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Seven ages of the family physician and the problem of ‘premature abdication’

Maxwell Cooper qualified from Southampton University, works as a GP at Beaconsfield Surgery, Brighton, and is a senior lecturer in primary care at Brighton and Sussex Medical School (BSMS).

Jason Heath studied medicine at St Bartholomew’s Hospital Medical School, works as a GP partner and trainer at Foundry Healthcare, Lewes, and is a part-time teaching facilitator at BSMS.

Sangeetha Sornalingam studied medicine at St George’s, London, completed academic GP training, and is a senior GP teaching fellow at BSMS.

Carl Fernandes studied medicine at The Royal Free and University College Medical School, works as a locum GP, and is a senior GP teaching fellow at BSMS.

Menaka Jegatheesan qualified from St George’s, London, works as a portfolio GP in urgent care, and is a senior GP teaching fellow at BSMS.

In 1599, Shakespeare famously described ‘seven ages of man’ in his comedy As You Like It. This biographical perspective also offers insight into the trajectory and fate of a career in general practice.

We might — with poetic licence — reinterpret the Bard’s ‘seven ages’ thus: the sixth former with ‘shining’ interview face desperate for medical school offers; the medical student seeking the ‘bubble reputation’ as a future neurosurgeon; the hospital trainee whose furnace-like puffing betrays a nascent desire to escape nights on the wards; the ambitious GP registrar ‘in love’ with their new career while, at the same time, having to learn to walk ‘step by step’; the canny locum GP acquiring survival strategies in the ‘canon’s mouth’ of overwhelming patient demand; and the GP partner beset by clinical targets, financial pressures, and staffing crises, not least the early retirement of experienced colleagues.

… a career in general practice is never linear and may end abruptly.

With advancing years, the GP partner (‘in fair round belly’) is ever just about holding on: uncomfortable with ‘modern instances’ (especially the loss of face-to-face consultations) and keeping half a spectacled eye on the pension pot; finally, comes the retired GP ‘content with liberty’ despite a niggling feeling there was still much to give had they felt more valued and work pressures not been so all consuming.

Unsung wisdom

These seven ages of the family physician highlight that a career in general practice is never linear and may end abruptly. The ‘premature abdication’ of older, experienced GPs — specifically, those who are partners and trainers — represents an enormous loss to the NHS. These GPs bring leadership, efficiency, wisdom and morale. They are experts in managing clinical uncertainty in the community rather than resorting to excess investigation or hospital admission. They have the experience and sanguine objectivity to embrace ‘off the guidelines’ solutions. They work their art through longstanding therapeutic relationships with patients and colleagues.

The time-honoured ways in which experienced GPs captain and steady the primary care ship are not visible to ministers of health, hospital colleagues, or the mass media. Strategies must be found to value this ‘lost tribe’ of older, experienced GPs and retain them within the NHS workforce. If evidence were needed of the appetite of older GPs to assume the ‘name of action’, one need look no further than their response to the recent COVID-19 pandemic.

Formative ‘first forays’ into general practice

General practice subsists within an epoch of ‘premature abdication’ and its prodrome is plummeting morale, stress, and burnout. Other more savvy industries, by contrast, nurture older colleagues for their experience and differential skill sets.

… the retired GP … feeling there was still much to give had they felt more valued …

The expertise of experienced GPs is not limited to clinical and consultation skills. They understand leadership, health service delivery, managing change, and how primary care can address health inequalities. Beyond that, they bring learner-centred skills in mentoring, teaching, feedback, and career guidance. It is these endeavours that ultimately bear fruit in the form of tomorrow’s registrars, trainers, and partners.

To safeguard this legacy, there is a need to forge new employment models for older, experienced GPs in a capacity to share their wisdom, specifically with medical students and younger doctors. This calls for stronger links between primary care employers, postgraduate education, and medical schools. It also requires vision to create new retainer models that keep GPs nearing retirement in clinical practice with time dedicated to the delivery of inspirational medical education.

This would serve to preserve experience and leadership in the NHS workforce hand-in-hand with prioritising frontline teaching and mentorship for medical students and younger doctors in their most formative years. Juniors’ ‘first forays’ into general practice constitute critical windows where personalised support and role modelling can shape perceptions and kindle career aspirations. Investing in these formative moments by engaging GPs close to retirement brings together hope for recruitment and retention but requires fresh thought and remuneration commensurate with experience.

A solution for undergraduate placements in general practice?

At the youthful end of the seven ages, a major challenge exists for medical schools in providing these formative early encounters in general practice. Recruiting community placements in general practice has become a challenge for many medical schools and is partly an outcome of remuneration that has failed to keep pace with locum fees.

Certain solutions to increase GP placements do exist, for example, establishing an out-of-area placement programme.1 Another way forward is for medical schools to invest in older, experienced GPs. Thus, undergraduate placement recruitment can be enhanced through established relationships with local surgeries and wider primary care services. Key to this model is employment for teaching, which is linked to ongoing clinical sessions in local general practice.

The value of experienced GPs as role models for aspiring future colleagues cannot be underestimated.

Given future risks of failure in procuring undergraduate GP placements, further plans should be laid now for alternative pathways for students to learn the art of ‘thinking like a GP’. One such model is to establish in-house, small group GP-led teaching across the undergraduate curriculum that is blended with regular simulation.2 Here, students can learn from experienced GPs and acquire the key principles of consultation and management for general practice and understand how these differ from hospital medicine.3

Through a longitudinal and flexible model, GP placements may thereafter be inserted in lieu of tutorials as opportunities arise. Experienced GPs are in an ideal position to bring fresh ideas to inspire medical students, be that teaching in patients’ homes, dedicated student-led clinics in surgeries, small group teaching in wider primary care services, engaging registrars in near-peer learning, or inviting patients into the medical school to co-produce apprenticeship in the art of general practice. This blended model has the advantage of delivering the longitudinal learning1 required to link practical general practice with its conceptual foundations2 but at a reduced cost.

Conclusion

The value of experienced GPs as role models for aspiring future colleagues cannot be underestimated. It is the power of bequeathing clinical wisdom to the next generation that lends general practice its most enduring sense of purpose.

Nevertheless, over the past decade the rich tapestry of undergraduate teaching that spans all ages of the family physician has started to unravel. Indeed, it is estimated that <40% of surgeries in England actually teach medical students.4

Stemming the tide of ‘premature abdication’ is essential but requires vision, tackling funding silos, and a solution in order for pensions not to militate against employment. The confluence of early retirement and declining GP placements presents an opportunity once again to weave undergraduate teaching into a tight thread across all ages of the family physician.

The NHS and medical schools must prioritise juniors’ ‘first forays’ into general practice in the certainty that these moments have a critical bearing on career destination and endurance. Older, experienced GPs possess a unique function in ensuring that formative encounters in general practice constitute constructive steps on that journey.

General practice constitutes a ‘great feast of learning’, but for this not to turn to ‘scrap’ we call for fresh thinking, new employment models, and redefined priorities. After all, radical measures are needed today if general practice is to be for all time and not of an age.

 

References
1. Cooper M, Jegatheesan M, Sornalingam S, Fernandes C. Student self-arranged placements: a solution for expanding and enhancing undergraduate experience in general practice? Educ Prim Care 2021; 32(6): 370–371.
2. Cooper M, Sornalingam S, Jegatheesan M, Fernandes C. The undergraduate ‘corridor of uncertainty’: teaching core concepts for managing clinical uncertainty as the ‘special technique’ of general practice. Educ Prim Care 2022; 33(2): 120–124.
3. Cooper M, Sornalingam S, Heath J, et al. Consultation dynamics and strategies: the Brighton guide. Innovait 2022; DOI: https://doi.org/10.1177/17557380221093654.
4. Rees EL, Gay SP, McKinley RK. The epidemiology of teaching and training general practices in England. Educ Prim Care 2016; 27(6): 462–470.

 

Featured photo by Jess Bailey on Unsplash.

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