By Choice: Not by Chance Supporting Medical Students Towards Careers in General Practice

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Professor Valerie Wass, Emeritus Professor of Medical Education at Keele University, is the Chair of the By Choice – Not by Chance report. Here she briefly explores the need for such an investigation and provides a summary of the task force’s findings and recommendations for the future.

The Challenge

Knowledge, technology and health care delivery advance rapidly. One of the greatest challenges facing medical schools is to ensure their graduates are prepared to adapt to changes in health care over a career spanning 40+ years. It is tough for educators to think that far ahead. Now, changing patient needs and increasing pressures on health care delivery have highlighted that medical schools must think more about future workforce requirements. As ageing populations and complex disease co-morbidities demand an escalation in primary care, Health Education England (HEE) aim to recruit many more General Practitioners (GPs). Across UK medical schools, the current graduate entry from Foundation posts into GP training varies from 10% – 30%2; the HEE target is 50%.

Why a Report?

 HEE and Medical Schools Council (MSC), therefore, commissioned a report to explore the mismatch between medical school output into training and workforce requirements. Representatives from major organisations (see report), GP trainees and students were invited to join a working group. Professor Deborah Gill from UCL was at the table! Most importantly, focus groups were held with students at five English medical schools selected to reflect different curricula and GP outputs: Birmingham, Cambridge, Imperial, University of East Anglia and Warwick. The student voice across the schools was amazingly consistent, honest and powerful. We formatted the report using their perspective.

So What Did Students Say?

Tensions and the primary secondary care interface

“There is an anti GP rhetoric in medical schools”

Students confirmed that they witness tensions between hospital consultants and GPs, stating that a “tribalism” exists between primary and secondary care doctors. This risks general practice being perceived as of lower status than hospital medicine. Yet students who had spent time with general practitioners, especially early in the course, appreciated that it is a complex and challenging specialty.

“Tell consultants to stop putting GPs down. It makes students feel as though it is a less valued career”

Students felt they should be able to defend general practice when consultants were critical but this is not easy to do. We became aware of a “hidden curriculum” where culturally it was easier at times not to declare any ambitions of becoming a GP.

“If a surgeon asks, I tell them that I haven’t chosen a specialty yet so they don’t treat me differently.”

At the same time, because NHS morale can be low and GPs are stressed, students experienced a “negativism” towards general practice as a career. On placements, some were discouraged from considering it by GPs themselves.

“We do not have any real lectures from General Practitioners”

Yet students met some excellent enthusiastic GP role models who should be more visible. They wanted more GPs teaching them in hospital as well as in the community.


The influence on students of “tribalism” and “negativism” must be addressed. The report made 15 practical recommendations, some of which are based on student ideas. I have selected a few for which you at UCL can become actively involved, but I do strongly recommend you read the report.1

Understanding General Practice Before Medical School Entry

“There is a need to demystify what a GP actually is.”

Much can be done to improve students’ understanding of general practice before medical school entry; the media are too hospital focused. Medical students are doing valuable work in schools, raising aspirations among pupils to enter medicine and become GPs. There is a real need to widen access to medicine and include GPs on medical school selection processes.

Increasing Exposure to General Practice and Raising the Quality of Placements

“There’s a lot of responsibility on a GP placement. You are one person with one patient. It’s kind of empowering in a way”

Nearly 300 international papers were reviewed. We found strong evidence that length of exposure to general practice has a positive impact on career choice, provided that the placements are of high quality. Medical schools must work on both quality and quantity of exposure. Students told us that not all placements are beneficial and that they are stuck there with no escape route, thus improving quality is an essential aspect on improving student experience.

You Can Be a GP and Do Research

“There are no research opportunities in GP”

We identified a strong perspective among students that a career in general practice did not offer research opportunities: a myth that needs dispelling urgently. The academic profile must be raised. UCL is well placed to drive this change.

Raising the Status of General Practice

“There’s an element of pride regarding a specialty – people want to be seen as achieving or winning.”

As Sir Bruce Keogh said, “It is a really hard job. It requires a lot of intellectual flexibility and people have to be really tolerant individuals. It is one of the hardest jobs in medicine”.2

One of the attractions of the flexibility within general practice is the opportunity to follow portfolio careers combining clinical practice with education, research or global health, something which students very much appreciated. Professor Gill is just one example of how successful this can be!

Not everyone is cut out to be a GP, but at UCL, as all over the country, this report aims to make everyone aware that general practice is not “second best.” It needs the brightest and best of medical students to be able to say, with pride, that they want to become GPs. We are one step nearer to achieving this.

By Professor Valerie Wass OBE

Emeritus Professor of Medical Education

Faculty of Medicine and Health Sciences,

Keele University


  1. Wass V, Gregory S, Petty-Saphon K. By choice – not by change. Health Education England. 2016.
  2. House of Commons Health Committee. Primary Care HC 408. 2016.