Returning doctors to medicineBMJ 1998; 316 doi: http://dx.doi.org/10.1136/bmj.316.7136.2 (Published 28 March 1998) Cite this as: BMJ 1998;316:S2-7136
Education and support build confidence say Maureen Baker and Gifford Batstone, who run courses for doctors re-entering medicine
- Maureen Baker, associate adviser in general practice,
- Gifford Batstone, postgraduate dean,
- Steve Kisely, Consultant in public health medicine
- Centre for Postgraduate Medical Education Queen's Medical Centre, Nottingham NG7 2UH
- 213 Hagley Road, Birmingham B16 5RQ.
Just as economies go through cycles of ‘boom and bust', in the medical world we seem to have either too many doctors or too few. Not so long ago, there were dire threats of medical unemployment.(1) Nowadays there are dire threats of not having enough doctors to meet the healthcare demands of the near future.(2) Without being alarmist, the report of the Medical Workforce Standing Advisory Committee (MWSAC) points out the gap between demand for medical services and the available supply of doctors and, amongst other recommendations, calls for improved measures to retain doctors in the medical workforce.
All medical disciplines are likely to feel some effects of a deficit in the supply of doctors, but problems will be most obvious in those fields such as psychiatry and anaesthetics where it is already hard to recruit consultants. Until the proposed change in medical student numbers is manifest as specialists and general practitioners, the situation is likely to remain critical. Further, it can be difficult to gauge accurately demand between differing specialties. This can result in large swings in the number of specialist registrars. Disciplines like obstetrics and gynaecology have gone from under to oversupply within a short time frame.
With the increase in the proportion of female graduates in medicine, the number of doctors taking career breaks will increase. If these breaks are prolonged, then there is a risk of losing good doctors unless some way of re-introducing them into clinical practice is found. In the last few years, recruitment and retention of general practitioners have posed particular problems and have focused attention on the need to make the most of the existing medical workforce. Recent work demonstrated that there are substantial numbers of doctors who are fully trained as GPs but who are not working as principals in general practice.(3) Some of these doctors wish to increase their commitment to medical work, but lack confidence owing to the time they have been away from medicine. Others have continued to work in general practice or medicine in some capacity, but feel they would have difficulties in taking on the extended role of a GP principal. It was for these reasons that the first re-entry course for general practice was developed and run in Doncaster in 1996.(4)
The aim of this course was to enable delegates to assess their educational needs for future work in general practice, and in particular to help them determine whether they would require a further period of time under supervision in a training practice. Delegates therefore had an educational assessment from an experienced trainer as well as sessions designed to update existing knowledge. It soon became apparent to delegates and course organisers that lack of confidence in knowledge and skills was a major factor in preventing these doctors from returning to unsupervised positions in medicine. One of the most important findings of the study was that virtually all of the delegates had their confidence in their ability to return as principals boosted by attending the course. It was interesting to find that the session which most helped confidence was the simulated surgery, as this was perceived by most delegates to be the most threatening area of the programme prior to the course.
The outcome of this project was encouraging in terms of doctors increasing their work commitments and making definite steps to return as principals following the course. Since then, further courses have been run and other models for re-entry to general practice are being explored. Regions such as the West Midlands and Wessex have developed different schemes to assist returners to general practice and regulations are being changed to allow greater flexibility in working practices. But could this type of approach work for other medical disciplines? Regulations are already in place which allow general practice returners to work in a supervised capacity in a training practice for a limited period, and for their supervisor to be paid a training grant. No equivalent mechanism yet exists in secondary care.
Surely it must be possible to allow a consultant or specialist registrar who had not practised for several years to return to medicine in a similar way. Re-training programmes would need to be devised by the postgraduate deans' departments in consultation with representatives of appropriate colleges. Returners would require supernumerary funding and the programmes agreed would give responsibilities to colleges, postgraduate deans and trusts to ensure successful implementation of these.
Unlike the situation in general practice, there is presently no evidence that substantial numbers of trained specialists are not working in medicine. But traditionally, women doctors and others who might intend to work part time have not chosen to train as specialists due to the inflexibility of training and working practices. As the proportion of women graduating as doctors continues to rise, there is little doubt that all specialties must accommodate more women doctors. We already have evidence that many more female doctors are planning careers in hospital medicine.(5) It would be reasonable to assume that many of them will want or need time away from medicine due to family commitments. It would be prudent to start making arrangements to facilitate re-entry for these doctors now, rather than risk losing many of them to medicine altogether.
At the end of the day, why should practices or trusts consider employing a re-entrant to medicine? Where there is competition for posts, will it not always be the case that the doctor with the ‘conventional' career will hold the advantage? Perhaps we should begin to value the experience these doctors will have gained from their lives outside medicine and ask ourselves how this might enrich their medical lives. After all, experience gained in raising a family, running a business or even recovering from personal illness can only help to enrich our understanding of the human condition. Trainees in public health medicine are presently encouraged to spend six months working in a relevant post outside medicine to foster insights into their medical careers.
There is also an economic argument to be made in favour of facilitating re-entry schemes for doctors. At current figures it costs approximately £200,000 to train medical students up to graduation. Further financial and intellectual investment by the state occurs as the trainees become fully trained specialists or general practitioners. If doctors are not working, or work less than they wish, the return on the state's investment is not being fully realised.
Future developments such as re-certification will introduce further barriers to re-entry, though the clear objectives imposed by the requirements for re-certification would be an advantage. Although re-certification is most likely to be introduced first in general practice, eventually there will be implications of re-certification procedures for both primary and secondary care. Re-entry training for general practice needs to be developed further and in a more structured fashion. A national overview of re-entry requirements would be helpful to ensure adequate courses are provided. As the demand for more flexible careers parallels the public demand for more doctors, then we will need systems which allow re-entry into the full spectrum of careers in medicine.
Moore J. Career development workshops. Clinician in Management 1997;6:1, 20.
I thank two fellow workshop participants, Judy Jones and Julia Moore, as well as Mike Garside and Tim Scott, who helped design the workshop, for their help in writing this article.
Further details about career development workshops can be obtained from the:
British Association of Medical Managers, Barnes Hospital, Kingsway, Cheadle, Cheshire SK8 2NY.