Developing a career as a GP educationalist: contemporary challenges and workforce solutions

ABSTRACT

GP educationalists are crucial in training the future medical workforce and in developing and advancing the field of primary care medical education, yet opportunities in the UK are patchy and varied. In this article, a group of GP educationalists summarise the challenges facing the sustainability of this particular group of clinical academics and outline opportunities available at each career stage, from medical students through to senior GP educationalists. Recommendations to support the growth of this workforce include the development of a nationally recognised framework for GP educationalist careers, collaboration with professional and educational bodies and taking steps to level out opportunities in order to reduce existing inequity.

KEYWORDS:

• Medical education
• primary care
• clinical academic
• medical careers
• general practice

Background

It is widely recognised that there are limited opportunities for General Practitioners (GPs) to develop a clinical academic career as an educationalist. Whilst clinical teaching is well established as a core component of a career as a GP, whereby the clinician teaches others in their workplace as part of their overall clinical role, the opportunities for GPs to embark on formal academic careers tend to be serendipitous. The Health Education England and Medical Schools Council report ‘By choice not by chance’ [1] highlights the need for the opportunities and profile of academic general practice to be increased through national intervention, yet significant challenges to this career remain and pathways are opaque and hugely varied [2]. General practice medical education is essential in creating the future generalist medical workforce [3] with GP educationalists critical to the progression and modernisation of the field and in raising the profile of academic general practice [4]. We define educationalists as being those with formal roles who are part of a community producing knowledge in medical education, whether that be through advancing theory or practice [5], through research, innovation or strategic design. In this article, we focus on university-related posts, as we see the value of inter-connection between the university environment and clinical service to facilitate communication, use and growth of scholarship in the practical aspects of work and teaching.

UK Government policy advises that 50% of medical graduates should enter training in general practice to meet the needs of the population [6], which has led to efforts to increase undergraduate time spent training in general practice and evolution of funding models [7]. We advise that action is required to support the development of academic educationalists with the skills and motivation to ensure high quality, evidence informed primary care education which meets the needs of the NHS and the UK population [8]. In this article, we draw on existing literature and our own experience as GP educationalists to summarise the challenges and solutions in supporting expansion of and investment in the GP educationalist workforce and make recommendations to facilitate progress. We make the case for a continuum approach to GP educationalist careers commencing at undergraduate level, and for equity and consistency of opportunity between educational and clinical research, and primary and secondary care throughout the UK. We acknowledge there are commonalities with other scientist professions who contribute to primary care medical education and whilst their career pathways are not the focus of this article, they are likely to share the challenges outlined.

Challenges

Despite the clear need for educational scholarship and innovation, in our experience opportunities for GPs are patchy and inadequate. The GP workforce is under significant pressure with reducing numbers of GPs and increasing clinical workload [9,10] which creates barriers to individuals taking time to develop a career as an educationalist. The changing demographic towards a greater proportion of GPs being female [9] and international medical graduates [11], who are potentially less likely to have the opportunity to progress in their careers [12] presents an additional challenge to increasing uptake of educationalist careers. More than half of those in training as a GP qualified in other countries. This group of international medical graduates face significant challenge during training [11] and there may be inequity of access to opportunities to develop as educationalists and role models who can inspire them towards this career pathway.

A lack of exposure of medical students to academic GPs has previously been highlighted as a barrier to being attracted to GP as a career in general [1] and particularly to academic GP careers [2]. While progress has been made at some institutions [7], the majority of students will not have the opportunity to interact with or be supervised by GP educationalists, due to their under-representation in the clinical academic workforce. GPs comprise 27.5% of the total UK medical workforce, yet academic GPs account for only 6.2% of clinical academics [13]. The number of clinical academics has remained static for the last ten years, many are close to retirement and there are significant issues with gender and ethnic diversity in the academic pipeline [14]. Overall funding for and numbers of medical educators across all specialities continues to decline [15].

Local opportunities are dependent on the presence of enthusiastic GP educationalists with both the time and skills needed to develop opportunities and thereafter supervise and mentor potential candidates. However, GP educationalists typically balance a clinical career with a large and often unrecognised associated workload, with an extensive teaching commitment, leadership responsibilities and research. In our experience, the research component of their role is often unofficial, unfunded and not necessarily recognised by academic institutions, in contrast to GP academics undertaking clinical research. The discrepancy in salary between academic and clinical roles experienced by many poses a further challenge and potential barrier to educationalist careers [2,16]. Doctorate degrees are sometimes a requirement for progression and promotion within academic institutions. With limited opportunities for GPs to undertake these degrees, there are few GP educationalists holding senior lecturer posts and in turn there are a very small number of professors in general practice medical education.

The reduction in departments of general practice [7] has also reduced the profile of academic general practice education and restricted the opportunities for GP educationalists to work alongside clinical research primary care colleagues. In England, for example the National Institute for Health Research (NIHR) School of Primary Care Research (SPCR) is a unique opportunity for primary care researchers to access NIHR funding and has made significant changes to promote collaboration outside of school members but is generally still limited to a handful of research active institutions and focussed predominantly on clinical rather than educational research. The lack of equitable and system-wide funding available for potential candidates to undertake qualifications and projects, for doctorate degrees and for supervisors and mentors are clear barriers to progress. The short-lived nature of many of the posts available, and the requirement to apply for further highly competitive opportunities may deter many candidates who desire stability of employment. Local groups of ASME (Association for the Study of Medical Education), SAPC (Society for Academic Primary Care) and SMERC (Scottish Medical Education Research Consortium) exist in some areas but are dependent on enthusiastic educationalist role models to guide and mentor developing students, trainees and doctors on a voluntary basis, resulting in inequity of opportunity in different regions.

In the light of these challenges, we discuss below existing opportunities and solutions for entering and developing the GP educationalist career at all stages of the career trajectory, from medical school training, to postgraduate training and beyond.

Undergraduate level

There are a range of opportunities that medical students can consider in making the first steps into the discipline of medical education. Many medical schools deliver peer-assisted learning schemes in which senior students engage in near-peer teaching activities with junior students [17,18]. However, how they do so is heterogenous, and less than half provide formal training in pedagogy for undergraduates [19].

All schools offer medical students the opportunity to select areas for more detailed exposure. This can include modules in medical education with time for students to undertake a small educational research project alongside developing teaching skills. Many undergraduates undertake a mandatory quality improvement project during their training (for an example an audit). This too can be designed around an educational focus and offering this within general practice settings may help increase awareness of the importance of medical education scholarship in community settings. Student summer scholarships can provide a funded opportunity for students to be immersed in an academic medical education environment, often with a research project component.

Many medical students intercalate, and a formal education qualification, for example the Masters in Medical Education, offers postgraduate-level study of the theory and practice of medical education including completion of an educational research project. However, it is important to note that these opportunities are only available to a minority and vary by institution. Some students will be fortunate to have selected an institution which offers opportunities aligned to their interests, but not all will have considered this during the application process. It is also important to consider that the demographic of those in undergraduate training is changing to include more individuals from minority ethnic groups, from social and educational disadvantage and with disabilities [20], some of whom cannot afford to add an extra year to their studies. If qualifications have the potential to increase the chance of success on this career pathway, then there must be equity of opportunity.

Foundation level

Specialised (academic) foundation posts in medical education and general practice are increasingly available around the UK and provide protected time and funding in an academic environment to develop early research skills and pursue a post graduate qualification in medical education. Proposed changes to the foundation programme allocation model may remove some of the barriers previously encountered by those from minority ethnic and other groups to obtaining their first choice of foundation programme, thus increasing the diversity in uptake of these posts [21]. ‘Foundation year three’ posts have also become a popular option to provide additional experience before embarking on speciality training. Some educational institutions and NHS Trusts offer these as ‘teaching fellow’ posts with minimal clinical commitment allowing the postholder to focus on teaching, educational scholarship and completion of formal educational qualifications.

GP speciality training

It is recognised that those training in general practice must be trained to teach, and the Royal College of GPs curriculum includes ‘support[ing] the education and development of colleagues’ as a core competency for all GP registrars [22]. Individuals can seek out opportunities to teach students at their practice during clinical training, although surveys have shown that GP trainees are offered more opportunities in their hospital placements than their GP placements [23], and not all training practices teach undergraduates. Formal opportunities provide more potential to develop as an educationalist in addition to developing as a teacher, and more substantial teaching and educational research roles can be taken on as part of the NIHR Academic Clinical Fellowship (ACF) programme. This Fellowship expands full-time training from three to four years, giving a split of 75% clinical to 25% academic training time programme [24]. In Scotland the Scottish Clinical Research Excellence Development Scheme (SCREDS) provides a similar integrated training and career development pathway supporting academic and clinical training to CCT and senior clinical academic appointment [25].

Integrated Training Programme (ITP) posts in medical education offer GP registrars between six months and two years spent working 50% clinically and 50% in medical education [26]. These posts afford opportunities to undertake postgraduate qualifications, become involved in a research project and may allow a Masters or rarely a Doctorate degree to be undertaken as an extension of the programme. These roles can also serve as a springboard into a Doctoral Fellowship, providing the supervision, experience and network required to attain this next step. Aside from these formal training pathways, many medical schools offer opportunities for GP registrars to deliver medical student teaching and assessment.

Post CCT GPs

Many undergraduate primary care departments employ GPs in tutor roles, usually to deliver small group teaching. Substantive university posts as GP lecturers are also available in some departments, which usually involve input in curriculum design, evaluation, and assessment alongside teaching. These posts can support holders to obtain further educational qualifications, occasionally to Doctorate level. Health Education England fund post-CCT fellowships in various areas including medical education, allowing recently qualified GPs to undertake undergraduate teaching and scholarship, and some federations linked to their local academic institution, offer similar opportunities.

The NIHR provides funding for a small number of clinicians in England or participating institutions from devolved nations to undertake pre-doctoral and doctoral fellowships, facilitating protected time for research and a personalised training and development programme. Included in the NIHR funding remit is high-quality medical education research with potential for practical application and potential impact on patients, the public or carers. The In-Practice Fellowship (IPF) scheme [24] is open to post-CCT GPs and candidates do not require extensive research experience or publications in order to apply. Applicants are required to specify a research project, an institution to host their fellowship, an appropriate supervision team and a development plan, which may include undertaking Masters level studies. The NIHR School for Primary Care Research career progression awards provide similar opportunities. NIHR Doctoral Fellowships are highly competitive and more accessible to those who have some early research experience and publications. They provide funding for candidates to undertake a PhD, three years full time or up to six years part time, with funding to support a personal development programme.

In Scotland, NHS Education for Scotland offer limited numbers of Medical Education Fellowships in General Practice for recently qualified GPs, with the opportunity to teach, obtain a postgraduate qualification and undertake an educational project, which can include research [27]. A further opportunity is the Clinical Academic Fellowship scheme which is hosted in collaboration with educational institution; this post is for one year only and allows 80% academic time within a university and 20% clinical time [27].

Senior GP Educationalists

In the UK, a variety of opportunities are available to support application or promotion to Clinical Lecturer and Senior Lecturer positions, which do not necessarily require a doctorate-level degree. External formal lecturer opportunities are offered by NIHR through their Advanced Fellowship programme which supports post-doctoral researchers to establish themselves as independent researchers. Most institutional teaching funded posts will have significant allocation of delivery and organisation responsibilities. However, scholarship interests can be integrated within these activities or in addition to this once in post. Some universities have separate teaching and research career promotion pathways. Others are combined, but with differing balance of expectations depending on the individual’s dominant activity (teaching or research). An academic framework to promotion might expect evidence of activity across research or innovation, teaching, citizenship and outreach or entrepreneurship.

At this career stage, it is important to consider opportunities for collaboration with colleagues. Networks and peers from different institutions have a key role to play in supporting ongoing development. There are often rapid changes in policy and governance expectations and having colleagues willing to share information and potential approaches can be incredibly supportive and constructive. Similarly, where international kinship evolves, ‘making the familiar strange’ can be a powerful learning tool for both partners: providing a critical eye to areas of similarity or dissonance, but also through sharing examples of scholarly approaches to practice.

Potential solutions and recommendations

Based on the opportunities and challenges discussed, we propose a number of recommendations to promote careers for GP educationalists Box 1.

Box 1: Recommendations to promote career pathways for GP educationalists

There should be a nationally recognised and accessible framework to develop a career as a GP educationalist, reducing the requirement for serendipity in these pathways whilst recognising that some will still enter the career through less conventional routes.

We recommend levelling out of opportunities so there is less variation between regions and institutions; ensuring that opportunities are resourced, promoted, accessible and seek to reduce inequity in order to represent the diversity of the GP workforce.

We commend NIHR for highlighting medical education as one of their themes and for implementing an incubator in clinical education to promote opportunities [1]. The incubator leads have included a number of GP educationalists in their workstreams (including two of the authors) and we are hopeful and expectant that the result of the incubator will see more successful applicants of NIHR awards in clinical education. We recommend that the work of the incubator continues to recognise the importance of educationalist careers in general practice in addition to other clinical disciplines.

The collaboration between the Royal College of GPs (RCGP) and the Society of Academic Primary Care (SAPC) to promote general practice including academic careers to students has strengthened and offers great potential for further developments. SAPC have funded a special interest group in educational research (coordinated by two of the authors) that has instigated several multicentre studies and role modelled the implementation of rigorous, well developed collaborative research. ASME and SAPC successfully joined forces to provide a one-day conference focussed on medical education. This provided an invaluable opportunity to network and share ideas across research and a range of clinical education disciplines, including other GP researchers and Educationalists. The group are meeting again this year and we recommend these collaborative efforts continue.

Flexibility and diversity of opportunity can promote equity of opportunity; it is important to offer pathways that support less than full time working and remove other barriers that individuals may face in pursuing this career pathway, with entry points for GPs at all career stages and the ability to successfully combine a clinical and academic career whilst working less than full time.

International medical graduate educationalists may be best placed to provide an academic role model to those who follow their path, with insight into the particular challenges faced by this group. Opportunities should be provided to connect these individuals with those embarking on training programmes.

Successful implementation requires infrastructure to support individuals on academic pathways, time for supervision and opportunities for recognition and promotion of those taking leadership roles in this field.

Collaboration and integration are key to facilitating GP educationalist career pathways, with medical schools, research colleagues (both in general practice and more broadly) and Health Education England/ NHS Education for Scotland all playing an important role.

Conclusion

Career opportunities for GP educationalists are of clear importance in ensuring that medical education adapts to meet healthcare needs. GP educationalists have an important role in contributing to the education of all medical students as the generalists required for the future, and in raising the profile of academic general practice. With infrastructure, collaboration and acknowledgement of the importance of clinical academic careers in GP education, we hope that the future will see parity of opportunity with those undertaking clinical roles and research.

Disclosure statement

The authors have no declarations of interest to report

Additional information

Funding

DGJM is an NIHR In-Practice Fellow, grant ID NIHR301988. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.