Why is general practice no longer a coveted career choice?
BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5939 (Published 15 November 2016) Cite this as: BMJ 2016;355:i5939
Abstract
Trainees used to queue up to get a job as a GP—but not any more. Mike Houghton reflects on ways to make being a family doctor popular again
As I retire from clinical practice I reflect on 32 years as a GP.
I hope that I will be remembered as a sympathetic, thorough clinician and teacher. While we have rightly moved towards putting patients at the heart of the consultation, my registrars have learnt that all the patient focus in the world cannot trump sound clinical skills.
At the beginning of my career I experienced quiet weekends seeing my own patients and later endured busier on-call shifts, seeing patients from neighbouring practices. Most emergency cases early on were genuinely sick people—encounters 10 years later were a combination of the old, the chronically sick, the occasional medical emergency, and an increasing number of minor illnesses.
There have, however, been many positive developments. Patients are seen more quickly, practice facilities are much better, and more formal training structures are in place both for doctors and for staff. When I started my training, my practice did not employ a nurse.
Political meddling and unnecessary change
But why in 1988 were there as many as 100 applicants to a decent practice whereas now there may be none? The reasons include political meddling and unnecessary change. Patient expectations have also grown and GP activity is scrutinised. Increasing numbers of female graduates have shifted professional focus away from the family doctor who was always available to a doctor who has many skills but also wishes for a good work-life balance. Doctors entering general practice understandably want manageable hours in nice areas.
It was no surprise then that the government in 2004, in the face of a recruitment crisis, conceded round the clock responsibility. Income shot up and trainee numbers rapidly increased. Life should have been perfect, so why did we elders feel unhappy?
This injection of cash turned the press, as well as the politicians, against us. We appeared to receive a fat pay rise for doing apparently less work. The truth however was that, in addition to seeing patients, a working day now encompassed increasing computer work, number crunching, and public health. Hours could be spent doing unnecessary tests, chasing the results of tests done by another party, or, worst of all, performing tests at the other party’s behest.
The current commissioning model means that many experienced doctors spend time in managerial roles for arguably little benefit. Practitioners are under pressure to prescribe less, to refer less, to manage comorbidities, to meet public health targets, and to deal with the rough and tumble that the public brings through the door—in 10 minutes. Not a week passes without the media finding another job for us—weighing patients at every encounter being a recent example.
We are told that primary care is on its knees. It needn’t be. While undeniably important, public health, notably the Quality and Outcomes Framework, is rewarded to the detriment of one-to-one patient contact. Managers overemphasise evidence based medicine but clinical decision making is far more complex than following guidelines. We are given neither credit nor financial reward for clinical ability.
A popular career choice?
So why have I enjoyed my career and why do I believe that with only a few modifications general practice could become a popular career choice again?
Medicine is fascinating and that fascination does not go away. Experienced doctors should be encouraged to resume patient contact—leaving management to others. Common sense needs to be applied to population targets and somebody needs to invent a way to reward clinical acumen.
The internal market model of the 1990s has led to a barrier between primary and secondary care. Misunderstandings between sectors abound. There are moves afoot—which I am proud to be involved with—to integrate some aspects of care, for instance dermatology and acute medicine. After further accredited training, doctors could have an important role straddling the primary/secondary care interface. Whether this dual role will encourage more young doctors into general practice is unknown. However, I know that my own career choice would have been much easier had that option been available.
Finally there have been the people. I’ve been fortunate to work with some wonderful colleagues in my clinical, teaching, and assessment roles. I’ve guided patients through troubled lives and even cured a few.
It is with sadness that I draw my medical career to a close. Would I do general practice again? With the above caveats the answer is a resounding yes.
Footnotes
Conflict of interest: I was a GP trainer in a rural Warwickshire practice for many years as well as a GP tutor and Royal College of General Practitioners’ examiner. Latterly I was a GP with special interest in acute medicine at University Hospital Coventry. All views expressed are personal.