Nishma Manek and David Haslam: Denigration of general practice is still rife 

We must confront systematic denigration within medical training, and foster mutual respect between specialties

 “If you students don’t start working harder, you risk ending up as paediatric cardio-thoracic surgeons.” 

Can you imagine anyone ever saying those words? It would be quite ridiculous.

However, replace those last four words with “GPs,” and the scenario will sound more familiar. 

When we were students, derogatory phrases like this were said to both of us—two doctors at the opposite ends of our careers. We were both furious. Fortunately, it didn’t stop either of us becoming GPs, and we might have hoped that such attitudes were dying out. 

However, all too little seems to be changing. The RCGP has just published a survey of just under 3700 medical students, and it confirms that denigration of general practice is still rife behind medical school and hospital doors.  

The report is littered with disheartening statistics. For example, 76% of students said that they’ve encountered negativity towards general practice from academics, clinicians, or educational trainers by their final year, and 70% of these were in a clinical setting. Some of the comments cited in the report (such as “a lot of [GP] consultations aren’t proper medicine” and “don’t you dare think about going into general practice—have some aspiration for God’s sake!”) shows just how deep the prejudice still runs in places. Yet many of these consultants won’t have stepped foot in general practice since their student days.

Consider the total amount of time a student spends in a hospital setting compared to general practice in their training. Very quickly these off-the-cuff remarks add up, leaving general practice tarnished with a reputation that’s hard to undo.

Disparaging remarks about GPs carry another implication: that their patients shouldn’t expect the best and the brightest doctors. Yet as patients, much of our own NHS contact will be through our GPs, who we would probably like to be the best and the brightest. It’s hard to reconcile those two observations.

The report also found that students are strongly influenced by each other, and 91% perceive their peers to be negative about general practice. The potential ripple effect of one student’s misconception to the rest of their peer group makes remarks like those cited above even more worrying.

We’ve all been there. Temporarily adopted by a specialty in your training, it’s easy to get caught up in the casual rebukes. The sheer strain of the job lends itself to scapegoating and defensiveness. Muttering snide remarks about GPs and their “inappropriate” referrals may seem fleetingly satisfying and seemingly harmless.

Except—as this report shows—it’s not harmless at all.   

This isn’t just about secondary care: we as GPs need to be equally mindful. The survey also found that GPs interacting with students on placements are the most influential group on their perceptions of the career. Mostly these were positive, but there were some examples of negativity coming from GPs themselves.  

Some will argue that if we were to fix the job, these archaic perceptions will fix themselves. Articulating the pressures on primary care certainly has its time and place—but perhaps we should pause to consider who else is listening. Our attitudes are influencing the very people who might be able to help. And frankly, efforts to improve patient care will be futile without the future workforce to deliver it.

Let’s be clear, this isn’t about censorship. Nor is it about eliminating banter. It is about confronting systematic denigration within medical training, and fostering mutual respect between specialties.

Choosing a specialty is one of the most important decisions a student will make. Those decisions are modelled by their view of the world. With so little exposure, that view is heavily shaped by what is projected onto them. This report is a critical reminder of the part all of us play in that projection, especially in secondary care. And once that seed is sown, it spreads through their peers to leave a cohort of clinicians looking at primary care through a distorted lens.

This matters more than ever before, because multimorbidity is becoming the new norm. We need to be training a workforce with the needs of our future patients in mind: a workforce of generalists.

Nishma Manek is a GP trainee in Cambridge. She was on the FMLM National Medical Director’s Clinical Fellowship Scheme 2016/17 at NHS England. She tweets at @nishmanek.

David Haslam is Chair of NICE. He is past-president and past Chairman of Council of the Royal College of General Practitioners, and was a GP in Cambridgeshire for many years.

Competing interests: None declared.