General medicine’s recruitment crisis: what happened to all the heroes?

Crisis in recruitment

When the first A-Team episode was aired in 1983, only 10.9% of graduates wanted to pursue a career in hospital medicine. By 1993, this had risen to 19.7%, and by 2006 to 21.9%.1 But less than half of junior doctors who express an initial preference for hospital medicine end up working in that job, compared with nine out of 10 budding general practitioners.2 Job content and work-life balance are the reasons most commonly given for such changes in career plans.3

Crucially, these headline figures also overlook the divergence between hospital medicine and GIM. Great disparity now exists between the demand for medical specialties that include GIM and those that do not. In 2010, for example, only four of 13 deaneries filled their specialist training year 3 posts in endocrinology, which includes GIM.4 In contrast, there were no vacant posts nationally in dermatology, which is a singly accredited specialty.

Data from the Royal College of Physicians suggest that specialties with a low GIM component, such as genitourinary medicine and infectious diseases, attract the highest calibre applicants, as shown by the proportion deemed appointable and their standard interview scores (see figure). Conversely, specialties with a higher GIM on-call commitment, such as acute medicine, attract applicants who score less well and are less likely to be considered appointable.5⇓

Bar chart showing the specialty trainee interview score and percentage of candidates deemed appointable by specialty. Data from the Royal College of Physicians

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Why do GIM?

Year on year, there are an increasing number of medical admissions and patients are more medically complex than cohorts cared for by previous generations.6 There is therefore a great and growing need for GIM registrars to ensure patients’ various failing organs are treated, but not independently of one another.

Despite this spiralling demand, medical specialties have left the general rota one after another. This has often been to provide and develop specialist interventions undertaken on call, such as primary angioplasty. Consequently, it is now common for the GIM registrar to be called to attend unchallenging medical problems in specialties that would have until recently been contributing to GIM provision rather than adding to its workload.

GIM registrars have also felt the repercussions of the restructuring of medical training, with its apparent emphasis on caution and homogeneity. Not so long ago, senior house officers ran takes and undertook procedures while the registrars looked after more complex cases or slept. This level of capability is now the exception rather than the rule, particularly with the large number of foundation year 2 and general practice trainees on senior house officer on-call rotas.

Today’s GIM registrars lack a clear and defensible identity. They may be the senior clinical decision makers in the hospital outside normal working hours, which make up 75% of the working year, but their scope for making decisions that impact on the service is ever narrower. This is partly because of the endless round of mandatory “senior reviews,” lengthy proformas and rigid protocols, and instructions of “specialists” at the same grade or managers shuffling beds. The increasing consultant presence on call is commendable in many respects, but it has further compromised the role and, paradoxically, the training of the registrar.

The registrar’s leadership role has also been eroded by the fractured working arrangements resulting from the European Working Time Directive. It is difficult to create a supportive atmosphere as team members’ strengths and weaknesses are often unknown, and the Hospital at Night system places a coordinator between the registrar and the rest of the team. The additional paging steps required to contact registrars, for example, mean registrars are less likely to know about acutely unwell patients.7 Registrars are also now more likely to be used as another pair of hands to help with routine tasks such as clerking.

Despite the medical registrar being busier than ever and facing a more complex workload with more restraints, the gulf between the skills required at senior house officer and registrar level is widening. The revision of medical training may have delivered a “soft landing” into the first foundation year, but it has also lowered expectations of trainees. There are senior house officers who are keen to expand their medical knowledge and experience to help close the gap to the registrar role. However, these individuals are thwarted by training that has cut hours of direct patient care and the requirement to undertake invasive procedures independently or routinely attend outpatient clinics. This results in a disproportionate reduction in exposure to the type of complex patient with chronic diseases who poses the greatest challenge when admitted acutely.

Making the role more attractive

We have heard recently that bankers must be paid vast sums of money to retain their services. Those in other stressful roles, such as pilots, are afforded long breaks between periods of intense work. Would these approaches entice prospective general medical registrars? They are appealing to some degree but would be successful only if they indicated that general medicine and its registrars are valued by colleagues and employers. We believe there are ways of showing value that would be less divisive and more appropriate. It will also be important to consider output from the Centre for Workforce Intelligence, as well as the Shape of Training project from the General Medical Council and work from the Royal College of Physicians on the Future Hospital Commission and Future of the Medical Registrar initiative.

In other complex and potentially risky situations, such as military action or commercial aviation, a group with clearly defined roles and responsibilities and clear leadership is central to achieving necessary objectives. The same is true in relation to the delivery of care in other medical contexts—for example, in the operating theatre. There is a pressing need to recognise that out of hours medical care must similarly be provided by individuals who are part of a team in more than just name. Such a change in GIM would lead to improved efficiency and communication, ready identification of training needs and opportunities, and more readily enforceable standards. It is also crucial to increase the opportunities for registrars to make decisions commensurate with their responsibility and to improve support for them in this leadership role.

There is also a need to prioritise training for registrars that includes a GIM component. Trainees undertaking dual accreditation can look forward to receiving close supervision during their specialty intervention lists and have clear subspecialty educational targets with regular review. In contrast, GIM training takes the form of repeatedly throwing registrars in the river in the hope they’ll learn to swim. Trainees in GIM should expect more in terms of supervision and education during clinics and on the wards. We believe they should be afforded more protected time than their singly accrediting contemporaries, such as for reduced clinics scheduled to facilitate training and for additional practical courses dealing with the management of acutely unwell patients. Their crucial on-call role should also be explicitly acknowledged in the organisation of out of hours care, with a drive to reduce unnecessary calls and ensure a greater involvement of seniors in the referring specialty.

The recent slump in applications for training posts including general medicine arises from the discrepancy between the commitment required and the value placed on such training and service. Practical solutions to this problem seem to exist but may be difficult to implement, so it will be important to raise the profile of the issue and debate potential solutions. All of those who have a stake in ensuring the delivery of high quality general medical training and service, from junior doctors through to senior clinicians, employers, and professional bodies, need to come together to facilitate bold and positive action. Failure to do this will see further decline in the status and quality of general medicine.