The rise of the medical McJob: why we should turn the clock back When Aneurin Bevan, William Beveridge, decade has been characterised by a paucity two-thirds. 7 With this, an emerging body of and Ernest Bevin proposed a National of public debate on major issues, and a opinion is concerned that the pendulum has Health Service in the mid-1940s, the idea tendency to dismiss the concerns of those swung too far the other way. 6 Women have was met with considerable resistance from holding a contrary opinion — woe betide brought much to medicine, including better the medical profession. It was eventually anyone who challenged the prevailing performance in exams 8 and more patient- accepted in 1948 with the promise of orthodoxy by, for example, suggesting that centred consultations. 9 Nevertheless, after sweeteners which were, for consultants and a spending spree financed by irresponsible four decades of feminist rhetoric, society GPs respectively, the right to continue levels of personal debt was not sound still expects women to do the majority of private practice and independent contractor economic planning. Secondly, a coarser childrearing, leading to most opting to work status (whether working single-handed or in form of capitalism spawned an economic part-time. 10 General practice therefore bears partnership). This prototype has survived system where corporate profit relied on a a disproportionate burden of the fallout, over six decades and is the one within flexible, ultimately dispensable workforce, such as maternity leave and loss of which most GPs still work. However, in especially in sectors such as catering, continuity of care. 11 There is a potential time recent years there has been a noticeable hence the soubriquet McJob. Not that bomb for general practice provision, trend towards recruiting doctors who work politicians had a wish to dismantle it, on the currently cushioned by the fact that most in other ways, and current vacancies are contrary, for it was the capitalists whom doctors over 45 years of age are male and most likely to be advertised as salaried they courted for party funds and who would full-time, while most younger colleagues are posts. In this essay I will argue that, far from wine and dine them in their lucrative semi- female, working part-time, and are unlikely being a laudable choice, the erosion of the retirement. The first Generation X, now in ever to work differently. 12 If any GP principal concept is a worrying trend early middle age is, by contrast, still flipping discrimination is currently taking place it is undermining the interests of patients, GPs, burgers, pulling pints, and often living with affecting men who intend to work full-time, and the wider medical profession. their parents. They exercised their choices, something that can only be justified were The trend for new recruits in general and discovered their folly. this group unlikely to make a significant practice to work in posts other than Inevitably, an attenuated version of contribution to the profession, which is principals has been a gradual evolution Generation X arrived at medical school, less plainly nonsense. rather than a revolution. However, the mid- directionless than the prototype, but neither Medical education is also being adversely 1990s — the time of my entry into general yearning for the good old days because they affected by the number of doctors reducing practice — appear to have signalled a didn’t have any good old days to remember. 3 their clinical practice. At medical school and pivotal point, which begs the questions: They clamoured for flexibility in their working in our postgraduate education, the how and why did this occur? lives, 4 and general practice, already memorable pearls of clinical wisdom were Without doubt, much of it was to do with perceived to be a family-friendly specialty, invariably delivered by tutors who were a generational change in attitudes, as values became a popular choice for such frontline clinicians, whether in the consulting such as security, authority and tradition graduates. There was no shortage of more room, on the ward round, in the operating became less revered. Douglas Coupland, in experienced colleagues to help them theatre, or even in the post-mortem room, his novel Generation X ,1 observed trends in through the options. In 1997 a guide for non- allowing theoretical knowledge and its young adults seemingly intent on an principals appeared in the BMJ ,5 describing practical application to marry up. I extended adolescence, unable to visualise a salaried partnerships (surely an oxymoron), contrasted this favourably with nursing future either personally or professionally. retainers, associates, assistants, locums, education where a clear dichotomy is in Easily bored, they opted for a series of and working for the London Initiative Zone: a place: theory taught by tutors no longer in ‘McJobs’ — low paid work in service bewildering array of alternatives. clinical practice, while ward and practice- industries with poor prospects, although Another important factor in changing based tutors, though providing the vital many came from comfortable, if not actually working patterns has been the rise in the training in practical skills, often lack privileged, backgrounds. number of female medical graduates. This academic recognition and support. 13 The last It was at this time that two important hitherto taboo subject has recently been the century has produced many outstanding trends conspired to sustain Generation X. subject of discussion. 6 There is no doubt teachers: John Fry and Julian Tudor Hart in Firstly, this was the era of the populist that historically there has been general practice, Hamilton Bailey and Harold politician, 2 none more successful than Tony discrimination against women for entry into Ellis in surgery, and Maurice Pappworth and Blair. The recent Prime Minister was adept medicine; however, all UK medical schools Sheila Sherlock in medicine, to name but at eulogising ‘choice’ and ‘change’, yet now have more women than men, and in half a dozen. This was a diverse group — despite the populist rhetoric, the last some the proportion of females exceeds Pappworth and Sherlock, for example, 380 British Journal of General Practice, May 2009 Essay publicly disliked each other — but they did wealth as a source of happiness. 20 personal physician) just a year after the share one other thing in common, in that Whichever way one looks at it, the pressure latter’s death, in breach of confidentiality they each had a large and diverse clinical on primary care continues to rise, and and of common decency. That remark practice. By contrast, and worryingly, many against this backdrop, selection into illustrates, however, that general practice’s medical deans now oversee postgraduate medical education of a large proportion of reputation had once been poor in the eyes education having relinquished all contact graduates likely to spend most of their of consultant colleagues, and while some with patients. Can we really do no better careers working part-time, and employment may still hold such views, there is no doubt than a bureaucrat pointing students to the opportunities commensurate with this that general practice’s stock has risen latest web-based toolkit? ambition, seems unwise. We must keep a considerably. Central to this has been Does this all matter? I believe that the sense of perspective: what gain is there in academic kudos, beginning with the trend to move gradually but inexorably from fretting over the quality of out-of-hours founding of the RCGP, through to the advent partnerships to working under other services 21 or advancing the cause of easy of vocational training, the membership contracts is damaging across a wide patient access to their health records 22 when examination, and research platforms. spectrum, adversely affecting patients, we cannot guarantee reasonable daytime Having fought hard for this position, doctors, and potential future recruits into continuity of care? The risk to general however, the chances of maintaining it may medicine, as well as the standing of general practice is that patients may conclude that not be propitious. Unless there is an practice both within the medical profession their care lies elsewhere, and the Darzi plan increase in graduates who are able to and in comparison to other professions. will succeed by default. commit themselves to the profession Beginning with patients, it is well Moving onto doctors, if the mood in the properly, and given reasonable recognised that chronic illness in an ageing current workforce was hale and hearty my opportunities in the job market to do so, population is the greatest driver of argument could cease at source. This is not general practice may become a Cinderella healthcare need. 14 In this respect, the UK is the case. Concerns are being voiced about specialty, a job sufficient to provide a similar to other countries of comparable the emergence of a two-tier workforce, with second household income rather than wealth; however, factors more specific to salaried doctors forming an unhappy serious professional endeavour. A truly our population may serve to exacerbate underclass. 23 More importantly, registrars in apocalyptic vision is the next generation of pressure on health care. Our population is general practice are despairing of ever GPs being chiefly a part-time, peripatetic easily the most ethnically diverse in Europe, finding a substantive post. 24 Established GP group with little stake in the profession or while enthusiastic adoption of the free principals may have tried to recruit new bond with a community, limited market has led to a widening gap between partners only to find applicants less opportunities for professional development, rich and poor. 15 The deleterious effects of committed than in previous generations, and no political clout beyond securing their deprivation on health have been well and it is indeed churlish of any doctor to own existence.