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Is medical school ‘toxic’ for prospective GPs?

Is undergraduate medical education contributing to graduates’ apparent antipathy towards general practice, asks Jaimie Kaffash

Medical school is the first step towards becoming a doctor, but some claim it is actively deterring would-be GPs from entering the profession.

Toxic image-online-330px-web

NHS chief executive Simon Stevens recently said that the Universities of Oxford and Cambridge were not producing enough GPs.

And the RCGP went further, making the extraordinary claim that a ‘toxic culture’ was putting graduates off general practice in medical schools.

RCGP chair Dr Maureen Baker says she had raised the issue of a ‘toxic anti-GP culture’ in meetings with education leaders. She adds: ‘I have always worked in this area, and I published a paper 15 years ago which looked at career choices of students and trainee doctors. At that stage, culture was clearly an issue.

‘On talking to students recently, I wondered what, if anything, has changed. I hoped it had changed, but I am wondering increasingly whether that is the case.’

Dr Baker puts the blame on a hidden bias in medical schools. She says: ‘I’m pretty sure that if we looked at the statements by medical schools, there is very little we would class as “anti-GP”.

‘However, if you look at how medical schools feature general practice on their websites and in their curricula, and how they speak about general practice at open days, positive things from graduates who have gone into general practice barely exist.

‘So many people tell us if they express their interest in going into general practice, it might be greeted with a comment such as: “What, a bright young woman like you?” That is not a medical school policy, but if they say these sort of things without challenge, these are things that contribute to culture.’

She says the RCGP will be meeting the Medical Schools Council (MSC) imminently, and the college intends to ‘pull together what evidence we have with respect to the influence that the culture in medical schools has on career choice’.

‘Obliterative’ change

That meeting will take place against the background of a prominent editorial in the BMJ calling for ‘obliterative change’ at the MSC and after the worst GP training recruitment round for seven years.

Applications for general practice fell 15% on last year, even though the overall number of medical graduates remained constant. And some trace the unfilled postgraduate GP training places directly back to the experience of medical students in university.

Richard Wakeford, a fellow at the University of Cambridge, said in the editorial last month that a ‘complete reorganisation’ of student recruitment and medical training was needed to produce more GPs.

‘Medical schools need to take notice of the workforce crisis in general practice’

Dr Krishna Kasaraneni, chair of the GPC training, education and workforce committee

The article pointed out that there are only two GPs on the 33-member MSC board, while only one school – Brighton and Sussex – had a section dedicated to general practice on its website.

Mr Wakeford went on: ‘These people are conflicted: they are responsible for delivering appropriate medical graduates to the NHS, but also have responsibilities (and loyalty) to their own – largely hospital specialist – disciplines and colleges.

‘Without a complete reorganisation of student recruitment, patients will be left badly served by medical schools that will continue to produce too many graduates inclined to hospital specialties and research.

‘Medical schools must act, and the Medical Schools Council’s membership requires obliterative change.’

Action is indeed badly needed. Data published by Professor Michael Goldacre, professor of public health at the University of Oxford, in the BJGP in January 2011, show only around 30%of graduates in 2009 chose general practice as their first choice of specialty.

Professor Goldacre told Pulse that a more recent study, examining graduates from 2012, showed similar patterns and that this is well below the Government’s aim of 50% of graduates going into general practice.

He says: ‘We’ve found that 25-30% of newly qualified doctors say that general practice is their first choice. If you count first, second and third choices, this becomes 50% who would be willing to do general practice.’

Funding inequity

Others say much more could be done to encourage new GPs. Dr Krishna Kasaraneni, chair of the GPC training, education and workforce committee, says the problem stems from the variation in payments received by practices who take on medical students.

He says: ‘The undergraduate tariff is set at £34,623 per annum for hospital placements and there is no nationally agreed payment for GP practices. 

‘Lack of a nationally agreed tariff for GP placements has brought huge disparities in students’ exposure to general practice. As a result, fewer than 11% of medical students from Oxford initially choose primary care, whereas over 31% of those from the Peninsula Medical School do.

‘Medical schools need to take notice of the workforce crisis in general practice and make sure that medical students’ experience of general practice is not compromised due to funding pressures. The NHS desperately needs more GPs and medical schools have a responsibility towards delivering that.’

Dr Kasaraneni says the GPC will be campaigning for equitable funding for GP placements and to address the lack of funding given to GP practices to take on medical students.

Dr Alex Harding, secretary of the Society for Academic Primary Care and a GP in Exeter, adds: ‘For example, in a medical school where 10% of teaching is delivered in general practice, the GPs only receive 5% of the funding – the absence of money to pay for the space that students take up when seeing patients is a major factor here.’

Dr Harding has undertaken research, which is yet to be published, showing the amount of time devoted to general practice in the curriculum has stalled at 13% after having increased gradually over 40 years.

It also shows the total amount of exposure to general practice over a course has, on average, fallen by almost two weeks over the past 10 years, while the number of integrated departments of general practice has halved.

So while the atmosphere may not be toxic, it is hardly conducive to producing the vital increase in graduates needed to make up the next generation of GPs.

But medical school leaders argue that they are not responsible for shaping medical students’ career paths.

MSC chair Professor Iain Cameron says: ‘It is not MSC’s role as educators to encourage students down certain paths at a younger age, when the experiences on which these sorts of career decisions are made often come after graduation.’

He adds: ‘MSC will continue to work with colleagues across the health and higher-education sectors to select the best students to study medicine and equip them to provide the highest-quality patient care, in keeping with the present and future needs of the workforce.’

GP Training numbers - December issue


Why are GP trainees worth less?

What is the funding mechanism for undergraduate medical education?

The ‘Service Increment for Teaching’ (SIFT) payment is designed to meet the costs associated with teaching students. It funds the time GPs and consultants spend on teaching students; medical schools’ costs in running and organising courses; and – in hospitals – payments for the space given over to training students.

What’s the problem?

Variability. Currently hospitals get a flat annual fee of £34,623 per student and are paid for the space given over to undergraduates. This is not the case for general practice, and the fees paid to practices vary greatly. There are also problems in the way SIFT funding is allocated. Often Health Education England (HEE) gives money direct to hospitals – rather than to medical schools – and it is redistributed from there.

What’s changing?

HEE and the Department of Health are reviewing SIFT funding. But the Society for Academic Primary Care is concerned the funding might be removed and replaced with separate tariffs for GP and hospital placements – which it says would be a ‘doomsday scenario’.

How does the funding need to change?

The GPC wants to see more time given to general practice teaching, which currently makes up just 13% of the curriculum. It also wants funding to be consistent between primary care and secondary care as the costs are similar. The funding stream also needs to be simplified from HEE to practices.

GPs are portrayed as ‘failed consultants’

Toby Holland

My experience at two medical schools, as an undergraduate and now as a postgrad, has been positive. General practice is integrated into the curriculum and with established community-based medicine departments. This gold standard promotes an encouraging attitude among staff and students.

However, this is not universal. I still recall one of my first lectures, where an esteemed professor consoled ‘… bad luck, half of you will turn out to be GPs.’

There is a fundamental issue with clinical education. Students exposed predominantly to the secondary care environment will naturally lean towards developing interests and role models in that area. This is perpetuated by the portrayal of GPs as failed consultants or those who want an ‘easy life’.

Medical schools must change the perception of general practice; it should not be seen as a back-up option. A GP is a specialist in generalism and patient-centred care. Many opportunities await the GPs of the future and deans must ensure students know this.

Dr Toby Holland is chair of the RCGP associates in training committee and an academic clinical fellow in general practice at the Defence Deanery.

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Readers' comments (15)

  • "You're wasted on general practice"

    "never had you down as a GP"

    "oh, you want to be a GP? I'm sure you can make it, its not that hard"

    "ah you want the easy life then?"

    yes, these were real comments from consultants when I told them that I wanted to be a GP or I was a GP trainee.

    Of course the culture is toxic. Thats why there is such a wide variation of doctors who want to be a GP.

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  • It is General Practice as a career that is deeply toxic NOT medical schools.Isn't it deeply unethical for GPs to be encouraging young students/doctors to enter a career which has been turned into the anal canal of medicine.My advice would be to stay in hospital medicine where the really sick patients.You will avoid being de-skilled and the public will respect you more.

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  • Good article. But that's not the toxic symbol, that's the radioactive symbol.

    The standard toxic symbol is the grinning skull and crossbones. OR there's the biohazard symbol.

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  • There has always been an issue regarding the tendency of some specialists to look down on generalists, wonderfully illustrated by the sarcoma/melanoma surgeon Prof M Thomas. From my experience the most 'self inflated' tend to be the most specialist - detached from the inconvenient inconsistencies and vagaries of real life - for the ultimate specialist only one kind of problem exists, carefully pre-defined in advance by someone else before even being seen.

    It is a shame that there has been a general shift away from generalists in hospitals towards ever more micro specialism. When I was in hospital there used to be consultants in "General Medicine". These guys new EVERYTHING...and they treated everyone. Today as far as I am aware they don't really exist ...except maybe under the guise of the Geriatrician. As far as I am concerned the old fashioned consultant in general medicine was the ultimate Dr. Now we have respiratory consultants, gastroenterologists with an interest in hepatology, gastroenterologists with an interest in inflammatory bowel disease, cardiologists, nephrologists and renal consultants - to name just a few. All of them know everything about their own field but routinely need a GP to refer the patient to someone else if the problem strays out of their area of interest. Woe betide a patient who's problem falls between two specialties.

    General Practitioners are the only real "all round" Drs left these days. Training has improved dramatically over the last 20 years and MRCGP for all its critics is a tough exam and if you've got it you know what you are talking about.

    It's bad news that GPs are being run down so widely and it infuriates me when I read articles by uber specialist surgeons like Prof Thomas attacking the only real Drs left in UK medicine.

    If medical students are put off from a career in General Practice I believe it's partly because of this growing tendency to over specialisation, which no doubt is taking secondary care further away from understanding the value of holistic medicine but mostly because general practice has become the underfunded, disrespected dumping ground of the NHS and medical students can see this just like anyone else.

    Why would you go and sign up for that?

    But in all truth the reason to become a GP is because GPs are the only real all round Drs left in medicine.

    If I wanted to be a useful all round Dr and I was at med school today...I'd train to become a GP and then I'd go work in Australia. But If you fancy doing that then hurry up because Australia, New Zealand and Canada are getting quite a few UK Drs these days.

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  • Hi, to the commenter above. General Practice in Australia is pretty awful. I left UK for aussie GP in late 2000s. If someone had told me that a type of General Practice existed that was worse than UK GP c.2007 I would have laughed and laughed... but, yes, being a contract GP in outer metro Australia is big time crap...and poorly paid....and the punters are the MOST entitled tight-fisted bunch imaginable, and you have to suck up to them to get any pay, it's like those restaurants that say"kids eat free" "happy hour - come on in"

    How bad is UK GP now?! (I dread to wonder)

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  • I disagree completely. The reasons that students do not wish to become GPs, are the same reasons that all the GPs are retiring early or leaving. If it were just Toxicity in Universities, we would have no problem with retention. But we do and the students who do GP rotations can see that GP land is the TOXIC place, with imposed Contracts, 11-13 hour days, falling pay [ 50% pay cut per consultation in 9 years], MPIG and seniority cuts and so on and on.
    It is a wonder that anyone wants to be a GP at all. Students can see the horror of General Practice and what it has become ie 90 % of Consultations on 8% of the budget. Make GP land attractive again and they will return. These folks are bright and they can smell decay from miles away. And to be honest, in this age of candour, I as a GP would ask them to stay away.

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  • Like one of the commentators has already pointed out:modern general practice = anal canal of medicine.
    Keep well away or go part time.

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  • Agree with my erstwhile learned friend above.

    This is the radioactive not toxic sign.

    If medical schools are radioactive, there would seem ample justification for an alternative career choice.

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  • actually medical students are well informed and realising that senior doctors are trying to replace them with nurse practitioners and physician assistants. would you join a sinking ship?

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  • This comment has been moderated.

  • This is not a marketing issue. Many GPs are retiring early or cutting their sessions after actually doing the job for 20-30 years.

    It's insulting to medical students to believe their tutors as so influential as to cause the decline in GP training.

    Many people come to GP later in their career - this is no bad thing but if the applicants of this cohort are falling do not blame the medical schools.

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