‘The fault, dear Brutus, is not in our stars, But in ourselves, that we are underlings.’1
One of the most commonly heard anecdotes on the plight of general practice in medical schools is the description of the packed lecture theatre in the first week. The lecturer asks the students, ‘How many of you want to become general practitioners?’ Only three raise their hands, enabling the lecturer to comment disparagingly, ‘Well tough, half of you will “end up” as GPs.’ This is a response that sadly embeds the belief that one ‘ends up’ in general practice instead of ‘arriving’ by choice. At the same time within the NHS we face a view, entrenched from its launch, that the consultant’s career pathway is ‘a ladder off which, if unsuccessful, one falls to become a GP’.2,3 How often does one still hear the comment reflective of this hierarchical assumption that, ‘I am just a GP’? This problem was highlighted by Denis Pereira Gray more than 35 years ago,4 yet such comments are still heard far too often.
This is a call for action to bridge the primary care/secondary care ‘fault line’2 and cling to the ladder to achieve equal status. The lecturer should be expounding the view to students that, ‘Unfortunately only half of you will feel you have the intellectual ability and personal attributes to become a GP.’ As a profession we must declare that current and future primary care demands some of the brightest and best students to deliver what must now be one of the most difficult and intellectually challenging careers. As the recent report from Health Education England (HEE) and Medical Schools Council (MSC)5 concludes, medical students have a different view of future healthcare delivery. They are asking why we are failing to promote our profession as intellectually difficult and where, compared with secondary care specialties, is the active academic research-oriented profile? A tough call, but the evidence is there.4 It is a genuine perception that we as a profession must address.
ENMESHED IN A ‘CATCH-22’ SITUATION
General practice faces a challenging ‘Catch-22’ situation.6 The Lancet report ‘Health professionals for a new century’ emphasises that education and workforce development are inextricably entwined. The provision of educational services generates the supply of workforce needed to meet the demands of the health system.7 In the UK, morale is low in the profession as the service fails to meet the population’s demands. Workload is unacceptably high, increasingly transactional, and recruitment of trained GPs is difficult. These all amplify the service pressures. When professional organisations, and the media, highlight the primary care crisis, a further negative impact on recruitment risks being created. It is not surprising that medical students, placed in general practice, experience and absorb the current pervading negativism.
The sad unintended consequence is the reinforcement of a growing view among the young that general practice is not the place to be, thus mitigating the educational drive essential to produce more GPs. Medical students are highly intelligent individuals who carefully weigh the pros and cons of career options as they move through training. They claim to be deterred rather than persuaded by career marketing.5 The power to influence lies in their personal interaction with GPs as educators and role models, and in their experience on primary care placements. Positive interactions are persuasive; negative experiences are difficult to reverse. Evidence for this is now well established in the international literature.5 The positive educational drive needed from GPs to meet workforce demands is lacking.
Much has been made recently of the denigration that undoubtedly exists towards career pathways in both general practice and psychiatry.8 This risks the conclusion that the failure to engage students to become GPs lies ‘outward within the stars’ and can be blamed on other specialties. Yet this professional ‘banter’ has remained entrenched for more than half a century while recruitment to general practice has waxed and waned. Yes, it is time to challenge this unprofessional and undermining behaviour but, at the same time, only general practice itself can raise its status from that of an ‘underling’. Playing the denigration card risks GPs being perceived as victims, self-perpetuating their own plight. This lacks the impetus needed to address the students’ challenge to inspire and engage them.
HOW CAN THIS BE RESOLVED?
So where do the solutions lie? The General Medical Council’s publication Duties of a Doctor states that:
‘You should be prepared to contribute to teaching and training doctors and students.’9
When the service pressure is on, we must not set this commitment aside. Students are very clear that they need to understand the breadth and complexity of what a GP does and the skills needed to achieve this. When they do, they can be inspired to become one, or, at the very least, defend any perceptions generated through denigration by others that it is a second-class career.
There are many ways this can be tackled even before a student starts in medical school. The HEE/MSC report5 outlines the importance of promoting general practice in schools, offering work experience in primary care before medical school entry and ensuring GPs are always involved in selection processes. There is a call for the GMC to revise its outcomes for graduates to reflect the rapidly changing workforce needs and ensure students develop a full understanding of primary care. General practice must be championed within the medical school curriculum and GPs must lead on this. Inspiring GP role models have a major impact on students. GPs must rise above the current professional negativism and offer a view of a bright future for students to aspire to. They must inspire and resist the temptation to deter.5
Perhaps one of the most staggering findings of the report5 is the dwindling, rather than expanding, drive for academic GP departments in medical schools. Only 6% of medical school clinical academics are in primary care, yet GPs form 50% of the workforce. Moreover, a large portion of general practice research is now held within the nine schools within the National School for Primary Care Research, diluting even further students’ access to primary care research across the remaining medical schools. How ironic at a time when research into the complexity of primary care should be escalating to rationalise and optimise service delivery.
A tension exists within general practice, as the report5 highlights, between those offering dedicated service delivery at the coal face and those following more academic career pathways. Students, and indeed secondary care doctors, perceive that general practice does not offer research opportunities and seeks to recruit from the less academic strata of students. The quote ‘you would be wasted in general practice’ is still prevalent and reflects this lower status. Unity within our profession is essential to address this.
WE MUST INSIST ON EQUITY
We believe the profession must work to bridge the perception that a career in primary care is a job for those falling off the secondary care training ladder. We shouldn’t aim to reverse the status and rise higher but we must insist that we merit equity. The move to a single GMC Specialty Register and title of ‘consultant in primary or community care’ is a report recommendation already under serious consideration.
General practice needs doctors with intellectual flexibility, resilience, and an ability to handle risk and uncertainty —not everyone has these attributes. It is too ‘scary’ for some.5 Any move to create a medical school focused on producing only GPs is therefore flawed. These professional characteristics need fostering and take time to develop. As one young doctor said, ‘It took time for me to recognise I could “go solo”.’ Ensuring flexibility of career pathways that bridge and foster mutual respect across the current divide between primary and secondary care is essential. We must resist the temptation to regard ourselves as underlings and find a way forward to overcome the current negativism that is turning students away from general practice. Adequate funding to support education in general practice must be addressed by the Department of Health and medical schools. But this will fail unless GPs too can role model to students that it is an intellectually challenging career to ‘arrive in with heads held high’ and not where one ‘just ends up’.
Notes
Provenance
Commissioned; externally peer reviewed.
Competing interests
Simon Gregory is employed by Health Education England, which is responsible for increasing recruitment to GP specialty training.
- © British Journal of General Practice 2017
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