BACKGROUND:Large variations in diagnostic imaging use raise concerns about low-value care, inequity, and inefficient use of resources. Magnetic resonance imaging (MRI) of the head, lumbosacral spine, and knee has been identified as potentially low-value examinations in several clinical contexts. OBJECTIVES:To examine variation in general practitioners' referrals to low-value MRI examinations in Norway and assess whether differences are associated with GP and practice characteristics. METHODS:Using national registry data, we linked patients' completed MRI examinations to their regular GP and calculated GP-specific MRI rates per 1000 listed patients. We classified GPs into deciles and compared the characteristics of GPs in the highest (High-10) and lowest (Low-10) referral deciles. We examined predictors of variation using pooled OLS regression models with year fixed effects and GP-clustered standard errors. RESULTS:GPs in the top referring decile (High-10) referred patients for potentially low-value MRI examinations at three times the rate of those in the lowest referring decile (Low-10). Experienced (specialist-certified) GPs referred approximately 2.7 fewer examinations per 1000 listed patients per year than less experienced GPs (non-specialists). Shorter consultation times, higher consultation frequency and higher hourly fee income were all associated with higher MRI use - with the strongest association for private MRI. A higher patient disease burden was associated with more total examination, but fewer private examinations per 1000 listed patients per year. CONCLUSION:Referral rates varied markedly between GPs. Specialist-certified GPs had lower rates than non-specialists, and higher activity levels and income from fees were associated with higher referral rates - particularly to private providers.
BACKGROUND:Interprofessional collaboration is essential to address the complex challenges in primary care. One widely used method for this purpose is interprofessional team meetings. Although the benefits are generally known, maintaining these meetings after their introduction remains challenging. OBJECTIVE:To understand the aspects influencing the sustainability of interprofessional team meetings. METHODS:An exploratory qualitative study was conducted with professionals (n = 39) from seven interprofessional teams that met regularly to coordinate elderly patient care. Data were collected through seven focus group discussions. Content analysis was applied, guided by the Consolidated Framework for Sustainability, to identify barriers, facilitators, and needs. RESULTS:Common barriers included unclear networks, lack of shared goals, and limited time, whereas facilitators involved strong team dynamics, clear structures, and flexibility. These findings point to five key needs: (i) adaptive team composition in response to patient care issues, (ii) shared ownership within interprofessional teams, (iii) shared meetings' aims and work agreements, (iv) a balanced structure with clear procedures, supportive tools and room for flexibility, (v) and a satisfactory perceived quality of the meetings. CONCLUSION:This study shows that nurturing team dynamics, tailoring organisational structures, and embedding ongoing evaluation are essential beyond patient care. This may need a new way of thinking to enhance the sustainability of interprofessional team meetings in primary care.
Background Early-to-moderate chronic kidney disease (CKD) is largely managed in primary care, yet reported practices vary across settings. Understanding how CKD is identified and managed in routine practice is essential to inform improvements in care.Objective To synthesise empirical evidence on the management of adults with early-to-moderate CKD in primary care in high-income countries including real-world practices and initiatives to improve CKD management.Methods We conducted a systematic integrative review of quantitative, qualitative, and mixed-methods studies published between 2000 and 2022. MEDLINE, Embase, the Cochrane Library, KT+, and PDQ-Evidence databases were searched. Eligible studies reported management practices for early-to-moderate CKD in primary care. Findings were synthesised using a convergent integrated narrative approach.Results A total of 90 studies were included (46 descriptive, 23 qualitative or mixed-methods studies, and 21 interventional), representing over 33 million patients and 3,180 healthcare professionals. Across studies, substantial variability in screening, monitoring, referral practices, and implementation of management strategies was reported. Low screening rates among at-risk populations, incomplete follow-up after abnormal results, variability in medication use and risk-factor control, and heterogeneous referral practices were common findings. Patients often had limited awareness of CKD, and organisational barriers affected engagement in care. Various initiatives, including interprofessional models, decision-support tools, patient education, and multimodal interventions, showed heterogeneous effects across settings.Conclusions Management of early-to-moderate CKD in primary care varies considerably across high-income countries. Reported findings suggest that improving CKD care may require context-adapted strategies combining organisational, clinical, and educational components, particularly those involving multidisciplinary collaboration and decision support.
Primary healthcare is facing unprecedented complexity, driven by multimorbidity, social vulnerability, health inequities, rapid digitalisation, and shifting professional roles. This opinion paper argues that strengthening primary care requires a fundamental reorientation of both research agendas and professional education. We propose a shift towards innovative, theory-informed methodologies capable of capturing how care works in practice, for whom, and under which conditions. Priority research domains include integrated care, interprofessional teamwork, the biopsychosocial health interface, care for vulnerable and superdiverse populations, and the responsible implementation of digital and AI-supported tools. To capture these dynamics, we advocate for innovative methodologies including longitudinal mixed-methods designs, pragmatic cluster trials, realist evaluation, implementation science, network analysis, and complexity science approaches. Participatory and practice-based research models are essential to ensure relevance and reduce research waste. Finally, we emphasise the need to embed research literacy, interprofessional learning, and digital competence within transformative education for future family physicians.
BACKGROUND:Intensive care unit (ICU) survivors frequently experience symptoms of post-traumatic stress disorder (PTSD) and reduced health-related quality of life (HRQoL), yet evidence for effective post-ICU interventions in primary care remains limited. This secondary analysis of the PICTURE randomised controlled trial provides an in-depth evaluation of HRQoL trajectories and potential treatment mechanisms. METHODS:The analysis included 319 adult ICU survivors with at least moderate PTSD symptoms, randomised to a brief general practitioner (GP)-delivered narrative exposure intervention or enhanced usual care. Longitudinal mixed-effects models estimated treatment-by-time effects on HRQoL, based on EuroQol Five-Dimension Five-Level (EQ-5D-5L) index and visual analog scale (VAS), with mediation via PTSD symptom change assessed using structural equation modelling. RESULTS:The mean baseline EQ index was 0.71 ± 0.27 and EQ VAS was 60.7 ± 19.4. Mixed-effects models showed a transient improvement in EQ VAS at 6 months in the intervention group (ß = 5.85; 95% CI 0.84-10.87), followed by a delayed improvement in the EQ index at 12 months (ß = 0.075; 95% CI 0.014-0.136). About one quarter of the 12-month EQ index effect was mediated by PTSD symptom reduction at 6 months. Domain-level analyses indicated greater improvement in anxiety/depression and mobility. CONCLUSIONS:In ICU survivors with PTSD symptoms, a brief GP-delivered psychological intervention was associated with clinically meaningful improvements in health-related quality of life over 12 months, with effects emerging over time and only partly explained by PTSD symptom reduction. TRIAL REGISTRATION:ClinTrials.gov: NCT03315390 (Registration date: 2017-10-20); German Clinical Trials Register (DRKS): DRKS00012589 (Registration date: 2017-10-17).
Background Female general practitioners (GPs) often encounter diverse challenges in sustaining a career in general practice, in addition to those experienced by their male counterparts, which may have implications for workforce planning and retention in Ireland.Objectives To explore the experiences and expectations of female GPs regarding a sustainable career in general practice.Methods Rooted in a constructivist paradigm, this qualitative study was conducted in Ireland. Thirteen online semi-structured interviews were conducted using ‘Love and Breakup Letter’ methodology as an elicitation prompt to facilitate discussion. Narratives were explored thematically.Results Participants viewed their GP role as an integral part of their identity. A career in general practice was found to be fulfilling, with a constant stream of new learning opportunities. The unique context of establishing long-term relationships with patients and having a supportive peer network was the primary motivation for pursuing and staying in this career. Yet, despite these benefits, dissatisfaction with the primary care system, competing family responsibilities and gender-driven challenges added further complexity to sustaining their careers. The incompatibility between work and family life has led many to adapt their careers, reducing clinical hours and pursuing diverse GP careers, to regain balance and manage competing demands.Conclusion The career of a GP was treasured among women who chose this profession; however, system changes are needed to ensure the ideals of sustained and satisfying GP careers are upheld. Equipping GP graduates with skills to diversify their careers and promoting a strong peer-support network and mentoring opportunities are recommended.
BACKGROUND:Identifying victims of interpersonal violence remains a challenge for general practitioners, who must rely on subtle clinical cues and foster an environment conducive to disclosure. OBJECTIVES:To describe the symptoms, behaviours, and communication strategies that facilitate the recognition of interpersonal violence in primary care consultations. METHODS:For this qualitative study, general practice consultations by three physicians in the Poitou-Charentes department, France, were audio-recorded from June to September 2019. Adult patients (≥18 years, fluent in French) were included unless they rejected audio recording. Only the audio-recording of consultations during which interpersonal violence was disclosed were analysed following an inductive approach to identify categories and themes until saturation was reached. RESULTS:In total 25/326 patients disclosed experiences of violence. Detection combined verbal cues (vague somatic complaints, ambiguous trauma references) by the patient and open-ended or direct questions by the general practitioners. Techniques included linking symptoms to violence, broad funnel questions, and most effectively, direct queries, such as 'Did someone hurt you?. The three physicians adapted their approach, balancing respect for the patient readiness and clinical conviction, often revisiting the topic from different perspectives. Empathy and a trusted doctor-patient relationship proved crucial for violence disclosure. CONCLUSION:Our findings highlight the value of the physicians' tenacity and empathic attitude for identifying hidden situations of violence, and suggest that integrating these strategies in routine general practice can enhance detection. The findings underscore the need of training physicians in patient-centred communication and suggest future research avenues for refining detection protocols in primary care.
Introduction Breast cancer is the commonest cancer in women, and screening can allow earlier-stage diagnosis. While there are European recommendations on the age-range and frequency of breast cancer screening, participation in these programmes varies substantially, and this could be due to differences in how they are organised and implemented. The role that primary healthcare professionals play in the process is unclear.We aimed to describe the breast cancer screening programmes in European countries and investigate how primary healthcare professionals are involved in this screening process.Methods A cross-sectional survey in 32 countries. Key informants with relevant expertise answered online questions about the characteristics of their screening programmes and general practitioners’ (GPs’) roles in this. Responses were refined through an iterative consensus process. Data were examined to identify patterns in GP engagement.Results We found important differences between European breast cancer screening systems. While most had population-based screening, four countries relied on opportunistic screening. In 15 countries GPs had little or no involvement in the process of breast cancer screening, and in 13 countries GPs had some involvement, including identifying eligible patients, issuing referrals, and following-up results. Screening uptake rates tended to be higher in countries with well-established population-based screening programmes which give little or no GP involvement. Few countries linked GP engagement to incentives or performance measures.Conclusion Countries with lower screening uptake should consider either enhancing GP involvement or transitioning to a structured, population-based screening system. Further research should explore how best to integrate primary care within national screening strategies.
BackgroundPharmaceuticals represent a major source of carbon emissions in primary care. General practitioners could avoid prescribing climate-harmful medications and consider eco-friendly alternatives in shared decision-making processes. However, evidence on patients' perceptions of discussing medication-specific environmental impacts in primary care consultations in Germany remains limited.ObjectivesTo explore patients' perceptions of discussing medications' environmental and climate impact during family medicine encounters and their willingness to switch to more eco-friendly options.MethodsThis qualitative study employed semi-structured interviews with patients recruited through GP practices in Northern Germany. Inclusion criteria were long-term use of at least one medication, legal age, and informed consent. Twenty-five interviews were conducted and analysed using structured content analysis according to Kuckartz.ResultsRespondents expressed surprise when environment/climate topics were to be discussed in medical encounters but demonstrated openness to these topics and desired more information about their medications' environmental impact. Many interviewees showed willingness to switch to eco-friendly medications despite potential disadvantages including more frequent intake, increased side effect risk, or co-payments. Patients exhibited high trust in provider recommendations and sought greater information and transparency.ConclusionResults suggest opportunities to incorporate climate/environmental aspects into shared decision-making. Understanding patient perspectives enables GPs to address environmental/climate-friendly medication topics in treatment discussions. Patients are receptive to these discussions and willing to accept eco-friendly alternatives despite potential drawbacks. The high level of trust in provider recommendations positions family physicians as key actors in promoting environmental stewardship.
Background: Point-of-care ultrasound (POCUS) is an increasingly valuable tool in general practice/family medicine (GP/FM). This position paper from the European Academy of Teachers in General Practice/Family Medicine outlines recommendations for integrating POCUS education across the continuum of training: undergraduate, specialty, and continuing medical education.Recommendations: POCUS should complement, not replace, the clinical examination. Key priorities include GP/FM-targeted curriculum development, early exposure during basic medical education, mandatory residency training, context-sensitive continuing professional development, train-the-trainer programmes, and GP/FM-led implementation.Discussion: Integrating POCUS teaching across all stages of GP/FM education may support effective and sustainable adoption in primary care. Educational strategies should be adapted to local contexts and healthcare systems while maintaining a focus on clinically relevant and evidence-informed use.Conclusion: EURACT recommends the longitudinal integration of POCUS education throughout GP/FM training and professional development. These principles aim to guide the effective, sustainable, and context-sensitive implementation of POCUS in primary care.
Background: Interprofessional collaboration (IPC) in outpatient care can improve patient outcomes and satisfaction, health prevention and economics. German primary care (PC) is challenged by an ongoing demand for health care professionals to extend services. PC in Germany is regularly provided by general practitioners and medical assistants. Models on how to establish interprofessional primary care (IPPC) are scarce. Objectives: Aim of the study was to explore stakeholders ' suggestions on IPC in German PC to support development of an IPPC model. Methods: Professionals from various nation-wide institutions and associations with professional backgrounds in general practice, medical assistance, nursing, physician assistance, social work and specialist medicine as well as from health insurance and law, were recruited. Semi-structured interviews were performed. Deductively identified main categories included strategies for implementing IPC on system-level, organisational-level, team-level and individual-level and were coded in sub-categories inductively. Results: On system-level professionals predominantly named accountability, funding and remuneration. On organisational level documentation systems, the necessity of coordination and the availability of qualified personnel were discussed. On team-level interviewees focussed on the necessity of a mutual understanding of roles and responsibilities, clear and collaborative distribution of tasks and team leadership as well as patient integration and health literacy support. On individual-level the acceptance of new roles and professions was pointed out. Conclusion: To establish IPPC in Germany, remuneration and accountability need to be addressed. Models of IPPC need to integrate suggestions explored, a step-by-step approach for general practitioners to enable change-management and longitudinal support to promote adapted leadership and sustainable implementation.
Background Unplanned hospital admissions are distressing for older persons and are associated with a high risk of adverse outcomes and a burden on health systems. Understanding the risk and protective factors for unplanned admissions can help to design new preventive interventions in primary care.Objectives To explore primary healthcare professionals’ experiences on factors affecting unplanned hospital admissions in community-dwelling older adults and identify opportunities for preventive interventions.Methods We performed a focus group study with a purposive sample of Dutch primary healthcare professionals. Four focus groups were conducted with a total of 22 primary healthcare professionals comprising 10 general practitioners (GPs) and 12 other primary healthcare professionals. All focus groups were recorded, transcribed, and thematically analysed.Results Factors affecting unplanned admissions were grouped into characteristics of the patient, the healthcare professional, and healthcare organisation. Patient-related risk factors included the presence of chronic conditions, health-seeking behaviour, the presence and capacity of an informal caregiver, and cultural expectations of healthcare. Continuity of care, advance care planning, and professional experience as a GP were identified as mitigating professional-related factors for unplanned admissions. Organisational factors that potentially contributed to unplanned admissions were poor informational continuity, suboptimal care coordination, and lack of alternatives to hospitalisation.Conclusion Unplanned hospital admissions in older adults were perceived to be influenced by patient, healthcare professional, and healthcare organisation-related factors. Strategies such as ensuring broad access to patients’ clinical information and treatment wishes, improving personal continuity of care, and structural provision of advance care may contribute to reduce unplanned admissions.
BACKGROUND:Educational level is an important social determinant of health and may contribute to healthcare inequity by affecting how patients present health problems. OBJECTIVES:Explore the interaction between patients' educational level (1), their presentation of health problems to general practitioners (GPs) and (2) GP's responses to requested interventions. DESIGN AND SETTING:Retrospective cohort study within a Dutch primary care practice-based research network. METHODS:All new episodes of care of patients' aged ≥25 years between 2014 and 2022 were included. Data were collected on the reason for encounter (RFE) at initial contact within each episode, and patients' educational level. Differences were analysed in incidence of RFE types (symptoms, intervention-requests, self-diagnoses) and GP's policies regarding requested diagnostic and therapeutic interventions among patients with low, medium and high educational levels. RESULTS:Patients with lower educational levels more frequently presented symptoms (59.7% versus 56.5%) and were less likely to present with intervention requests (OR 0.88) or self-diagnosis (OR 0.83). They requested more urine tests (RR 1.28), but fewer blood tests (RR 0.90), diagnostic imaging (RR 0.75) and referrals to primary (RR 0.74) and secondary care (RR 0.87). GPs responded more often to urine test requests (RR 1.25), but less often to referral requests to primary (RR 0.68) and secondary care (RR 0.80) among patients with lower educational levels. CONCLUSION:This study emphasises GPs' need to understand how educational status affects patient's presentation and intervention preferences, which can improve communication, shared decision-making and enhance equitable healthcare delivery by addressing an important social determinant of health.
Background General practitioners (GPs) face numerous challenges that can contribute to stress. Understanding these factors is crucial for developing interventions to support physician wellbeing and maintain high-quality care.Objectives The study aims to explore the factors associated with perceived stress among European GPs, including attitudes towards person-centred care (PCC), demographics, and professional characteristics.Methods The PACE GP/FP study is an online, cross-sectional, multi-centred survey conducted in 24 European countries between November 2022 and January 2024. The survey tool included the Perceived Stress Scale (PSS), the Patient-Practitioner Orientation Scale (PPOS), and questions on GPs’ demographics and practice characteristics. Linear mixed models analysed the relationship between these variables and perceived stress.Results In total, 3522 GPs were included in the analysis. The mean PSS score indicated moderate levels of stress. Female gender and younger age were associated with increased stress. Also, a higher number of daily patient contacts and a greater perceived responsibility for vulnerable patient populations (e.g. migrants, those with limited social support, or psychiatric vulnerabilities) were significantly associated with higher stress. A stronger patient-centred orientation was associated with lower perceived stress.Conclusion The findings have implications for interventions to reduce GP stress, such as training programs promoting PCC, optimising patient contact rates, and providing targeted support for GPs caring for vulnerable patients. Further research is needed to explore these factors’ complex interplay and impact on GP wellbeing.
INTRODUCTION:Endometriosis is a chronic, systemic condition affecting 5-10% of individuals assigned female at birth. Due to its non-specific symptoms, diagnosis is often delayed. OBJECTIVES:This study aims to explore diagnostic challenges and decision-making processes that general practitioners (GPs) encounter when managing patients with symptoms suggestive of endometriosis in Denmark. METHODS:A qualitative research approach was employed, incorporating the co-production of three fictional clinical vignettes representing diverse endometriosis presentations. Semi-structured interviews were conducted with 27 practicing GPs (7 males and 20 females) from urban and rural areas. Participants had a mean age of 50 years (range 41-66) and clinical experience ranging from newly qualified to 27 years. Interviews involved engagement with the vignettes, and data were analysed using thematic analysis. RESULTS:Findings reveal the challenge of the non-specific nature of symptoms, the role of cyclical symptom patterns in diagnosis, the influence of diagnostic hierarchies, patient-centred care approaches, the bio-psycho-social perspective in management, the persistent stigma surrounding gynaecological symptoms, and GPs limited trust in general gynaecologists. GPs were more likely to suspect endometriosis when symptoms followed a cyclical pattern, whereas gastrointestinal presentations were less commonly linked to the condition. While many GPs adopted a patient-centred, shared decision-making approach, some still adhered to mind-body dualism in their clinical reasoning. CONCLUSION:Diagnosing endometriosis in primary care is challenging due to non-specific symptoms, diagnostic hierarchies, and stigma. Encouraging GPs to routinely inquire about the cyclical nature of symptoms may serve as a valuable diagnostic tool, particularly in cases involving gastrointestinal complaints.
Background Prescribing epidemiology in general practice shows gabapentinoid drugs to be independently associated with unexpected, drug-related death. There is an increasing trend of gabapentinoid deaths throughout Europe and North America.Objectives The overall aim of this study was to assess how patient, practice and health system factors might be associated with gabapentinoid prescribing in primary care.Methods Case series following a critical incident of an unexpected death in a patient prescribed a gabapentinoid drug in a single general practice. Unexpected and expected deaths in patients prescribed a gabapentinoid drug deaths over an 11-year period in a single general practice. We examined patient, prescriber and health system factors. Toxicology and post-mortem data were provided by the Coroner.Results There were 36 deaths (four unexpected and 32 expected deaths) during the study period. Of the four patients who suffered an unexpected death, one of these patients’ cause of death could be attributed to drug and alcohol toxicity. Over half of gabapentinoid prescribing (n = 19,53%) was hospital initiated, often ‘off-label’ (n = 6, 17%) and commonly co-prescribed with opiates (n = 15, 42%) and benzodiazepines (n = 11, 31%) to patients with high multi-morbidity.Conclusions Gabapentinoids are often initiated in the outpatient setting in clinically complex patients, often for ‘off label’ indications, with high polypharmacy. Patient, practice and health-system related factors need to be addressed in relation to gabapentinoid associated deaths and reflected in clinical practice guidelines. There is critical value in using toxicology reports from Coroner’s offices in cases of unexplained gabapentinoid death in general practice.
Introduction Strengthening Primary Health Care (PHC) is essential for building resilient and equitable health systems, but PHC faces barriers in implementation, resource allocation, and political prioritisation. This study aimed to develop a strategic roadmap to enhance PHC by identifying core values, priorities, and actionable strategies through expert consensus.Methods A two-round Delphi study was conducted with 210 stakeholders from 35 countries, including PHC professionals, policymakers, and public health experts. Participants evaluated the importance, feasibility, and policy prioritisation of key PHC values. Quantitative data were analysed using descriptive statistics.Results The response rate was 81.4% (171/210) in round one and 73.5% (97/132) in round two. The majority of participants (89%) had a background in medicine. A consensus (>80% agreement) was reached in the first round regarding PHC values. Key recommendations included increasing investment in PHC workforce development, particularly in underserved areas; strengthening health information systems and integrating telehealth solutions; enhancing PHC governance models to support multidisciplinary collaboration and citizen-centred care; and adapting processes to improve chronic care management, end-of-life support, and standardised assessment frameworks. In the second round, when participants assessed the feasibility of these recommendations, agreement levels ranged from 61 to 92%. When asked about the policy prioritisation of these measures, agreement dropped, ranging from 22 to 51%.Conclusions This study highlights that PHC stakeholders perceive a critical need to align health policies with the core values of PHC, while addressing systemic barriers to implementation. Future efforts should focus on bridging the perceived gap between expert recommendations and political prioritisation to achieve sustainable PHC improvements.
BACKGROUND AND OBJECTIVES:Population health management (PHM) is increasingly promoted as a strategy to improve health outcomes, enhance healthcare quality, reduce costs, and, more recently, support clinician well-being and advance health equity - the Quintuple Aim. However, how PHM is conceptualised within the primary care context remains unclear. This scoping review explores how PHM is conceptualised within this context. METHOD:Five databases (PubMed, Embase, CINAHL, Web of Science and Scopus) were searched to find publications that conceptually addressed PHM and its interaction with the primary care context. Data extraction focused on definitions and related terms, the bidirectional influence between PHM and general practice, and interpretations of the components 'population' and 'management'. RESULTS:27 publications were included. Definitions of PHM varied, with few explicitly addressing the primary care practice level. They highlighted the need to proactively address social determinants of health beyond clinical outcomes. Both top-down and bottom-up dynamics make general practices accountable for and increasingly involved in the identification of populations, risk stratification and impact assessment, with both clinical judgement and real-world primary care data. Management involves team-based and technology-supported care. CONCLUSION:Considering PHM within primary care highlighted the importance of general practice's accountability, its consideration of social determinants of health beyond clinical outcomes and its community alignment to enhance equity. What the potential added value of general practitioner's clinical intuition and real-world primary care data in assessing impact warrants additional exploration.
Background: In Flanders, Belgium, the 3-year specialised training in General Practice includes a specialty training rotation, for which trainees may choose their training site. After graduation, General Practitioners (GPs) decide where to establish their practice. Objective: This study explored the factors influencing GP trainees' choice of training location, reasons for settling in a specific region after graduation, and motivations for remaining in or leaving a practice. Methods: In May 2024, the Interuniversity Centre for Education of General Practitioners distributed an anonymous online survey with closed- and open-ended questions to all GP alumni graduating between 2014 and 2023. Quantitative data were analysed using linear regression; qualitative data underwent content analysis. Results: Of 772 alumni respondents (26.7% response rate), 93.4% were still practising as a GP. Most were female (70.9%), and 37.2% engaged in additional professional roles. Key influences on training location choice and practice settlement included colleague connections, proximity to home, and opportunities to work in group practices. Decisions to stay in or leave a practice were shaped by interpersonal relationships, practice organisation, and work-life balance. Working as a substitute GP was a frequent reason for changing practices, especially among recent graduates, to explore varied working environments. Conclusion: Both interpersonal and logistical factors strongly influence training practice choice and later GP practice settlement. High-quality training practices and supportive work environments are essential to promote sustainable GP careers and achieve a more balanced geographical distribution of GPs.
