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2.Why do GPs become GPs? Family, education and vocation |
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University of Glasgow |
In my interviews with Paisley's general practitioners (GPs), the doctors (no matter their age) reported that their parents had influenced their choice of medicine as a career. However these parental influences were exerted in different ways according to social class. A separate factor shaping the choice of general practice as a career was the changing conditions in and the subsequent image of general practice at various stages over the last fifty years – the attractiveness of general practice has waxed and waned over time.
The family emerges as particularly significant in decisions that lead to the study of medicine (1). Earlier research suggesting that fathers positively shaped the medical careers of their children (2) was confirmed in our study. Similarly a large proportion of general practitioners (GPs) had fathers in the ‘higher professions’, including medicine [9], science [2] and religion [2] (3 see table 3).
And it was the authority of these fathers that was recalled as influential in deciding how and where their young would be educated. While some fathers encouraged entry into medical schools, there were others who tried to deter their children, especially daughters, from studying medicine. Such attempts at dissuasion could galvanize rather than diminish ambitions.
For those doctors who originated in families in which parents were employed in lower middle and working class occupations the role of fathers in career decisions was less pronounced. Amongst these GPs the importance of schoolteachers and school friends was more likely to be stressed. And the role of mothers tended to be recalled by interview partners who had been raised in less privileged circumstances.
While the influences surrounding application to medical school have altered little since the Second World War, the motives for entering general practice have changed during the same period. So, when older retired family doctors speak about joining their first practices their narratives are marked by a lack of autonomy .In contrast younger practitioners are more likely to suggest that working in general practice was a positive choice.
The narrated career histories of the younger cohort was less fatalistic than those offered by their predecessors, but there were also subtle differences between the ways different younger GPs talked about their choice of profession. The doctors who qualified in the late 1960s and afterwards discussed their lack of appropriate attributes and attitudes for careers in hospital medicine. Some believed that they lacked the social capital to participate in a system of patronage. But they also expressed many more criticisms of secondary care than their older colleagues made. Most of the younger GPs concluded that medicine in the community offered a freedom from hospital medicine’s hierarchies and regimes. And finally there were those who entered the profession in the 1980s and claimed that this was the only medicine that they had ever wanted to practice. Along with other younger doctors they stressed the promise that general practice seemed to offer.
There were differences across the generations between those who had entered general practice by chance and those who had entered the profession as a matter of choice. That joining the profession is recalled along such distinct lines could be seen as evidence of the outcomes of improving conditions and the subsequent rise in morale that flowed from the Family Doctor Charter and the subsequent contract of 1966.
Change in general practice has also transformed the impact of practice on the family lives of doctors. In earlier times, especially before the 1960s, many GPs had depended on wives to act as receptionists and even as nurses (4). Practice premises, the introduction of practice receptionists, appointment systems and more recently out-of-hours services have meant a separation between home and work. General practice has become an important choice for those wanting a family friendly option.
In conclusion, the influences leading to entry into medicine changed very little between 1940 and 1990 according to the practitioners who were interviewed. While the mix of entrants remained the same in respect to their social origins, there were changes in the gender composition of entrants. Medicine arranged along authoritarian and hierarchical lines was particularly alien to those who were raised in working and lower middle class households, as well as to female entrants more generally.
There is also evidence of significant changes in the way the Paisley doctors talk about entry into general practice. A period of low morale in practice, similar to today’s crisis, was ended by an improvement in material conditions and future prospects. In the 1970s and 1980s general practice became a positive choice for many, a situation that would improve primary care’s ability to play an effective and leading part in the delivery of health services.
The oral evidence
Choosing medicine
Douglas H: ...All my life I've been kind of led in the direction of
medicine. I think my father would have liked to have been a doctor; he was in the RAMC
in the First World War. ...When I finished school [in] '43 ... I had a notion to
join the Indian army... My father it was who said, 'Don't be a fool, you'd be much more
use to humanity with a medical degree…' ...As it happened I got my war later
anyway... (5) (6).
Eleanor H: And my mother was definitely subservient. It was his [father’s] authority that held within the house. He guided me into the scientific school career. I was good at languages at school and he told me that I was to stop French and Latin and do German, cause he reckoned that German was the language of science and I still remember that phrase (laughs). … I think he was quite proud that I did medicine (7).
There were some fathers who were against their children entering medicine.
Gerldine H: I don’t think my dad [who was a GP] was particularly keen
for me to do medicine – well he said he said he wasn’t. …I don’t think
that he was particularly fond of doctors … and I could see his point when I
came to university there were an awful lot of tossers ...that did medicine …We
were kind of I’d say slightly apart from the large majority of the Hutchie [Hutchesons'
Grammar School], Glasgow Academy, Glasgow High, Notre Dame type people .I don’t
know what school you went to, but I hope I’m not offending you? (8)
Fiona T: I always wanted to be a doctor from primary school age and
that was it.…My dad was a general practitioner. …I wouldn’t say I
was particularly encouraged to go into medicine. My father was very much
that I shouldn’t do this. Educating women was a waste of time. It was going
to cost a fortune and I would get married and throw it all away and that I
should do something else. I can
remember a terrible fight about this. … I held off from having children for
a long time …and it came to the stage where my father was getting angry at
me for not giving him grandchildren (laughs). And I felt like saying, “Well
make your mind up. Do you want me to be a doctor or do you want me to be a
wife and mother? And why should I do what you want me to do anyway?” (9)
Some recall their mothers being directly influential. John H’s mother worked in a variety of part-time office jobs and his father was a joiner with Glasgow Corporation.
....Mum's quite a sort of driving force. I think she decided I was going to be a
doctor when I was a baby and I’ve resisted that right the way through until
I actually had to fill in my form for university.… Both of my parents have
had a lot of influence in my life. My dad’s a fairly placid guy with a
wicked sense of humour and my mum’s got quite a bit of drive. It was really
my mum who I think got the family where it is today. I think they look on it
as a big achievement to have two kids who are doctors, having come from a
pretty poor background (10).
Linda F’s father was a welder and her mother worked as a lathe operator before taking part-time cleaning jobs. Linda attended a single-sex, fee-paying, school in Glasgow.
My [school] friend’s parents were doctors and I’m sure that’s where it
came from. I was back and forwards to their house all the time. Her eldest
sister did dentistry and her brother did medicine, so it was all medicine talk
(11).
Others, like Colin R, were encouraged by schoolteachers to consider medicine as a career.
[I] had no great ambition to be a doctor. ...But when I went to the careers
master he said, “Well, you’ve got a good group of Highers and you’re not
brilliant at anything, but you’re ok across the board”. And he would
suggest medicine or law, and I didn’t fancy law - stupid me (laughs) (12).
Choosing general practice
During the Second World war Hector M was a senior house surgeon in the old Royal Alexander Infirmary, until 1st July 1944.He was waiting to be conscripted into the armed services.
But I was told by the War Medical Committee that I would have to do some
time in general practice. They were short of general practitioners and had plenty in the army at
that time, so I was offered the choice of going to Caithness, Stornoway and
somewhere equally outlandish or to Doctor R. R. Barr, 15 King Street, Paisley... (13).
Six years later Douglas H ‘got his war’ when he served as a Regimental Medical Officer in Korea, ‘Just general practice, but in a rougher circumstance’. On leaving the army he found that,
Beggars couldn’t be choosers … jobs were not hanging on trees… The last
place I wanted to work was in Paisley, because my father was a minister in the
town and it’s not always a good thing... I could have been labelled just his
son and not developed an identity of my own... (14).
By the 1960s general practice was changing and the attitudes of entrants were changing too.
Robert B: ...I never saw general practice as being a place for failed
surgeons or physicians, never … the new hospital consultants in Glasgow
without question … [would say], “Oh, you’re just a GP”... (15).
Andrew K: I had my fellowship [from Edinburgh] and then ... I had to decide
what I was going to do … I applied for a post, for a step up, in urology..., which
I didn’t get, because there was a lot of applicants… and I said to my
wife at the time, “If I don’t get this post I am going to go into general
practice”. That was really the decision. Looking back on it part of this was
I don’t want to bend at the knee. I don’t like this hospital set up... (16).
Linda F: It was weird. I just suddenly thought, “No, I don’t
think I really quite fancy this.” I could see all the backbiting and the
backstabbing … You also saw how people used their contacts, their own
personal family contacts in working out jobs and stuff like that. I realized I
didn’t actually have any of these footholds… But having said that, general
practice [in 1978] .... was the primary choice.... (17).
Christopher J: ...I’ve always had GP stamped on my bum … I’m
independent minded and bloody minded and I hate being told what to do. ... I got
the impression ... that in general practice you could really rule your own life
(18).
Later family influences
Peter V’s first child was born in 1980, ‘two years before going to general practice’.
I think when you’re married - first of all it shapes your career. And then your mobility is severely limited by having children. If I hadn’t been married and I hadn’t had children my career would probably have been quite different. To take a research registrar’s job was severely crippling financially and certainly one person can survive well, but not a family, you couldn’t live on it, no (19).
Eleanor H: My original reasons were that I wanted to do something that definitely involved patient contact. And I wanted a job where I would be using my medical diagnostic [pause] skills. I was engaged and I knew that I wanted to get married and wanted to have a family in due course. So, I want the kind of job where I can take a part-time commitment and at that stage there were no sort of part time medical jobs whatsoever (20).
Postscript
Many years later some continue to keep their parents in mind.
Colin R.: ...I think …if this was my mother what would I want her
doctor to do for her? And if it’s good enough for my mother then it’s good
enough for your mother.…(21)
References
1. Twenty-six out of 31 of the interviewed practitioners provided family histories when recalling their reasons for choosing careers in medicine.For further details about the oral history of general practice in Paisley project see Smith, G, Nicolson, M, Watt, G.C.M, An oral history of everyday general practice: speaking for a change, Br J Gen Pract, 52: 516-7. The project was funded by the Wellcome Trust’s History of Medicine programme.
2. Bevan M Family and vocation: career choice and the life histories of general practitioners. In: Bornat J, Perks R, Thompson P, and Walmsley J, eds. Oral history, health and welfare. London: Routledge, 2000. 21-47.
3. See http://www.shef.ac.uk/~scharr/hpm/GS/table3.htm
4. Margaret G, was reliant on her mother who would answer the telephone at night (GPP 25).
5. GPP 16.
6. For a younger doctor with a father in medicine who encouraged him to go into medicine see GPP 06.
7. GPP 12.
8. GPP 31. This is a recording of a telephone interview. All other interviews were conducted face-to-face.
9. GPP 28.
10. GPP 21.
11. GPP 18.
12. GPP 22.
13. GPP 13.
14. GPP 16.
15. GPP 23.
16. GPP 25.
17. GPP 18.
18. GPP 02.
19. GPP 01.
20. GPP 12.
21. GPP 22.
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