Career counselling in general practice
BMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7062.2 (Published 12 October 1996) Cite this as: BMJ 1996;313:S2-7062
The little that exists is provided by untrained advisers, argues Ruth Chambers, senior lecturer in primary health care at Keele
Most doctors do not have access to careers guidance from well informed careers advisers, as our research shows.(1)
General practitioner registrars fare better than general practitioner principals, but their career advisers are the same course organisers who take overall responsibility for their vocational training. It seems that appointment as a course organiser is assumed to confer automatic career adviser status, though most have little specialised knowledge about careers guidance or opportunities. Likewise, some general practitioner principals look to GP tutors and local medical committee officials to act as careers counsellors, despite the fact that they usually have no career guidance skills or knowledge.
There are no definite qualifications or criteria for a doctor acting as an adviser about medical careers. Elsewhere, careers advisers might be expected to possess a diploma in careers guidance, offered at several universities as a one year full time or two years' part time course followed by a probationary year in service.
Issues in GP career counselling - 1
Retaining: Dr M heard about the GP retainer scheme casually from a friend while she was completing her vocational training for general practice. She did work on the scheme for a year but soon wanted to do more than the two weekly sessions allowed. A friend was leaving her part time post as a junior in palliative care. Dr M replaced her and now job shares a consultant post in palliative care.She had initially been keen to be a general practitioner but is happy enough with her alternative career. Had she sought and received careers advice as a GP registrar she could have made a considered choice about her future career specialty rather than allow her career to develop opportunistically.
Availability of careers guidance for general practice
The subjects in our survey were asked to identify anyone in their district or region whom they knew provided careers advice or guidance to medical students, junior hospital doctors, general practitioner registrars, or principals, and to state what help they gave.
Two thirds of respondents did not know of any provider of careers guidance for general practitioner principals. Regional advisers,general practice tutors, and local medical committee secretaries were named most frequently as sources of careers advice for principals. Most of the help given was defusing partnership disputes or providing information about practice vacancies. One third of respondents did not know of any careers counselling provision for general practice registrars. Where available it generally took the form of discussions led by course organisers about future partnerships. Occasionally individual counselling was given to registrars who sought it for themselves, but it was rarely offered routinely.
The few respondents who had contact with medical students and junior doctors gave many examples of good practice, including individual counselling, proactive career reviews, networks of tutors available to junior doctors, and careers seminars.
Issues in GP career counselling - 2
Reviewing: Dr A has been a GP principal for five years and is beginning to be bored by a seemingly repetitive working cycle of surgeries and visits. He's wondering whether he should leave medicine, or reduce his practice commitment and combine his GP work with another post within or outside medicine. He does not know who to ask for advice and whether whoever advises him will offer a cosy chat or an impartial proactive careers review. With the correct advice about personal and professional development his GP career could flourish.
Coordinated counselling needed
There was a consensus among respondents to the survey that each regional adviser should organise a coordinated scheme using current educational networks, manned by trained advisers with dedicated time for careers counselling. This proposal is in line with the British Medical Association's recent recommendations for careers guidance provision for all medical students and doctors.(2)
What should it offer?
A comprehensive and effective careers counselling service for general practice should be an integral part of a widely based service offered to all doctors, whether they work in hospital, in the community, or in general practice. This would hopefully lead to a balance in the numbers of doctors switching between specialties rather than there being a potentially one way shift if dissatisfied general practitioner principals were the only group to receive careers counselling about parallel careers or changes of direction.
An ideal careers counselling resource should have all the hallmarks of any quality service - of equity, availability, accessibility - and be well advertised to doctors and medical students. It should offer effective, efficient, appropriate services and follow up support.Strong links with medical schools would provide a seamless careers service for medical students as they became qualified doctors and ensure that all doctors had the opportunity to access unbiased information about a wide range of medical careers.
Training for careers advisers is important if the guidance given is to be impartial and match students' and doctors' aptitudes for their chosen careers. Such training should include an extensive knowledge and understanding of careers in all medical and health management specialties, the qualifications and experience required, as well as an understanding of personal aptitude and personality types best suited for particular specialties. The untrained regional advisers, general practice tutors, course organisers and local medical committee officers currently giving careers guidance will base much of their advice on their own personal experiences, which, although valuable, reflects their opinion rather than a structured review of the alternative options.
A careers counselling service should be responsive to the changing times in the NHS and help accommodate individual preferences and domestic or other constraints, challenging traditional career paths.This flexibility will be important if doctors who are judged to be under performing in an area of their specialty need to be rehabilitated or redirected to alternative medical work for which they are skilled or suited.
Issues in GP career counselling - 3
Refocusing: Dr R has been a GP principal for 14 years. His extra practice activities have snowballed recently and he is now in a dilemma about which career path to follow. He needs to find an experienced careers counsellor for advice about alternative careers in health service management, academia, medical education, or his own commercial enterprise, and the combination of any of these with service work. He now needs unbiased and informed advice about the diverse range of career opportunities to make the most of his potential contribution to medicine.
Morale, manpower, and careers guidance are inextricably linked
Improving career satisfaction and fulfilment could contribute to resolving the low morale and manpower issues in primary care. Several surveys have described registrars' and principals' dissatisfactions and frustrations with their career choice of general practice.(3-5) The resulting general practitioner workforce has become increasingly demoralised with early retirement and less than full time working becoming more common. The actual number of doctors who leave clinical medicine seems to be in some dispute. Allen's report that more than 90% of the doctors she studied who qualified in 1976 and 1981 remained working in clinical medicine(6) is at odds with the 1995 medical workforce review that “up to one fifth of any given cohort of doctors may not be working in the NHS five years after qualification.''(7)
A review of the economic value of careers guidance from studies of many different organisations and countries found that the number of people leaving their jobs was reduced by good careers guidance.(8)
Three steps to a service
NHS management and the medical educationalists will both need to be active partners to establish coordinated careers counselling services.Firstly, current worries over the dwindling general practitioner manpower especially in the inner cities and isolated rural areas,disenchantment, and recruitment problems should motivate those with the power to establish careers counselling services for the medical profession.
Secondly considerable funding will be required for infrastucture, training, service provision and, advertisement of regionally or district based careers counselling services. Such investment should be justified if careers guidance is effective when the cost of training a doctor, the reduced doctor wastage figures, and increased numbers returning to work are taken into account. There is positive evidence from other organisations that careers guidance is cost effective,(8) but an economic evaluation should be an integral part of any new careers advice service for doctors. Thirdly,doctors will have to be encouraged to use the services provided.Doctors are notoriously reluctant to ask for help with their own healthcare and wellbeing, and several of the respondents to the careers survey predicted that established doctors may be similarly reluctant to seek careers guidance or help.(1)
Lastly, there needs to be a cultural shift where mid career change is seen in a positive light. Such change can provide opportunities for personal growth and revitalisation for doctors who have become stale in their long held posts.