Commentary

The Changing World of Doctors

A recent BMA study¹ found that over half of junior doctors now take a break during their training. Twenty-six percent take a break to travel. Twenty-four percent take time out for maternity or paternity leave. Twenty-one percent step out to do locum work, and 19% to improve their health and wellbeing. Many use the break out time to decide on their preferred specialty. A high proportion interrupt their training at the end of their pre-registration (intern) year. The findings of the survey emphasise that post-graduate training bodies should be aware that trainee doctors are seeking greater flexibility. While most doctors will return to training programmes, it cannot be taken for granted. Doctors’ trainers need to be constantly aware of the recruitment and retention of young doctors. Doctors are a scare and invaluable resource. They need to be used in a smarter way. The doctor’s future role should be one of partnership in a supportive environment that recognizes that no one person can do it all.

On drilling down into the Report further insight is obtained². In the UK, over 75% of junior doctors who took a non-training post outside the UK, went to Australia or New Zealand. Doctors who are unsure about their specialty choice are more likely to seek a break in their clinical training. The top four factors that influence the choice of career are autonomy, patient content, control over workload, and the ability to combine career and family responsibilities. Currently junior doctors who work less than full-time training feel that they are perceived negatively by training bodies.

The BMA Presidential Project 2017 states that doctors have traditionally been adaptable to change³. However, the rate of change within the structures and environments in which doctors work has created difficulties for the profession. In the UK, since 2011 the proportion of doctors going into specialty training fell from 72% to 50% in 2016. Another finding was the high rates of early retirement among GPs, 40% over 5 years. The cited reason is increased workloads and increased consultations. In England there are 340 million consultations annually among a population of 55 million. The ground is shifting in the relationship between doctors and patients. Doctors need to manage the expectations of patients who think that they can access any treatments and who believe everything will always go well. A commonly quoted example is the patient who arrives at the clinic with a selection of internet print-outs. An emphasis on shared management is a useful way forward. The doctor can help by interpreting the information through his/her prism of experience and knowledge.

In the UK some specialties are declining more rapidly than others, notably GPs. One problem is that only 17 out of 28 European countries recognize general practice as a specialty. Recruitment is hindered by the limited exposure to general practice during training.  GPs have a key role in the continuity of care for patients. It is universally accepted that all patients need a good, well-informed GP who will them to make the right decision. Seeing a doctor face to face will be important if patients feel suddenly ill. At other times they will be satisfied with an online consultation, for example an on-going condition. Flexibility is key in the interaction between patients and doctors.

Doctors must be resilient if they are to survive the long gruelling training and constant exposure to death, distress, and disability. They need to be committed, persistent, confident in their ability, while remaining compassionate to their patients⁴. The factors that aid resilience are maintaining an intellectual interest, self-awareness and self-reflection, good time management, continued professional development, support from colleagues, and helpful mentors. In studies of resilience, being female and maintaining a work-life balance are two consistently helpful factors.

Resilience among healthcare professionals can break down in the face of the rising blame and claim culture. It can also be fractured by repeated reorganization within an institution. The resultant downsides of poor change management are unwelcome shifts in routine, customs, and practices. Existing working relationships, that have served patients well, may be damaged. Senior staff may take early retirement which deprives services of invaluable organizational memory.

There is much debate about how we best educate medical students and train doctors. There has traditionally been an emphasis on the bright overachievers. Perhaps it is time to place an increased interest in the average student, as they will form the bulk of the medical workforce. In other words, what are the recruitment and training priorities? Where does kindness stand alongside the basic sciences in the education of doctors? There is an understandable tendency to focus on what can be examined and measured. In the face of the rapidly developing innovations in medicine it is important to preserve the humanity aspects of clinical practice. Trainee doctors state that they want to be valued, treated as an individuals, and allowed an opportunity to make a difference. This request poses major challenges for the current largely impersonal hospital management and human resources structures.

Medical leadership is a vexed issue. While all organisations pay lip service to the concept of leadership it is frequently discouraged in daily practice. The problem is when the individual with the leadership qualities is not the person in charge of the department or facility. In these circumstances innovative improvements may be quietly placed to one side. It is strange that the constructive suggestions of a highly educated workforce are seldom taken into account by policy makers and their managers. This needs to change if national health services are to fare better. Those on the front line must be facilitated when they report and advocate on what should be done. One suggestion is to create a fast stream for young doctors interested in management. Career structures should be created where leadership is part of the job. Too often medical management is restricted to doctors nearing the end of their medical careers.

JFA Murphy
Editor

References
1. Rimmer A. Majority of juniors take a break from training, survey finds. BMJ 2018;360:k987
2. Understanding trends among current doctors in training. BMA 2017
3. The changing face of medicine and the role of doctors in the future. Presidential project 2017. Bma.org.uk
4. Balne E, Gerada C, Page L. Doctors need to be supported, not trained in resilience. BMJ 2015;Sept 15

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