General practice as a career: insights for workforce policy

Australia’s general practice workforce is contracting on two fronts — in mid career and late career. The average general practitioner is working fewer hours in clinical care, with many choosing to work part-time.1,2 In the next 5 years, about one in 10 doctors will leave medicine.3 The career decisions that GPs make, especially decisions to reduce their clinical hours, have implications for GP workforce planning, patient outcomes, GP business models and cost structures. Yet little is known of the timing and reasons for experienced mid- and late-career GPs moving away from working with patients.

Much of the discussion about solving Australia’s workforce shortages in primary health care has been dominated by arguments about attracting sufficient young people to the profession; international recruitment; task substitution by nurses or other health professionals; and removing inefficiencies in practice. Comparatively little attention has been paid to policies that seek to limit the drift of experienced GPs out of clinical practice. Career development theory, we suggest, offers insights that help to reconceptualise general practice as a lifelong activity. Applying this theory to workforce development is relatively new, but policymakers are beginning to see it as a useful tool.4 A recent Primary Health Care Workforce Roundtable for a sustainable workforce included developing a career structure for GPs among its key recommendations.5

To explore the working lives of GPs, we need to distinguish between general practice as a profession and general practice as a career. A profession is a relatively static concept, defined through its body of specialised knowledge, work boundaries and a commitment to service.6 Older GPs refer to this concept when they criticise younger doctors who work fewer hours, as they see this, in part, as professional abrogation.7 A career, on the other hand, is dynamic and individual, encapsulating a lifelong sequence of attitudes and behaviours associated with work experiences.8 Individuals construct their careers as one of life’s roles, and job satisfaction depends on how well they are able to synthesise vocational roles with other life roles.

In the past 20 years, the nature of work and career patterns have changed in our society, with jobs becoming less permanent, workloads increasing, new technology being introduced and more people changing jobs and careers. The traditional career that relies on a steady climb up the corporate or professional ladder is less dominant as new dynamic patterns such as the “boundaryless career” and the “protean career” emerge. The boundaryless career embodies physical and psychological mobility as individuals are no longer tied to one organisation.9 The protean career is directed by the individual rather than an organisation, and is characterised by a sense of personal or internal psychological success and individual values.10

Most careers proceed through developmental stages. The Box outlines typical career stages — exploration (training and initial work choices); establishment (the early and mid-career stage of advancement and career consolidation); maintenance (the late career stage); and, finally, disengagement. At each stage, the individual has different concerns and development needs. As individuals age and gain experience, self-concepts and work preferences change, potentially leading to a questioning in mid career about previous career choices.11 In the late career-stage, individuals refine and preserve their self-concepts, holding to what has been established and discovering new challenges.11 Throughout their careers, individuals adopt various life roles around work, family, self and community, often simultaneously and changing over time.

Although GPs’ working lives evolve through similar developmental stages,12,13 the features of a typical GP’s career differ significantly from those in the Box.

In the exploration stage, GPs have a traditional but particularly detailed upward career path, passing through what sociologists call “regularised status passages”.8 For GPs in Australia, these vocational milestones include graduation with a declaration of commitment to ethical behaviour; full registration; completion of hospital residency and training as a general practice registrar; obtaining a Medicare provider number; and attaining Fellowship of the Royal Australian College of General Practitioners. Typically, GPs remain at this career stage until they are in their early 30s.

Mid-career advancement and consolidation for GPs in the establishment stage also differ from what is experienced by people in many other careers. Despite opportunities for professional development, GPs’ careers often level out at this stage.

This raises the question of how highly qualified and experienced GPs respond when confronted with relatively flat career trajectories. Career studies have found that the impact is strongly influenced by how the individual defines career and success.14 GPs may respond in many ways. They may seek new challenges by moving to a practice with a different patient mix and range of medical problems, or by taking on a specialist GP role. Alternatively, they may become involved in non-clinical roles related to general practice, such as teaching, policy input, practice management (in a corporatised practice) or practice ownership (in a traditional practice). Finally, some GPs may choose to move away from general practice altogether.

Research into mid-career behaviour of GPs from a career perspective is likely to lead to a different and possibly more realistic set of policy solutions to maximise the potential of the existing workforce. Indeed, more information about GP career progression and options may also help to attract students to study medicine and take up careers in general practice.

Increasingly, GPs are less likely to work as traditional solo practitioners, or in partnerships that endure over a working life providing long-term continuity of care to patients. Modern careers are often more transient, with people frequently changing their place of work, business environment and roles. The authors of a United Kingdom study argued that new social values (eg, expectation of greater work–life balance, and pursuit of “nice” work) are shaping a portfolio career structure15 — a career based on a series of varied shorter-term jobs, either concurrent or consecutive.

The extent to which these different career structures exist in the medical workforce, and how GPs define career and success, is unclear. The influence of gender on career development is also uncertain. Female medical students first outnumbered male medical students in 1996. The increased participation by women has affected all sectors of the medical workforce, with women comprising 57% of GPs and 46% of specialists under the age of 35 years. While the average hours worked overall by female GPs are less than those worked by male GPs, the most significant decrease in workforce participation between 2002 and 2007 occurred in male GPs under the age of 35 years.1 Careful study of the construction and evolution of careers among younger GPs is necessary to explore the implications of younger GPs — both men and women — working fewer hours than their older colleagues. Studies in other sectors of middle-class, dual-income couples suggest that shared “scaling back” often occurs throughout the course of people’s lives together, with an emerging pattern of husbands and wives trading family and career responsibilities. This tends to begin with women scaling back in the earlier career (or exploration) years, often when their family responsibilities are for very young children.16 If this pattern occurs in general practice, it will have significant implications for career planning and support for both male and female GPs.

Managing GP workforce problems in Australia is not just a matter of forecasting population growth and the number of GPs. GP career preferences, work choices and career behaviours also need to be taken into consideration. The ground-level career choices made by an individual GP depend on the role of work in the GP’s life as a whole. This connection between the role of work in GPs’ lives, individual career behaviours and overall workforce outcomes provides the basis for using career development theory to enhance the GP workforce.