My mother tells me that it was from the age of about eight that I first said “I want to be a doctor!” Apparently it coincided with me getting my first toy doctors kit. This consisted of a plastic stethoscope (naturally), ophthalmoscope (for looking up my brother’s nose), syringe (to “give medicine”), clipboard (to take notes once I had “give medicine”) and a hammer (um…to repair Dad’s shed? – only recently realising this was for tendons). Unfortunately it was my younger brother who took the brunt of my first experimental steps as a (very very) junior doctor, with weekly laparotomies on his tummy that were closed with an Elastoplast or two.
By the time I was 13 I started to really appreciate the wonder of science and it wasn’t that long before I proclaimed I would one day “find a cure for cancer”. Well unfortunately I haven’t found the cure for cancer (although I have a much better understanding of the disease), but looking back I now realise that the idea of doing research in medicine, then applying it to patients made so much sense to me, and a seed had been sown.
So you want to be an academic?
My route to a becoming a clinical academic began a little more unusually in that I was already a postgraduate (having done a BSc and PhD in basic sciences) before I entered medical school. Although I knew I wanted to remain academic, I wasn’t sure in which clinical field. However, for me it became crystal clear which medical speciality I wanted to dedicate my career to once I had done my first month-long placement as a fourth year medical student: it had to be general practice.
As Iona Heath said in her monograph – “The Mystery of General Practice”:
“Each person and each context is unique and this is the joy and the challenge of general practitioner care”.
Despite dabbling with thoughts about being a gastroenterologist or a paediatrician, I couldn’t get away from the appeal of being a generalist. Providing long-term continuing care to my patients at all levels, where every encounter was unique.
The desire to be academic didn’t dessert and it soon dawned on me that being a generalist and an academic seemed even more appealing. I increasingly started appreciating the vast amounts of uncertainty and unanswered questions in general practice. So, I wanted to find the most relevant unanswered questions and provide my patients with the answers.
Why is academic GP so important?
Innovation and clinical research can improve the care and services we provide to patients in primary care. As a marker of this the RCGP have a dedicated team and network to drive this forward. Recognising the importance and growth of academic general practice and primary care research in the UK, the research arm of the NHS, the National Institute for Health Research (NIHR), have committed a further £30 million over the next 5 years to the School for Primary Care Research, to build capacity and capability in the field.
Key to this NHS commitment is the recruitment and retention of innovative and forward thinking academic GPs. A recent editorial in the BMJ highlights the invaluable role that academic GPs play, stating: “Academic GPs make an essential contribution to the NHS through education, research, clinical practice, and service development, usually while continuing to provide direct patient care.” Given the widely stated statistic that 90 per cent of patient interaction is with primary care services (mostly general practice) it’s not that surprising to consider GPs as perfectly placed to work with other primary care researchers in identifying and delivering research priorities to improve patient care and service provision.
There are countless examples of impactful research outputs from academic general practitioners working in research teams that have or will lead to patient benefits. Examples of such work has led to a greater understanding of the: benefits of warfarin versus aspirin in preventing stroke, technology needed to support NICE guidelines to limit the use of antibiotics in primary care, interventions to reduce unplanned hospital admissions, programs to reduced domestic violence in general practice, quality of care from NHS primary care services, and ways to evaluate cardiovascular risk in primary care. Academic GPs are even world leaders in teaching us how to read a scientific paper. These are just a handful of examples of the impactful work with which academic GPs have been involved.
Academic GPs are also at the forefront in providing undergraduate medical education within university settings as well as general practice and community attachments. Teaching provides opportunities for professional development, reflective practice and is an asset to many academic departments, with funding streams available to compensate for teaching time. Many GPs already find teaching undergraduates on placements very rewarding as do patients involved with community based teaching. Some academic GPs go on to devote some if not all of their academic time to lead undergraduate teaching. For example some academic GPs take up 50:50 split clinical academic posts within medical schools and provide dedicated teaching and organisation of entire community based undergraduate curriculums. Access into this can be through more formal routes such as undertaking higher degrees in medical education, while for others this happens more organically through their research or independently advertised posts. The types of medical education to get involved with can be as equally diverse as research topics. Some GPs undertake research into medical education and others go on to become supervisors and mentors to primary care researchers undertaking a PhD.
Pathways to academic GP
My pathway to becoming an academic GP began a little unusually, having entered medical school as a biomedical graduate. Nevertheless about 10 years ago more formal training pathways were created that aided my progression and if anything now offer even more opportunities.
The 2005 report of the Academic Careers Sub-Committee of Modernising Medical Careers and the UK Clinical Research Collaboration, chaired by Sir Mark Walport, laid the foundations for medical and dental graduates to have the opportunities to enter into integrated clinical academic careers. As a result academic GP training is supported in England, Scotland, Wales and Northern Ireland.
In England, with the continued support from Health Education England and Department of Health, careers in academic general practice can begin as soon as medical school ends. The UK Foundation Programme Office (UKPFO) provides opportunities for foundation doctors to spend a portion of their FY2 time, usually 3-4 months, in an academic primary care department. A proportion of the week is spent attached to a GP practice seeing patients with a trainer and the remaining time engaging in academic activities within the department. During my FY2 placement, I was able to discuss with my academic GP supervisor a programme that gave me exposure to clinical practice as well as well as support my interests in research, develop medical education skills, conference attendance and networking with other academic GPs.
The integrated clinical academic pathways continue into GP specialist training with the academic clinical fellowships (ACF). In England, these posts, largely supported by the National Institute for Health Research (NIHR), differ from standard ST1 – ST3 training with the addition of an extra year of training. During ST3 and ST4 years GP trainees usually have a 50:50 split between their clinical time in practice and their academic activities. However there is flexibility to provide time in each area as needed. Many of the ACF posts come with support for Masters level training and conference attendance.
Personally this worked really well for me and if anything, spending two years in GP as a specialist trainee, provided me with an opportunity to get to know and look after a cohort of “my patients” for longer – which they appreciated. It also gave me more clinical exposure and time to achieve all my competencies. I also got a much better understanding of the unanswered issues we faced in our doctor-patient relationship. This meant I ended up bringing more ideas to my academic time. I also utilised some of my academic time to gain a postgraduate diploma in health research.
Clinical academic training pathways continue after GP qualification. Many GP ACFs are encouraged to apply for a doctorial fellowship to undertake a PhD (often 4 or 5 years part-time) in a focused area of research or education while maintaining clinical practice. Many of these are supported by funders such as the NIHR, MRC, Wellcome trust and others. Some GPs interested in academia consider In Practice Fellowships upon qualification. These are specifically designed for those with little formal academic training and wish to enter academic GP. For those choosing general practice from another speciality, prospects exist to slot into academic GP training posts at most levels. If the research idea is good, opportunities are certainly there.
Beyond this there are Clinical Lectureships in General Practice, Clinician Scientist, Post-Doctoral, Career Development and Senior Research Fellowships which can all support your academic GP career. Many university departments often show commitments to the most productive academic GPs by offering them Senior Lecturer or Professor posts after this. An outline, and by no way definitive, sketch of the integrated pathways available to prospective academic GPs is shown below.
Challenges of an academic GP
Despite so many opportunities, there are always challenges. One of the more consistent challenges of academic general practice (and one that I still ensure I stay aware of) is being able to get the balance right between your clinical and academic time. This usually first arises during specialist training ensuring that your number one priority is to gain your clinical competencies leading to your MRCGP while secondary priorities include developing your academic skills. My attitude was that I am always first and foremost a GP. Getting the balance right doesn’t go away later on, if anything becomes a greater challenge as your career grows. Your commitment to your patients is balanced with commitments to ensure academic outputs continue, develop new ideas, gain new project funding and in some cases teach as well, make it sometimes feel like a circus-juggling act. In addition, it’s safer not to think that academic GP involves “time off” from the hustle and bustle of clinical practice. All too common you can find yourself under pressure to deliver a program of work, or preparation of teaching material which easily leads to you to be working unsociable hours to complete. That said time in academia can be flexible which can also work well with having a family life. Plus most doctors are fairly resilient and each academic GP finds a way to get the balance right for them, allocating a proportion of their time for each activity in their week.
Conclusion: #whyGP? #whyacademicGP?
So while being an academic GP is not easy (which aspect of being any type of doctor is?) it can complement and support the care of your patients, be intellectually challenging, stimulating and rewarding (occasionally all at the same time), provide added diversity, build skills in leadership, create added networks and lead to a long term and successful portfolio career.
In a purely self-indulgent way (if you will forgive me), I can honestly say that I love being an academic GP – and here is why. Whether I’m seeing my patients in an inner city GP practice, completing research projects that become part of guidance, supporting the priority of primary care research for the NHS, providing commentary on research, working with current and future leaders in my field or teaching here and abroad – the week is never dull and I feel I’m a better GP for it. My patients seem to like it too, certainly as they have got to know more about what I do outside of practice. Not infrequently do our conversations reflect my academic work and can begin with “so anything new in the world of research then Dr Mahtani?” or better still, in the midst of a shared decision making conversation, they have been known to say “….yes, but what’s the evidence for that?”. It adds a whole new layer to our conversations. Brilliant.
General practice is an amazing vocation and will always need future leaders and innovators. Academic general practice might be the perfect platform to support them.
Try it, I promise you won’t regret it.
Further useful links
Mahtani K.R. (2015) #whyGP? How about #whyacademicGP?
The views expressed are those of the authors and not necessarily of the any of the institutions mentioned in the article.