interest in medical topics, the variety of tasks, and the close work with patients. Participants described, however, a discrepancy between these expectations and experiences towards and during their MA job at a young age and their personal needs and priorities in later working life (e.g., higher salary, work-life balance/family friendly working hours, better career prospects). Many emphasized that their decision to quit the MA profession was carefully considered and not made hastily. In fact, quitting was perceived to be often delayed due to personal reasons (e.g., low self-confidence with regard to one’s skill and career prospects, not seeing any alternative career path for oneself), financial reasons (e.g., being dependent on the salary as a single parent), a sense of loyalty towards colleagues and the employer/supervising physician. In addition, participants felt that their exit from the profession was delayed, because the physician attempted to keep MA down (compare verbatim quote Q1 below). Further, they felt ”emotionally blackmailed” by their supervising physician who took advantage of the loyalty of MA towards their colleagues (i.e., higher workload for colleagues if MA leaves due to staff shortage).
“I had to earn money. So, there was a total interdependency, and one was afraid, or one wasn’t confident enough to say: ‘I’ll find something new in another medical practice.’ It is especially your bosses who convey this feeling of dependency to you: ‘You’ll never find a new job if you quit now.’ This is really exhausting. And as a young woman, you actually believe that and then you’re too afraid to quit.” (Q1, ID 7123; for verbatim quotes see Appendix 3).
Some participants felt that changing the profession was like a natural progression in their career. By contrast, for others it felt like a difficult decision. The experienced working conditions as a MA made them feel that merely changing their employer (while continue working as a MA) would not have improved their situation. The mainly positive experiences they had made in the new profession and the disbelief that MA working conditions will improve soon, led most participants to believe that they would not return to the MA profession.
Reasons to exit from the MA profession
The former MA reported various reasons to quit their profession and emphasized that there were often multiple reasons (for an overview of the reasons for MA profession turnover see Appendix 4).
Constantly high workload
Many described that a constantly high workload was a key reason for their decision to quit. Different facets of such a high workload were mentioned: First, the reasons for a high workload were mentioned. These were, first, a high number of patients and the limited time to fulfill tasks and adequately care for patients. This made participants feel stressed and emotionally blunted (Q2, for verbatim quotes see Appendix 3). Moreover, the high number of patients made it necessary to triage patients on the phone according to the perceived severity of symptoms. Frequently, having to turn patients down on the phone or discussing with them how urgent their complaints were (not) was perceived as stressful (Q3). A second reason for the perceived increasing workload that contributed to quitting were increasing administrative tasks (e.g., accounting, documentation, data protection). Participants often felt that documentation was at the core of their work rather than working with patients.
“And eventually, it was not about the patients anymore, you just had to fill in more and more documents.” (Q4, ID 6912).
A third perceived contributor to the high workload were cumbersome and outdated processes (e.g., slow digitalization, faxing, necessity to print documents), which were experienced as time consuming, highly inefficient and frustrating, because time was perceived as scarce (Q5).
Aside the causes, participants also explained the consequences of the high workload. A high workload was perceived to result in long waiting times for the patients which was felt to translate into substantial dissatisfaction among patients and into working overtime for the MA. The perceived consequences of a persistent lack of time due to a high workload were (i) an inability to provide adequate patient care; (ii) lacking opportunities to expand medical knowledge during working hours (e.g., discussing patients with physicians); (iii) often not having a single break throughout the work day and (iv) feeling stressed. Work stress was felt to lead to physical and psychological complaints (e.g., back pain, burnout) and negatively influence the team atmosphere (Q6).
“It’s getting more and more. It’s not decreasing and it’s not stagnating either. On the contrary, requirements have increased more and more, but the salary certainly hasn’t. The way we treat each other in the team has also become less pleasant, because we all reach our limit at some point.” (Q6, ID 6734).
Long working days due to the high workload and the operating hours of physician offices with long midday breaks, often including (expected daily) overtime, in some cases even unpaid, were felt to be frustrating (Q7). These consequences of a high workload were mentioned as factors contributing to the decision to leave the MA profession.
Finally, concerning a high workload, former MA felt that there was a shortage of skilled MA which leads to a vicious cycle of – on the one hand – increased stress-induced absenteeism, which then reinforces staff shortage and increases the workload for the remaining MA (Q8, Q9). On the other hand, the lack of skilled MA was perceived to result in constant spontaneous changes in working shifts without the workload being adapted to the reduced workforce (e.g., rescheduling appointments), negatively affecting the private life (Q10, Q11).
Perceived barriers to further training and poor career prospects
Many former MA expressed that the limited further training and career prospects made them leave the MA profession (Q12). Participants felt that the missing career prospects had led to a sense of missing challenges and increasing boredom.
“I don’t want to spend another 20 years printing out prescriptions, talking to people on the phone and making appointments.” (Q13, ID 9162).
One former MA criticized that although MA could acquire skills through further training, they often did not have the legal permission to apply these skills. This means for example that they are not allowed to act as a formal training supervisor for MA in training. This is the sole legal responsibility of the physician in Germany. This was perceived as generally unfair and criticized as physicians do not have to complete any relevant training. Others felt the need to leave the MA profession as they perceived that the further training and novel skills could not be applied (Q14). On the one hand, they mentioned limited demand and thus restricted opportunities to apply their skills particularly in rural areas and/or small practices. On the other hand, the limited willingness of the employers to pay according to the acquired qualifications was mentioned, which was partly seen to be due to restricted financial leeway (i.e., small practices with limited revenue).
“The stagnation. In other words, I didn’t have the chance to have more responsibility, or earn more money anywhere.” (Q15, ID 9162).
Moreover, the costs for further training were often not or only partially covered by employers. Alternatively, coverage of fees was subject to conditions (e.g., continue working in the practice for five more years). Such conditions were not well received according to participants as further trainings were often only offered during their leisure time (i.e., Wednesday afternoon, weekends), were expensive in relation to the MA salary and were perceived to ultimately benefit the practice.
Interpersonal factors
Supervisor
A core theme that emerged from the interviews was the perceived behavior of supervisors towards MA as a reason for leaving the MA profession. This included insufficient recognition, poor support, exploiting dependency relationships and disrespectful/aggressive behavior. Many participants expressed to not have felt adequately appreciated by their supervisor(s). In this respect the salary was often alluded to which was perceived as insufficient and unfair in light of the responsibilities of MA, also in comparison to similar healthcare professions (e.g., nurses, nurse assistants) (Q16). They felt they were unable to financially support themselves (and their family) despite working full-time. Some MA only became fully aware of the low salary later in their working life.
“Back then, I couldn’t imagine that the money I was getting was very little. So, I didn’t realize that you can’t actually live off the salary of a medical assistant.” (Q17, ID 8982).
Participants frequently criticized that employers were not obliged to apply the collective wage agreementFootnote 1. Many reported that the contracts were only “based on” the collective agreement, therefore not legally bound by it and often paid less. Further, even if strictly applied, wages according to the collective wage agreement were nonetheless perceived as insufficient as everyday “amenities” like owning a car or buying a pair of new shoes could not be afforded (Q18, Q19). The collective agreement stipulates that employees are assigned to different salary categories based on their qualifications and years of employment. Former MA said that they were not grouped correctly within the collective agreement according to their qualifications and years of experiences and respectively were paid less than they were entitled to which contributed to exit from the profession (Q20). Some former MA acknowledged that considering the profits that employers made under the current remuneration system applying to outpatient physicians, a higher salary for MA would be difficult to implement. Moreover, participants expressed that as long as other work-related factors were satisfactory, these seemed to compensate a salary that was perceived to be inadequate.
Former MA also shared that they felt that physician supervisors considered themselves as superior, that they felt that MAs’ performance and professional skills remained unrecognized and they were disappointed about the lack of their say within the practice.
“For me, it was mostly about the lack of recognition of what you were doing there whatsoever. […] It’s hectic, it’s chaotic and so on, but that has never really been an issue. For me, it has always been the lack of recognition, at least at the end.” (Q21, ID 8463).
The latter included, amongst others, that employers/supervising physicians decided without conferring with MA when to take their vacations. This implies that the practice remains closed during that period of time and MA, consequently, had to take their own vacation, too (i.e., leaving no remaining vacation days for individual vacation planning). Further, there was a perceived lack of say with regard to decisions on practice organization (e.g., communicating with MA how processes in their work areas can be optimized, instead of supervisors deciding alone) (Q22). In addition, a lack of support from supervisors for MA made them feel left alone and overwhelmed with the responsibility in certain situations (e.g., writing medication plans without supervision, training newly hired MA, implementing new measures), and lack of support for MA in front of patients was even perceived as degrading by one MA (Q23).
Some participants mentioned the strong dependency relationship between supervisors and MA as problematic. It resulted in the feeling that MA are kept down and feel to be at their supervisor`s mercy (e.g., things are promised during the job interview, but are revised after the start of work; not being given any responsibility; the range of tasks not corresponding to the MA training).
“[…] Well, in the practice […] our cleaner quit. And then my colleagues started cleaning the practice. And I was like: ‘Are you crazy?’ I would never do that. Not because I consider myself too good for cleaning. I’ve earned a lot of additional money with cleaning. But they hired me as a medical assistant and not as a cleaner, so there’s a limit there.” (Q24, ID3647).
They felt restricted in their capabilities to take action against these conditions, as supervisors are often also the employer and legal protection against dismissal is low in small companies with less than 10 employees. This motivated some former MA to change into the public service sector or to larger companies where employees’ rights are better protected.
Former MA alluded to overemphasized economic thinking of the employer as a further reason to quit. This included that employers wanted to limit the time of social interaction between MA and patients (e.g., on the telephone) due to economic reasons (Q25). Also, MA in training may be hired instead of trained MA to reduce staff costs. Participants felt that the focus was on economic efficiency rather than quality of patient care or wellbeing of the employees (Q26). They found this disappointing and perceived this as dissonant with their reasons as to why they chose the MA profession in the first place (Q27).
Colleagues
For some former MA, strong differences of opinions within the team and a constantly tensed team dynamic like bickering, lack of identification with MA colleagues, bullying, non-constructive team meetings were reasons for changing the profession (Q28).
Patients
Former MA frequently expressed that the patients’ pronounced (and increasing) demanding behavior (e.g., immediate receipt of prescriptions or appointments, unwillingness to wait, impudence, lack of consideration for other patients and work processes) sometimes combined with aggression, was perceived as stressful, frustrating and to strongly reduce work satisfaction (Q29).
“Expectations have become much higher in the last years. That means, they want something, and they want it right now. And I’m not talking about people who lost their arm, you know? […] Rather, these are people who need a prescription, […] They forget about it, but we have to do it right away. And then, you always have to ask yourself: ‘Alright, should I argue with that person or should I just do it?’ And then you try to make your position clear and tell them: ‘Please let us know at least one day in advance.’ Well, somehow you always have to discuss it. ‘Well, can’t you just quickly do it on the side?’” (Q30, ID5975).
Further, former MA discerned a lack of recognition from patients towards MA and the MA profession, amongst others not being perceived as medical personnel, questioning of MA professional competence (Q31).
External factors
Former MA also referred to external factors which influenced their decision to leave the profession. For instance, politics were mentioned in terms of the inadequate legal frameworks they provide which was perceived to ultimately influence MA work and/or working conditions (e.g., only simple tasks can be delegated to MA by the supervising physician, budgeting of health services by the statutory health insurances, which forces employers to think more economically and adversely influences salaries paid by them to MA). Moreover, former MA perceived a lack of recognition from society for the MA profession in general and in comparison to other health care professions such as nurses and physicians. For some former MA the feeling of low recognition by society and politics became very apparent during the COVID-19 pandemic. For instance, despite their exceptional commitment (e.g., being “COVID-19 experts” for patients, being constantly exposed to SARS-CoV-2 positive patients, working overtime), they did not receive COVID-19 financial bonuses like many other professions in health care in Germany or workers in other areas who worked from home (Q32, Q33).
“Well, people who were at home got it. (laughs) [note: single payments during the COVID-19 pandemic] And I’ve been there for ten hours instead of eight, and people giving me a hard time for ten hours and I simply didn’t get it.” (Q33, ID 5975).
Potential interventions
Former MA suggested several interventions that may help to motivate MA to stay in their profession. Table 3 provides an overview of the addressed actors (e.g., employers, fellow MA, policy makers), the interventions and examples of how former MA thought the interventions can take shape. Participants mentioned many potential interventions that directly address the specific reasons for quitting. These include, amongst others to reduce staff shortage, to increase recognition of MA, to increase the salary, to strengthen supervisor’s leadership skills, to create better career prospects, and to address demanding behavior of patients. Three interventions addressed aspects not specifically mentioned as a reason to quit, but were believed to be particularly feasible and effective for staff retention. The first addressed supervisors and suggested to provide more work flexibility to MA by offering working from home for administrative tasks. The second addressed politics by proposing to increase the quality of the MA training (e.g., oblige supervising physicians to teach certain learning content, differentiate according to medical specialty), which was perceived to indirectly strengthen the MA profession. The third intervention suggestion emphasized that the MA themselves should strengthen the MA profession by standing up for themselves more, engaging more in networking and encouraging each other to talk about the terms of their contracts.
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