3. What to do after VTS


	GP REGISTRARS often finish training with an anticlimax. They’ve got a JCPTGP certificate, they can call themselves GPs, but they often don’t have a base and without a permanent job the future can be rather daunting. The days of sleep walking from medical school to house jobs, into a VTS and then a partnership without any breaks are almost gone. Although those heady days of starting at medical school seem just yesterday, time flies by. Suddenly nine or more years have gone and you’ve finished GP training. Your parents brim with pride as they tell their friends you are now a GP, but you may feel less happy. After five years at university and four years in the NHS you’re on your own. It’s time to make some real decisions. The hospital years may have consisted of physical and mental torture sustained only by a now, much missed camaraderie. The GP year may have been a culture shock of proportions impossible to explain to non-GPs, a storm of assessments, things to discover, experience to gain and boxes to tick. But you’ve come through it, and, despite it all you are convinced it is enjoyable. It is where real medicine is at. You are trained to deal with anything and you look forward to a life in general practice. On finishing, you should relax, with a capital R. Having been burped out of the system you are now free to choose where you go, what to do and when. The world is your oyster….. The only thing to stop you buying crates of champagne and swanning off to a beach for a long time is money. Hopefully you’ve cleared those medical student debts by now and you do have the cash to take some time off. Take a good break, a month or two. You’ve undoubtedly earned it; especially if you’ve had no breaks throughout the years of training. A break will give you time to recharge the batteries, to consider where to go next and to catch up on a few activities you’ve been wanting to do for………how long? The options from here: Become a principal; Become a non-principal; Going back to hospital medicine or clinical work overseas; Do a non-clinical medical job; Do a non-medical job; Not working. Becoming a principal Most registrars want to become principals, eventually, but few feel ready when they finish their training. If a good practice comes up as you finish, you know the partners, you are settled in the locality, and, you feel ready, then go for it. The health service needs as many trained doctors to work full time as possible. It costs about £250,000 to train you so there should be some obligation to put something back. You can put little more back than full time partnership. Try to be sure you’re ready. Almost perfect practices are a rare thing. If you think you have found one, apply for the job, you’ll have at least six months mutual assessment to make your mind up. See the chapter on Becoming a Principal for more. Becoming a non-principal The term non-principal is terrible. The negativity is almost unacceptable. Despite this being widely acknowledged nobody has thought of a better term without getting rid of the term principal. Suggestions on a postcard please to the NASGP. An article in Pulse once stated that non-principals should be called non-stressed doctors! On the whole it’s probably true but how sad for principals who would therefore be the stressed doctors. Surely this isn’t true? There were five types of non-principal in general practice until about 1994. These were Locum, Retainee, Assistant, Associate and Deputy. Since 1994 and the arrival of London Implementation Zone Educational Initiatives (LIZEI) several new non-principal posts have been created, many with an academic emphasis. The 1997 NHS (Primary Care) Act paves the way for another group, Salaried GPs. In addition to these posts some health authorities are currently creating their own ‘salaried doctors’ schemes to deal with local recruitment difficulties. Locums work wherever they are needed doing either just short surgeries or longer stints. Locums are normally self employed and experience the greatest variety of practices and patients. Locums have the most flexibility in being able to choose where and when they work, but are also the most vulnerable when work is short. When working on a regular basis in one place (eg for more than three months) the Inland Revenue is likely to regard locums as employees and therefore not allow the tax benefits of being self-employed. To compensate, it is advisable to gain some employment benefits (with an assistant’s contract) which will enable joining the NHS pension scheme. Retainees are doctors who work within the Retainer Doctor Scheme. It provides limited amounts of work for doctors with other commitments, usually women with children, enabling them to retain their skills and stay up to date. It is very restrictive at present and barely pays for the costs incurred. Revamping of the scheme is expected soon. See the chapter on Retainees. Assistants are doctors who tend to work regularly for a practice full or part time. Some doctors will be assistants in more than one practice or will be locums at the same time. See the chapter on Assistants. Associates are few and far between. They have tended to be in rural areas and are mainly in Scotland. They are a formal grade of non-principals, defined in the Red Book. Other schemes around the country have called GPs “associates”. These are similar to ‘official’ associates but the posts are created especially for that scheme and so terms and conditions of service will vary. See the section on Associates. A Deputy is really any doctor who is acting for a principal. For general medical services a principal is under no obligation to give treatment personally if reasonable steps are taken to ensure continuity of treatment by another doctor, be that a partner, assistant or locum. In this respect most non-principals are deputies. Principals are responsible for the acts and omissions of any doctor who acts as their deputy. However, they are not responsible for the acts and omissions of a deputy who is on the list of the same or some other health authority or board. Health authorities have to be told of standing deputising arrangements unless the deputy is an assistant. In general the term deputy has come to mean those doctors to whom out of hours responsibility is transferred. In 1996 principals were able to transfer all or part of their responsibility for out of hours and many have done so. Healthcall is the largest commercial provider of deputies. See chapter on Out of Hours. A recent survey in North and East London found that deputies were predominantly UK trained males, with an average age of 42 (32-70) years. Going back to hospital medicine or clinical work overseas Going back to hospital jobs is an acceptable option if you have a specific interest in, say, one speciality. You are likely to stay in the service providing SHO ranks unless you do the speciality’s postgraduate exams and spend some time back in hospitals. Consider how useful such work is for a career in general practice. Probably few partnerships would expect higher qualifications in specialities although they are unlikely to be a hindrance. This does not mean that you should spend your SHO years doing one speciality diploma after another. Few of these have GP input and the RCGP recommends that SHOs concentrate on getting core experience and the MRCGP. If you are unsure about a career in general practice after completing your training a bit more time in hospitals should help with the decision. SHO posts are a way of biding time, getting more experience and superannuation. This can be useful if you are waiting for your partner to find out where he or she is going next. VSO and other third world agencies are another alternative. Combining travel with gaining additional experience in poor parts of the world will be a dramatic change from general practice in the UK. VSO have relaxed their requirement to commit yourself to two years (see useful addresses). Clinical work in the developed world is becoming harder to get. New Zealand is a popular destination. Australian work permits for hospital posts are harder to get than they used to be with most states requiring the doctor to have passed the Australian medical exams. Agencies advertise in the BMJ for GP locums in Australia and recently in the USA too (with the promise of not having to do the American exams). You can now work anywhere in the EC (with a JCPTGP certificate) but you’ll need a good grasp of the language! Non-clinical medical jobs There aren’t many of these. Jobs in the pharmaceutical industry often expect higher specialist qualifications rather than generalist ones. People with a tough skin may consider NHS management - those with some experience of management or the NHS are likely to get in quicker and progress faster than others. Public Health is a good place to get some experience although there are few SHO posts and becoming a registrar means joining the career conveyor belt. Time spent in Public Health enables you to learn more about the NHS, the way it is structured, the way decisions are made and who is who. This can be exceptionally useful as a GP and should be part of training. Departments of Public Health are involved in analysis of local needs and provision. It’s a fantastic opportunity to read all the editorials and evidence based review articles that you’ve always meant to plough through. Departments try to implement such work locally but this can be a frustratingly slow process. Public Health is usually the speciality that deals with local media and its interest in health (scares). Training for handling the media is fun and useful. If you like dealing with the media you could consider becoming part of it. There has been an explosion in the number of medics writing in the medical and lay press, broadcasting on radio and appearing on television. Much of this is freelance and casual but it can snowball if you want it to and, if you can write. One-day courses on medical journalism have been run for a number of years for BMA News Review by Tim Albert, a former editor of News Review. I went on one of these courses a few years ago and now I’m doing this so they must be good! Further details on Tim Albert’s courses are available from TAA Training. Telephone 01372 361633. A group called the GP Writers Association (GPWA) publishes and sends to editors a directory of members and their interests. The GPWA is open to anyone who publishes or aspires to publish written work of any nature, fact or fiction, prose or poetry. Details from the General Secretary, 633 Liverpool Road, Ainsdale, Southport, PR8 3NG or visit their website. The 1997 subscription is £30. This includes their new ‘How to…’ guide written by members. It’s free to members but £7.50 to others. Media Medics is a company founded and run by doctors who felt that there were too many lay people writing and broadcasting on health matters. As the public gets most of its medical education in this way Media Medics set about to redress the balance by putting doctors with an interest in the media in contact with producers and publishers. For an application form contact Dr John Cormack at Deben House, Chapel Row, Woodham Ferrers, Essex, CM3 8RN. (No fee at present). Thinking of leaving medicine? Leaving medicine after spending at least nine years doing it is a waste, but, if you’ve had enough, take a break. The world is your oyster. You can always come back. Make sure you get your JCPTGP certificate first, otherwise if you leave it more than seven years you might have difficulty demonstrating sufficient clinical contact to get one. If you are unsure about what to do, you could consider professional careers advice. Careers advice in the NHS is poor although many tutors and trainers will give you the best they can. Professional advice can be sought from Medical Forum, a professional careers guidance and personal development service. Medical Forum provides booklets and workbooks on career appraisal and one to one personal career planning. Further information is available from Medical Forum, Greyhound House, 24, George Street, Richmond, Surrey, TW9 1HY Telephone 0891 4244046 for recorded details (calls cost 50p per minute). Further information in RCGP information sheet 18: Additional Career Options in General Practice - available from the RCGP website. Career focus Career focus is published weekly at the front of the BMJ’s classified section. Its mission is to publish high quality information that helps doctors to develop their careers. Articles published are relevant to all doctors from juniors in training to established general practitioners who wish to undertake career development. The section was established in July 1996. There are now more than 80 articles on career-related topics on the web site (all articles are available in full text).