How about a career in academic general practice?

Making a difference

“If you devote yourself to being the best practitioner you can be, you will improve the lives of thousands of patients in your working lifetime. If you teach students and young doctors, you will help to improve the lives of hundreds of thousands of patients. If, through research, you change the way we all practise, you will help to improve the lives of millions.”

I still recall those inspiring words of my mentor Paul Freeling, who taught me about general practice as an undergraduate student, and then about primary care research as a half time research fellow, at St Georges, London. I like to think he was right, as research to which I’ve contributed has led to changes in practice within my working lifetime. Regular assessments of severely mentally ill patients,1 and the use of questionnaires to measure severity of depression before treatment,23 are now widespread in UK general practice. Research in primary care is at the applied end of the spectrum, which means that useful results can be implemented for the benefit of patients within a few years of publication.

Primary care is where the large majority of common and costly medical problems are managed, and where public health and health promotion interface with clinical care. Academic general practitioners have made major contributions to the care of many millions of patients through widely cited epidemiological surveys,456 observational studies,789 randomised controlled trials and systematic reviews,1011121314 developments in service delivery,1516 and methodological developments in health care research and development.1718

Academic general practitioners have also been instrumental in the development of community based undergraduate medical education, which now makes up a large part of every medical school’s curriculum.1920 The broad scope of general practice means they can identify key learning across the range of medicine, and they have led the way in developing new teaching techniques, helped by the fact that they came later to undergraduate education and were not as constrained as their specialist academic colleagues by previous traditions of hospital based teaching.21 The director of education in my medical school, Chris Stephens, is a general practitioner (GP) and the same is now true for many schools in the United Kingdom.

It’s a wonderful life

A clinical academic has to balance seeing patients with teaching, research, and management. Managing these competing demands, however, is enormous fun, because academics have a huge degree of control over their day to day work. Continual challenges from patients, students, funders, editors, and colleagues means it’s never a boring life. And you get to see the world. Richard Smith, former editor of the BMJ, famously opened one of our academic conferences with the line, “The mark of a true academic is how quickly he can turn raw data into airmiles.” I travel to four or five conferences, all around the world, every year. Mind, these privileges have to be earned by working into the evening and at weekends in order to meet the ever present deadlines.

The career ladder for academic GPs

In 2006 a structured career pathway for medical academics was set up as a result of a joint working party of the United Kingdom Clinical Research Collaboration and the Modernising Medical Careers initiative, led by Mark Walport of the Wellcome Trust. The working party took advantage of Modernising Medical Careers’ reorganisation of medical training to dovetail a new academic career pathway with clinical training (see www.ukcrc.org/PDF/Medically_and_Dentally-qualified_Academic_Staff_Report.pdf) (box 1). It’s important to stress that it’s a pathway you can join or rejoin at various points, whether you are a student, trainee, or fully qualified GP.

New funding allows 5% of doctors in the second year of foundation school to get some exposure to research for four months in academic foundation year 2 placements (AF2). General practice AF2s are offered in a number of foundation schools (consult the deanery websites). Academic clinical fellowships provide funding to lengthen GP training from three to four years, securing time to get some initial research training and prepare applications for doctoral fellowships from the Department of Health, the Medical Research Council, the Wellcome Trust, or other charities. Clinical lectureships provide 50% funding for four years to allow GPs with a doctorate to develop independent research programmes and secure postdoctoral or career scientist fellowships from the national funding schemes. Finally, “new-blood” senior lectureships, the stepping stone to a professorial post, are for up to five years, funded 50% by the Higher Education Funding Council for England, and 50% by the Department of Health.

Where to start

Students who are already sure they want an academic career should get experience in research through an intercalated degree, or special study module. A first-class degree, prizes, distinctions or honours, and research related conference presentations and publications gained as a student will make you more competitive for an AF2 post. In turn, securing an AF2 post will help, but is not essential, to secure an academic clinical fellowship post during specialist training. In 2006-7, seven academic departments of general practice in England (Bristol, Cambridge, Keele, Manchester, Oxford, Southampton, and University College London) secured programmes that between them provide a total of 45 academic clinical fellowships and 29 clinical lectureship posts for GPs over five years. Other departments have secured funding from their local deanery, to provide similar academic training opportunities during the GP specialist trainee years. Links to academic departments can be found through the Society for Academic Primary Care (www.sapc.ac.uk). Further information on academic clinical fellowship programmes in general practice can be obtained from the National Institute for Health Research’s Coordinating Centre for Research Capacity Development (www.nccrcd.nhs.uk).

If you are already a practising GP, it’s not too late to consider an academic career. In common with many of my academic colleagues, I decided to try to get into research later, after five years’ experience working as a full time clinician. In recognition of the fact that this is actually a more common route for GPs, the Walport Report also recommended funding academic in-practice fellowships for fully qualified GPs who can show evidence of an interest in research, to allow them to pursue masters-level research training half time for two years, and prepare an application for a doctoral-level research training fellowship.

Doctoral-level research training fellowships are awarded in open national competition by the National Institute of Health Research, the Medical Research Council, the Wellcome Trust, and other charities. A period of experience working in an academic department is an essential prerequisite for successful application, however, whether it is for an academic clinical fellowship, an academic in-practice fellowship, as an academic GP specialist trainee funded by the deanery, or funded by the department itself. Speak to your local professor, who will meet you with enthusiasm.

Medical education

Most of the academic clinical fellowships, academic in-practice fellowships, and clinical lectureship posts are research posts, although a minority are provided in medical education. The career ladder in education, however, is better defined through the postgraduate deanery route, rather than through the undergraduate academic departments, although in some parts of the country undergraduate and postgraduate departments are happily merged. Box 2 lists ways in which you can get involved in GP education.

Undergraduate students and foundation school trainees are usually involved in some teaching of students in the years below them. Taking medical students for placements from your local undergraduate department is the best place to start once you are settled in your practice, and experience of teaching medical students is valued among those selecting postgraduate GP trainers. Experienced GP trainers may decide to take time out of their practice on a regular basis to become course organisers of training schemes, associate directors, or directors of postgraduate GP education within the deanery structure. The other alternative is to get involved in continuing medical education for GPs through local postgraduate centres and programmes, as a GP tutor.

All teachers should undergo training and achieve qualifications in education. Courses in education leading to postgraduate certificate, diploma, or masters qualifications are offered at a number of universities. Popular courses include those at Warwick, Cardiff, Dundee, and the Open University, in education that is broader than medical education alone. The Association for the Study of Medical Education lists a range of courses on its website (www.asme.org.uk). In addition, every postgraduate deanery team will have access to training courses in education locally. There is a newly formed Academy of Medical Educators, which is exploring a more formalised training and career structure for medical education.

Those who can . . .

The Collins English Dictionary includes these definitions of academic: “Of purely theoretical or speculative interest;” “Excessively concerned with intellectual matters and lacking experience with practical affairs;” and “Conforming to set rules and traditions; conventional.”22 None of these applies to academic GPs, who make a difference, practise what they preach, and enjoy unconventional and exciting careers.