There are few environments as personally and professionally challenging as a general practice that registers only patients (and their children) with a substance abuse problem. The surgery where I work as a salaried GP is one of two such practices on Teesside offering general medical services to about 1400 patients registered with one of two GPs and a team of clinical nurse specialists. The premises are dilapidated and cramped, but staff morale is high. Medical challenges abound. A ‘typical’ morning might include assessing a client newly discharged from prison and already addicted again; infant immunisations; the story of a teenager who raised her siblings when her mother walked out and who started selling drugs in order to buy food for the family; a lad with regular seizures who never makes it to outpatient appointments; a middle-aged woman who ‘self-treats’ with glibenclamide because ‘it makes her feel less depressed’.
Setting aside the task of keeping up to date, perhaps the greatest challenge of working in such an environment is the daily questioning of one's own attitudes to human behaviour and relationships. Trying to work out ‘what makes people tick’ and regarding patients without prejudice, as the General Medical Council encourages us to do,1 is an ideal to strive for, but not one that is always easily achieved.
For those involved in teaching medical students, there can be few clinical environments as rich with scenarios for discussion. Each encounter with a patient often reveals an almost unbelievable story — yet these stories make up the fabric of life lived on the margins of society. Recognising the value that such a stimulating workplace can contribute to our own continuing personal and professional development, it is obvious that all healthcare students would stand to gain enormously from work placements in such clinical environments.
Facilitating early professionalism in medical students needs to occur in well-functioning clinical contexts that demonstrate the qualities we hope to foster as clinical educators. These include altruism, accountability, duty, integrity, respect for others, and lifelong learning.2 Such experiences might also counter the rise in cynicism among students, which some clinicians have observed.3 Not only is there a wealth of opportunity for learning associated with providing health care for such a disadvantaged patient population, but the dynamics of a well-functioning healthcare team are a potent learning opportunity too. The importance of exposing students to good quality placements has been identified as an important determinant in long-term career choices.4
As defined by Julian Tudor Hart,5 the relationship described by the inverse care law is seen again when marginalised clinical settings struggle to recruit staff, thereby exacerbating the combined pressures of teaching and managing clinical workload. This, in turn, results in fewer students being exposed to less mainstream health care contexts, and consolidates the negative spiral — the less that students experience positive clinical placements in challenging environments, the fewer who are prepared to take up work in such contexts on graduation. Areas that have been identified as deserving of special attention in professional development include teachers as good role models and exposure to the ‘diversity and cultural aspects of medical practice’.6 This is a critical situation, sitting alongside the wider problem of sustaining enthusiastic and committed clinical teachers in a working environment, that is ever more pressured and increasingly complex.7
My practice may no longer be able to contribute to teaching medical students as our caseload rises. If we are unable to recruit an additional partner our commitment to undergraduate teaching will end. This may not be unique, but it draws attention to the problem of the diminishing resource of clinical placements that are able to both teach and inspire students to see aspects of medicine not offered by mainstream environments. The consequent loss of diverse clinical role models will be to the detriment of all.
- © British Journal of General Practice, 2004.