Portfolio careers for medical graduates: implications for postgraduate training and workforce planning

Profile of Irish female GPs and factors affecting long-term commitment: a descriptive study

BACKGROUND

Over the past two decades, many countries have reported an increased percentage of female staff in the general practice workforce. Considering the importance of general practice workforce planning, it is necessary to investigate the current working patterns of female GPs.

AIM

To describe the female GP workforce in Ireland and to investigate factors that may affect their long-term commitment to general practice.

DESIGN & SETTING

Descriptive, cross-sectional study conducted with female GPs in Ireland.

METHOD

A 'membership survey' was emailed to 1985 female GPs in November 2021. In total, 345 female GPs responded, providing a response rate of 17.4%.

RESULTS

The study revealed that a majority of the female GP workforce in Ireland worked in the position of the GP principal (62.3%), but also provided out-of-hours services (64.3%), and undertook caring responsibilities (84.1%). In total, 41.2% of the responders disclosed having at least one paid additional role, mainly in the field of academia and teaching. Most female GPs worked fewer than eight clinical sessions a week (80.5%). GPs who held General Medical Services (GMS) contracts (72.8%) were significantly more likely to work more clinical sessions a week and had been longer employed in general practices (>5 years) than GPs who did not have GMS contracts.

CONCLUSION

Irish female GPs demonstrated a significant adjustment of their working patterns, including reducing their number of clinical sessions and balancing between additional roles, to ensure their long-term commitment to general practice. Current practices and vision on GP roles must be recognised and supported to allow for adequate workforce planning.

'A sense of self, empowerment and purposefulness': professional diversification and wellbeing in Australian general practitioners

BACKGROUND

Burnout and workforce shortages comprise a vicious cycle in medicine, particularly for Australian general practitioners (GPs). Professional diversification, whereby individuals work multiple roles across their week, may help address this problem, but this strategy is under-studied.

METHODS

We surveyed 1157 Australian GPs using qualitative and quantitative questions examining professional diversification, values, autonomy, and wellbeing. Quantitative data were analysed using inferential statistics, whilst qualitative data were analysed using inductive thematic analysis. We triangulated the data by using the qualitative findings to inform further quantitative testing.

RESULTS

Approximately 40% of the sample had diversified. Although diversifying was not significantly associated with wellbeing, the qualitative data indicated that diversification supported GPs' wellbeing by enhancing career sustainability, accomplished through various pathways (e.g. value fulfilment, autonomy, variety). Subsequent quantitative analyses provided evidence that these pathways mediated the relationship between diversification and wellbeing. To diversify, GPs needed particular personal qualities, external supports, flexibility, and serendipity. Barriers to diversifying mirrored these factors, spanning individual (e.g. skillset) and situational levels (e.g. autonomy, location).

CONCLUSIONS

Diversification can support GPs' wellbeing if it meets their needs. Organisations should focus on publicising opportunities and accommodating requests to diversify.

General practice registrars training part-time: a cross-sectional analysis of prevalence and associations

While GPs are working fewer clinical hours and many GP trainees (registrars) do not foresee themselves working full-time in clinical practice, little is known of the epidemiology of registrars training part-time. We aimed to establish the prevalence of general practice part-time training (PTT), and part-time registrars' characteristics and practice patterns. A cross-sectional analysis was conducted of data from the Registrar Clinical Encounters in Training project, an ongoing cohort study of Australian GP registrars' clinical experiences over 60 consecutive consultations in each of three training terms. Univariable and multivariable logistic regression analyses were conducted with the outcome 'training part-time'. 1790 registrars contributed data for 4,135 registrar-terms and 241,945 clinical encounters. Nine hundred and twenty-two registrar-terms (22%, 95%CI:21%-24%) and 52,339 clinical encounters (22%, 95%CI:21%-22%) involved PTT. Factors associated with PTT were registrar characteristics - female gender, older age, in a later training stage, performing other regular medical work; practice characteristics - working in a higher socioeconomic status area; and patient characteristics - seeing more patients new to the registrar and seeing more patients from a non-English-speaking background. No consultation or consultation action factors were significantly associated with PTT. Registrars, practices, and patient associations have GP training implications. The lack of registrar consultation or consultation action associations suggests there may be limited impact of PTT on patient care.

Provision of other medical work by Australian early-career general practitioners: a cross-sectional study

Introduction There is a trend towards GPs diversifying their role by working in health areas beyond general practice. However, little is known about whether this trend is apparent among early-career GPs once they make the transition from training to independent practice. Aim To describe the prevalence of and characteristics associated with early-career GPs providing other medical work. Methods A cross-sectional questionnaire-based study of GPs ('alumni') who had fellowed within the past 2 years from three of Australia's nine regional training programs. The outcome factor was provision of medical work in addition to clinical general practice. Associations of independent variables (encompassing alumni demographics, current practice characteristics and vocational training experience) with the outcome were estimated using univariate and multivariable logistic regression. Results Of 339 responding alumni, 111 (33%) undertook other regular medical work. Sixty-five (59%) of these were in medical education. In multivariable analysis, factors associated with providing other medical work were having a spouse/partner not in the workforce (odds ratio (OR) 5.13), having done any training part-time (OR 2.67), providing two or more of home visits, nursing home visits and after-hours care (OR 2.20), working fewer sessions per week (OR 0.74), and currently working in an area of lower socio-economic status (OR 0.84). Having dependent children (OR 0.27), and being female (OR 0.43) were associated with not providing other medical work. Discussion In this study, many early-career GPs are providing other medical work, particularly medical education. Acknowledging this is important to general practice workforce planning and education policy.

Perspectives of GPs working in or alongside emergency departments in England: qualitative findings from the GPs and Emergency Departments Study

BACKGROUND

Around 43% of emergency department (ED) attendances can be managed in general practice. Strategies to address this include directing appropriate patients to GPs working in or alongside EDs (GPED). Views of GPs choosing to work in GPED roles may inform planning and implementation of GPED services as well as wider general practice provision.

AIM

To explore the experiences and motivations of GPs choosing to work in GPED services in England, and to identify factors that may support or hinder GPs working in GPED roles.

DESIGN AND SETTING

Thematic analysis of 42 semi-structured interviews of GPs working in 10 GPED case sites across England.

METHOD

Qualitative GP interviews from a mixed-methods study of GPs in GPED roles were thematically analysed in relation to research aims.

RESULTS

Four themes were generated: the 'pull' of a portfolio career; the 'push' of disillusionment with general practice; professional reciprocity; sustainability of GPED services and core general practice. Flexible, favourable working conditions, collaboration, and professional development made GPED an attractive workplace, often as part of a portfolio career or after retiring from core general practice. Working in GPED services was largely driven by disillusionment with core general practice. Both GPED and core general practice were thought to benefit from GPED GPs' skills. There were concerns about GPED sustainability and destabilisation of core general practice.

CONCLUSION

GPED may extend the clinical careers of experienced GPs and support recruitment and retention of more recently qualified GPs. Despite some benefits, GPED may destabilise core general practice and increase pressure on both environments.

Clinical Teaching Fellows, the new norm?-Experiences of fellows and education faculty

Background

In the United Kingdom, there is an increasing tendency for doctors in the first 2 years after graduation, to step off the training pathway and take up Clinical Teaching Fellow (CTF) positions. We aimed to explore stakeholder experiences of CTF positions to inform future planning and support.

Methods

Individual semi‐structured interviews with 10 stakeholders (five CTFs and five education faculty members) from one institution in England were conducted. Interviews explored the participants' views of the CTF position, its benefits and challenges. Inductive thematic analysis was performed.

Results

CTFs and education faculty views strongly aligned and three themes were identified. These were (1) developing a career, (2) developing confidence and competence as a clinical teacher and (3) developing a position that works for all. Participants reported that the CTF position allowed time for specialty decision making and curriculum‐vitae strengthening and provide CTFs with the opportunity to work autonomously and to establish a better work–life balance by stepping away from training pressures and focusing on other aspects of life. There were differing thoughts on how the position should be structured, although retaining a clinical role with boundaries to constrain competing responsibilities was important.

Conclusion

A brief hiatus in clinical training, where individuals feel supported to progress personally and professionally and to renew their energy for the next steps of clinical training, seems important. The ideologies of providing the CTFs with autonomy, time to explore options, recharge and form connections with colleagues should be considered when structuring the posts.

An innovative training and recruitment programme in surgery

Introduction

Staff shortages and rising locum costs prompted Barking, Havering and Redbridge University Hospitals NHS Trust to design an innovative training pathway for doctors in surgery. The 'Academy of Surgery' is a 2-year structured educational programme with rotations through surgical and emergency care specialties and includes a funded MSc.

Methods

We recruited 27 doctors over a 2-year period. The first cohort started in October 2018, the second in October 2019. These doctors are heavily supervised in a 2-year programme that aims to prepare them for higher specialty training. They undergo regular assessment and annual review of competencies and progression. They receive regular formal classroom teaching and there are regular sessions to discuss welfare.

Results

Surgical rotas are now fully staffed and not reliant on locum doctors. This has led to significant cost savings. Locum spending in 2017 was £3,856,000 vs £1,284,000 in 2020 - a net saving of £1,187,000 over 2 years.

Conclusion

This innovative training programme has contributed to full staffing of a number of surgical rotas within our Trust and delivered a large financial saving for the NHS. We hope to expand this work into neighbouring trusts.

Exploring the impact and experience of fractional work in medicine: a qualitative study of medical oncologists in Australia

OBJECTIVES

Fractional (part-time) appointments are becoming more commonplace in many professions, including medicine. With respect to the contemporary oncological landscape, this highlights a critical moment in the optimisation of employment conditions to enable high-quality service provision given growing patient numbers and treatment volume intensification. Data are drawn from a broader study which aimed to better understand the workforce experiences of medical oncologists in Australia. This paper specifically aims to examine a group of clinicians' views on the consequences of fractional work in oncology.

DESIGN

Qualitative, one-on-one semistructured interviews. Interview transcripts were digitally audio recorded and transcribed verbatim. Data were subject to thematic analysis supported by the framework approach and informed by sociological methods and theory.

SETTING

New South Wales, Australia.

PARTICIPANTS

Medical oncologists (n=22), including 9 female and 13 male participants, at a range of career stages.

RESULTS

Four key themes were derived from the analysis: (1) increasing fractional employment relative to opportunities for full-time positions and uncertainty about future opportunities; (2) tightening in role diversity, including reducing time available for research, mentoring, professional development and administration; (3) emerging flexibility of medical oncology as a specialty and (4) impact of fractional-as-norm on workforce sustainability and quality of care.

CONCLUSION

Fractional appointments are viewed as increasing in oncology and the broader consequences of this major shift in medical labour remain unexamined. Such appointments offer potential for flexible work to better suit the needs of contemporary oncologists; however, fractional work also presents challenges for personal and professional identity and vocational engagement. Fractional appointments are viewed as having a range of consequences related to job satisfaction, burnout and service delivery. Further research is needed to provide a critical examination of the multiple impacts of workforce trends within and beyond oncology.

Is less-than-full-time training in dentistry swimming against the tide?

With ongoing changes to the demography of the dental workforce coupled with the changing expectations of those participating in early career post-graduate training, dentistry is experiencing a shift in how it might manage trainees. Drawing on experience from medicine and the anticipated behavioural differences, it is worth considering a way in which training might be able to adapt to the requirements of newer graduates, to ensure that the profession does not lose out on preparing the best candidates possible for careers that improve the state of dentistry both as a vocation and for patient benefit.

A mixed methods analysis of experiences and expectations among early-career medical oncologists in Australia

AIM

A viable and sustainable medical oncology profession is integral for meeting the increasing demand for quality cancer care. The aim of this study was to explore the workforce-related experiences, perceptions and career expectations of early-career medical oncologists in Australia.

METHODS

A mixed-methods design, including a survey (n  =  170) and nested qualitative semistructured interviews (n  =  14) with early-career medical oncologists. Recruitment was through the Medical Oncology Group of Australia. Qualitative data were thematically analyzed and for the survey results, logistic regression modeling was conducted.

RESULTS

Early-career medical oncologists experienced uncertainty regarding their future employment opportunities. The competitive job market has made them cautious about securing a preferred job leading to a perceived need to improve their qualifications through higher degree training and research activities. The following themes and trends were identified from the qualitative and quantitative analyses: age, career stage and associated early-career uncertainty; locale, professional competition and training preferences; participation in research and evolving professional expectations; and workload and career development opportunities as linked to career uncertainty.

CONCLUSION

Perceived diminished employment opportunities in the medical oncology profession, and shifting expectations to be "more qualified," have increased uncertainty among junior medical oncologists in terms of their future career prospects. Structural factors relating to adequate funding of medical oncology positions may facilitate or inhibit progressive change in the workforce and its sustainability. Workforce planning and strategies informed by findings from this study will be necessary in ensuring that both the needs of cancer patients and of medical oncologists are met.

Exploring the tensions of being and becoming a medical educator

BACKGROUND

Previous studies have identified tensions medical faculty encounter in their roles but not specifically those with a qualification in medical education. It is likely that those with postgraduate qualifications may face additional tensions (i.e., internal or external conflicts or concerns) from differentiation by others, greater responsibilities and translational work against the status quo. This study explores the complex and multi-faceted tensions of educators with qualifications in medical education at various stages in their career.

METHODS

The data described were collected in 2013-14 as part of a larger, three-phase mixed-methods research study employing a constructivist grounded theory analytic approach to understand identity formation among medical educators. The over-arching theoretical framework for the study was Communities of Practice. Thirty-six educators who had undertaken or were undertaking a postgraduate qualification in medical education took part in semi-structured interviews.

RESULTS

Participants expressed multiple tensions associated with both becoming and being a healthcare educator. Educational roles had to be juggled with clinical work, challenging their work-life balance. Medical education was regarded as having lower prestige, and therefore pay, than other healthcare career tracks. Medical education is a vast speciality, making it difficult as a generalist to keep up-to-date in all its areas. Interestingly, the graduates with extensive experience in education reported no fears, rather asserting that the qualification gave them job variety.

CONCLUSION

This is the first detailed study exploring the tensions of educators with postgraduate qualifications in medical education. It complements and extends the findings of the previous studies by identifying tensions common as well as specific to active students and graduates. These tensions may lead to detachment, cynicism and a weak sense of identity among healthcare educators. Postgraduate programmes in medical education can help their students identify these tensions in becoming and develop coping strategies. Separate career routes, specific job descriptions and academic workload models for medical educators are recommended to further the professionalisation of medical education. (Tensions, Fears, Healthcare Educators, Medical Education, Postgraduate Programmes, Identity, Career Choice, Faculty Development, Communities of Practice).

'It was serendipity': a qualitative study of academic careers in medical education

CONTEXT

Despite a demand for educational expertise in medical universities, little is known of the roles of medical educators and the sustainability of academic careers in medical education. We examined the experiences and career paths of medical educators from diverse professional backgrounds seeking to establish, maintain and strengthen their careers in medical schools.

METHODS

Semi-structured interviews were conducted with 44 lead and early-career medical educators from all 21 Australian and New Zealand medical schools. Questions explored career beginnings, rewards and challenges. Transcripts underwent systematic coding and independent thematic analysis. Final themes were confirmed by iterative review and member checking. Analysis was informed by Bourdieu's concepts of field (a social space for hierarchical interactions), habitus (individual dispositions which influence social interactions) and capital (economic, symbolic, social and cultural forms of power).

RESULTS

Participants provided diverse accounts of what constitutes the practice of medical education. Serendipitous career entry and little commonality of professional backgrounds and responsibilities suggest an ambiguous habitus with ill-defined career pathways. Within the field of medicine as enacted in medical schools, educators have invisible yet essential roles, experiencing tension between service expectations, a lesser form of capital, and demands for more highly valued forms of scholarship. Participants reported increasing expectations to produce research and obtain postgraduate qualifications to enter and maintain their careers. Unable to draw upon cultural capital accrued from clinical work, non-clinician educators faced additional challenges. To strengthen their position, educators consciously built social capital through essential service relationships, capitalising on times when education takes precedence, such as curriculum renewal and accreditation.

CONCLUSIONS

Bourdieu's theory provides insight into medical educator career paths and the positioning of medical education within medical schools. Medical educators have an indistinct practice, and limited cultural capital in the form of research outputs. In order to maintain and strengthen their careers, educators must create alternative sources of capital, through fostering collaborative alliances.

Australian doctors’ non-clinical activities: results from the Medicine in Australia: Balancing Employment and Life (MABEL) survey of doctors

Objective The aim of the present study was to investigate non-clinical work conducted by Australian doctors. Methods This study was an exploratory descriptive study using data from Wave 5 of the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey, collected in 2012 from Australian medical practitioners (2200 general practitioners (GPs), 3455 specialists, 1270 specialists in training and 1656 hospital non-specialists). The main outcome measure was the number of hours worked per week in non-clinical work. Regression analysis was used to determine associations between non-clinical activities (i.e. education-related, management and administration and other) and personal and professional characteristics, including age, gender, job and life satisfaction, total clinical working hours, sector of practice (public or private) and doctor type. Results Australian doctors spend an average of just under 7 h per week, or 16% of their working time, on non-clinical activities. Doctors who worked more hours on non-clinical activities overall, and in education-related and management and administration specifically, were male, younger, had lower life satisfaction and generally spent fewer hours on clinical work. Lower job satisfaction was associated with longer management and administration hours, but not with time spent in education-related activities. Specialists were more likely to work long non-clinical hours, whereas GPs were more likely to report none. Hospital non-specialists reported relatively high management and administration hours. Conclusions Further work is required to better understand the full range of non-clinical activities doctors are involved in and how this may impact future workforce projections. What is known about the topic? Doctors usually engage in a range of non-clinical activities, such as research, education and administration. Policy documents suggest these activities are expected to comprise 20%–30% of a doctor’s time in public settings. Understanding how engagement in non-clinical activities affects doctors’ time in direct patient care, their career progression and job and life satisfaction is highly important and poorly understood. What does this paper add? This national study provides the first empirical data on doctors’ non-clinical activity, and shows that non-clinical hours are traded off with clinical hours, and are associated with personal and professional characteristics. What are the implications for practitioners? Any changes in doctors’ non-clinical hours may influence doctors’ satisfaction as well as their clinical working hours. Workforce planning needs to take non-clinical hours into account.