Selection of sources of evidence
The initial search identified 1,143 records, of which 45 were eligible for the scoping review; 25 focused on medical students (excluded records are available in Additional file 4). Figure 1 summarizes the results in line with the PRISMA-ScR reporting tool [16].
Documents included in the review
Characteristics of sources of evidence
The characteristics of the included sources of evidence are reported in Table 2. Of the 25 documents reviewed in this article, 14 are articles and 11 are technical and policy documents, all written in English. Eight articles present qualitative studies based on interviews, questionnaires and focus group, and four are cross-sectional studies. The documents report four interventions in Germany, three each in England, Estonia, France and Ireland, two each in Scotland and Switzerland and one each in Belgium, Greece, Italy, Slovakia and Türkiye. Interventions identified fall in two groups: by individual education institutions (N = 14) and policy interventions at national level (N = 11). These targeted undergraduate (N = 11) and postgraduate (N = 14) medical students. In 16 documents, the results of the intervention are available.
Table 2. Documents included in the review.
Results of individual sources of evidence
Interventions by individual education institutions
There have been education interventions in six countries, reported in 14 documents. Interventions at undergraduate level in Germany include introducing an extracurricular longitudinal teaching project, called ‘Leipziger Kompetenzpfad Allgemeinmedizin’ (‘Leipzig Competency Pathway for General Practice’—LeiKA), that provides mentoring and networking [25], and the inclusion of a workshop on physicians’ earning opportunities, workload and job satisfaction as part of a mandatory general practice clerkship [26]. Other interventions are the creation of a longitudinal integrated clerkship (18 weeks) in an Irish university [28], and, in England, a near-peer teaching model (senior learners mentoring more junior learners) [38] and doubling to 4 weeks of exposure to general practice (with 4 weeks module for 4th-year medical students at Nottingham University) [40].
In England, interventions at regional level consisted of exposure to general practice in the first year of the two-year Foundation Programme that follows undergraduate medical studies [39]. In the Canton of Bern, in Switzerland, there are new postgraduate curricula and longitudinal internships, supported by a ten-year state-funded vocational training programme [36]. At national level, the state has invested, since 2000, in Institutes for PHC that introduced various curriculum changes to attract more students to PHC, including an expanded GP training module (Praxis Assistenz) that places trainees in GP offices for 6–12 months [35]. In France, postgraduate general practice residents alternate clinical training in hospitals and in PHC settings, in principle, under the supervision of a GP trainer (Maître de stage). However, not all settings have staff trained to provide that supervision [21].
As regards results of these interventions, the German LeiKA and the workshops on general practice initiatives have had a positive influence on students’ views of working as a GP, but no discernable impact on choosing a career in PHCS [25, 26]. In England, increased exposure to general practice with innovative, paired, career tutorials and exposure in the first year of the two-year Foundation Programme augmented the likelihood of considering a career as a GP [38,39,40]. In Switzerland, longer, part-time internships and training modules on general practice were associated with higher rates of choosing a career in PHCS [35, 36]. In France, a study of the density of GPs in all the country’s municipalities showed that, for the years 2018–2021, it had augmented by 1.36% where postgraduate students had done their residency in general practice under supervision [21].
Some documents reported interventions that had the objective to attract students to practise in underserved areas, such as rural, remote, poor urban or with marginalized populations. Even if it was not explicit, these would principally target future GPs or family physicians. The Martin Luther University Halle-Wittenberg and the University of Leipzig introduced the MiLaMed [23] (“Central German Concept for the Longitudinal Integration of Rural Medical Training Content and Experience in Medical Studies”, [https://www.milamed.de]) that includes adding “rural” content in the compulsory and elective parts of the curriculum, supplementary online teaching and support during rural placements in four target regions. Also, a study describes how students in three German medical faculties—Erlangen, Würzburg and Regensburg—undergo a practical year in a rural general practice before choosing a specialty [24]. In Scotland, in 2016, the University of Dundee School of Medicine piloted a 40-week Longitudinal and Comprehensive Integrated Internship for Year 4 students in rural areas [32]. Moreover, in Scotland, a “Targeted Enhanced Recruitment Scheme”, offered a financial incentive (£20,000) to GP trainees accepting a targeted post, typically in a rural area or an urban one with a history of difficulty of recruitment [33]. In Ireland, the North Dublin City General Practitioner Training Programme (NDCGP) is designed to train future GPs to work in areas of deprivation and with marginalized groups [27]. The NDCGP was the most successful, as almost all participants eventually chose to pursue a career as a GP in an underserved area [27]. German MiLaMed [23] and the Scottish Long Comprehensive Longitudinal Integrated Clerkship [32] had a positive effect on intentions to continue training in general practice [23] and reporting of positive feelings about eventually working in PHCS [32]. Scotland’s financial incentive scheme had a low impact on the choice of a targeted posting [33]. The North Dublin specific training programme was more successful as almost all participants eventually chose to pursue a career as a GP in an underserved area [27].
National policy interventions
There have been policy interventions in eight countries, reported in 11 documents. The most common policy intervention is increasing the number of places for residencies in general practice or family medicine, as occurred in Belgium, Estonia, France, Ireland, and Italy [17, 18, 20, 22, 29, 30]. France also increased the period of general practice residency by one additional year of postgraduate training in ambulatory care settings, preferably in underserved areas) [22]. In 2020, Estonia implemented a national reform of medical specialty training to make it more flexible and to offer part-time options [19]. This is expected to augment the number of GPs, though not at a sufficient level to meet the projected [18, 20].
Slovakia created a residency programme for GPs including training in outpatient facilities during undergraduate medical studies [34]. Türkiye used a mix of interventions to increase enrolment in medical schools in general and in postgraduate family medicine programmes in particular. It also re-trained PHC doctors to recertify as family doctors [37]. Greece has introduced a new compensation system to attract more physicians to PHC. In education, innovations include the offer of a family medicine module in the basic curriculum, now available in 75% of universities and a pilot programme of training periods in general practice to help undergraduate students make “informed decisions” about their choice of a specialty [31]. Only the combination of interventions in Türkiye showed results with an increase in the number of family physicians [37]. Increases in the number of residency places implemented in Belgium, Italy, Ireland and France [17, 22, 29, 30], are too recent to show results.
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