Portfolio CareersBMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7057.2 (Published 07 September 1996) Cite this as: BMJ 1996;313:S2-7057
Author, lecturer, charity worker, medicolegal expert, politican, and consultant histopathologist Carl Gray on the benefits of maintaining a career portfolio.
From the earliest days of the NHS doctors have done different bits and pieces of work, but the concept of a portfolio career has become now fashionable throughout the world of employment. In his book The age of unreason Charles Handy argued that so long as earned income is sufficient, satisfaction will come from a widely based portfolio of both paid and unpaid work, which can be varied over time to suit the needs and wishes of the individual. By contrast, the traditional linear career in which a person does one job for his or her working life is decreasing in availability, and may be gone for ever in many walks of life. In a rapidly-changing world employers prefer flexibility and short term contracts for their workforce.
Doctors with portfolio careers avoid the expectation that their job will continue the same for 30 years, have a richer professional life, and prevent burnout. A varied portfolio would accommodate family life and maternity or paternity leaves and prepare for an active “retirement.” Extra remuneration may be welcome and many activities give direct benefit to the NHS in the form of teaching and research, or indirect benefits such as extra skills or increased flexibility to meet future change.
The possible disadvantages include overcommitment and exhaustion as multiple part time jobs always add up to more than one full time job. Diary conflicts between commitments can be troublesome and a crisis in one job becomes a challenge to them all. Some loss of interest in the main job is inevitable.
The seven year itch
Many hospital consultants pitch into their clinical job and are completely satisfied, but many get bored about six or seven years into their consultant jobs. Sufferers from this version of the seven year itch, having achieved their original goal, wonder “Is this it?” Many hospital dining rooms contain examples of the “made it” but unsatisfied consultant - the haunted look, leisure well sorted, but deeply bored with clinical work and the prospect of more of the same for 15 to 25 years to come. Some who do just the one day job complain of insufficient remuneration especially when families have arrived.
Many specialties are undersubscribed because potential new entrants have rejected them on lifestyle grounds. Premature retirement is becoming the norm, as senior doctors discuss longingly the possibility of escape. The underlying reasons include overwork, but also a growing lack of job satisfaction.
Multiple jobs are possible for hospital consultants with part time sessions or can simply be fitted in: a wide range of paid and unpaid employment and roles is feasible (see box), but many do just private practice.
The current generation of applicants for consultant jobs still includes some who aspire to a “Traditional Consultant Job”! These very young fogeys expect to climb into a ready made niche at the apex of a pyramidal firm of juniors and middle grade supporters. They are finding that the traditional features enjoyed by their own trainers and keenly awaited for themselves are illusory: cost effective teamwork is the order of the day, and the most appropriately skilled person should do each task, including the consultant. The world has changed, the job has changed and inevitably they themselves will have to change. Reductions in the dignity and trappings of consultants were long overdue: respect is now earned, rather than granted on appointment. Professional satisfaction must henceforwards come from a wider base, not simply implicit in attaining the highest rank.
Because most attention will have been focussed on getting qualified and finding the right consultant job, what happens next may have been neglected. Being a specialist may not be enough for a full rich life, and will probably not provide enough income either. Just doing your job brings no points or merit awards under the rules and there are no marks for effort, only achievement.
Entrepreneurial career routes
The liveliest will seek development routes and training to extend their skills. Some will need training in advance of practice; some can be done locally in a trust and some need to be cultivated at the national level. Success will reward early planning and a patient approach, but of course luck and opportunity will still play a large part in individual outcomes. Several avenues should be cultivated at once: these may mature at different times.
The specialist needs specialist training and registration and a consultant appointment. During the first two or three years of basic service establishment, recognition, and growth, the consultant can start looking for one or more optional extras and cultivate development routes locally, regionally, or nationally. By middle age he or she will hopefully have a satisfying portfolio of roles including paid and unpaid work. By late middle age the portfolio can be adapted to retirement from the main job, and many worthwhile professional activities can continue beyond the NHS retirement age. Senior doctors have a wealth of experience which does not vanish on their 65th birthday.
Trainees can of course cultivate additional skills before consultant appointment. All young doctors these days should become comfortable with inter-personal skills, able to work computers and information technology, and be capable of speaking in public or making a case in a committee: in other words renaissance men and women! Experience in student societies - arranging meetings, showing films, working the projector and the video, meeting and lunching the distinguished visiting speaker becomes invaluable in adult life, and local BMA work can also provide excellent practical training in negotiation, chairmanship, and personnel management, in company with the shrewd and suave officials of the BMA.
NHS trusts should recognise that their doctors should not be single dimensional specialists and that there are benefits to trusts and the NHS as a whole in peripheral activities. Even so, the most parochial hospital managers do dislike their doctors doing other than their paid work in the trust and may obstruct participation outside. Many doctors feel the need for extra remuneration and finding it from outside keeps them cheaper for the NHS. Development routes are needed for likely high flyers, and trusts could do more to provide deputy and assistant roles in management. Trusts should also ensure that training extends beyond narrow disciplinary boundaries. The usual NHS consultant contract requires not more than five to seven fixed sessions with other duties flexibly worked, so consultants should be
Wider world of opportunities
Professional satisfaction comes from many sources: patient care, the job well done, the exercise of hard won skills or having a part in determining policy or practice. Unpaid activities such as professional leadership or representation can be highly satisfying and influential. A theme initiated as an interest in a portfolio can remain a hobby, or could later become a part time or full time job. An initial effort may bring a remuneration stream which starts years later.
The new rigidity
The traditional routes to diverse careers and medical add ons are being curtailed by the new bureaucratic rigidity and brevity of specialist training regimens. Their defined duration and prescribed curriculum allows less scope for irregular time out to learn a skill or follow a whim. College rules are reaching a new baroque in inflexibility for training.
Patterns of consultant practice are changing under the new circumstances. Serendipitous career planning will no longer work as well; wise trainees will now expect and plan a portfolio of activities to sustain job satisfaction and income throughout their medical career. Trusts should expect and encourage their senior hospital doctors to be active in a range of fields. In service training should encompass more than professional continuing medical education and “management” courses, and should focus on the doctor's career in its different stages. As specialist training becomes more narrowly defined and strictly administered - to each dog its licence and numbered collar - trainees must themselves take the initiative in developing a wider outlook. Young doctors face a choice of over 100 specialties for training, but there are many possible additional activities for a wider professional life (table) and you can probably think of more. NHS specialist training leading to specialist work alone may prove to be an insufficient basis for a satisfying professional life, and a monospecialist training may have the risks of inflexibility for the changing world ahead.
Opportunities for your portfolio
Private practice, service development, super specialisation, emerging areas of medicine (eg HIV care in the 1980s), medical officer to other organisations, locums
Teaching and training, educational management & deanery examining
Research, academic writing, editing learned journals, pursuit of a personal chair
Audit, quality management, complaints work
Clinical management (head of department, clinical director), hospital management (chief executive, medical director), NHS trust committees, working parties
MEDICINE & THE LAW
Medicolegal practice, expert witness, forensic medicine
LEADERSHIP & POLITICS
Medical politics and the BMA, party politics, professional leadership, royal colleges, learned societies & associations, GMC, local medical societies and clubs, inter-disciplinary bodies, cancer organisations, confidential inquiries, pressure groups
Writing, publishing, editing, broadcasting, entertainment, public speaking
HANDS ACROSS THE SEA
Medical travel, World Medical Association, lecture tours, exchanges, voluntary service, ship's doctor
Pharmaceutical companies, consultancy, non-medical businesses, directorships, non-executive directorships
Information science & technology, medical computing, expert systems, librarianship, medical historian or curator, medical museums and archives, local history, ethics & philosophy
IN CORPORE SANO
Expeditions, sports medicine, youth organisations, HM forces, territorial army
PRO BONO PUBLICO
Medical charities, fund raising, refugee and torture victim support, governmental agencies, civil service roles
What have you got in your portfolio? Don't think: “What career shall I choose”; rather: “How will my portfolio develop from 25 to 75 years of age?” If you want to play 2nd bassoon in the millennium concert you will have to start learning now!