“I am sorry to trouble you, but she says she’s bedbound and would rather die than have further chemo.”
This message elicits the immediate response it deserves. The GP received his patient’s call at 5am, prompting his call to me. I promptly organise help for the patient who is thankfully stable but rattled. Much later, I ask her the question that intrigued me.
Of all the emergency hospital contacts she had been provided, why did she call the GP who didn’t even have access to her hospital notes? I expect to hear that she lost the paper or forgot the advice – instead, she replies: “Because I trust him the most.” Self-consciously, she consoles me that I’m OK, too, but her unvarnished praise for her veteran GP warms my heart and I agree with her that he indeed saved her life.
In emergency, I overhear a specialist telling a patient that her GP probably made a mistake. “Excuse me”, the patient retorts, “you have no idea what my GP does and how good she is.” Her full-throated defence silences the room.
Weeks later, I find myself addressing students about a career in medicine. One group contains high school students and the other incoming medical students. The landscape of medicine is unrecognisable since my student days, but some things haven’t changed a bit.
Nearly every student’s motivation for becoming a doctor is “because I want to help people”.
This is a good starting point because without liking, and wanting, to help people, you can’t care about their hernia, schizophrenia or cancer. Every aspiring doctor should want to help people, so this intention never feels worn.
Then there are the unsolicited comments when students reveal what kind of specialist they will be. Recently, there was a neurosurgeon (“I just like the idea”) and an orthopaedic surgeon. Also, budding cardiologists (“the heart is amazing”), anaesthetists and even an oncologist (“but I worry it’ll be depressing”).
Upon encountering this precocious certainty of career choice, my first response is bewilderment. How do they know? Upon entering medicine at age 17, I spent an entire decade suspended in curiosity. My future felt like a blank canvas but not foreclosing my options, and hence being open to persuasion, ultimately led me towards a mostly fulfilling career. Therefore, my advice for students is to be slow to hurry.
I can’t help but note that of the hundreds of students I meet, hardly anyone wants to be a GP. After all, these are young people whose most likely productive contact has been with their GP. Many have thankfully not needed to set foot inside a hospital, let alone seen a brain surgeon, foot surgeon or oncologist in action.
Australia’s continuing drought of GPs has been dubbed the “most terrifying statistic” in healthcare. Specialists are growing at a much higher rate than GPs, with a resulting skew in employment that serves neither patients well nor society.
So, if there were one surefire way of helping people and indeed, rescuing the healthcare system, it would be through becoming a GP. Then why is a generation of students automatically discounting this valuable career?
The American journalist HL Mencken said that for every complex problem there is an answer that is clear, simple and wrong.
We often say that general practice is so poorly remunerated that no one cares for it and, since pay is linked to prestige, why should any ambitious doctor settle for less? But while neurosurgeons and GPs may inhabit opposite ends of the pay scale, this comparison is flippant and attributing career choice to a question of money alone is reductionist.
The Gen Z students (roughly born between 1995 and 2010) I meet are thoughtful, smart and altruistic. They navigate the new stresses and demands of the world in more nuanced ways than I did at their age. To some, monetary reward for effort matters greatly (often with good reason) but many actively look to marry career with purpose. Compared with their parents, these students emphasise intangible notions of wealth such as flexibility or freedom to serve a cause, leading a McKinsey report to call them the purpose-driven generation.
So, if students enter medicine to make a difference but end up treading the familiar path of superspecialisation, how can we change the status quo?
In six years of medical school, I met every manner of specialist but strikingly few GPs. The lack of exposure translated into a lack of consideration of general practice as a meaningful career. The idea that universities flip the medical curriculum, so students train in the community and rotate into hospitals, has significant merit for an ageing population. It would expose students to the intersection of chronic disease, disability and psychosocial problems and showcase the broad skills required to create a coherent narrative out of fragmented specialist interactions. Students would see the harms of siloed medicine and realise there is no such thing as “just” a GP.
To unravel tradition will take time and infrastructure but I think there is something educators – from high school to medical school – could do now.
Schools love inviting their prominent alumni to address the student body, a nice way of honouring past students and inspiring current ones. Having attended numerous events as a speaker and a listener, I have met a virtual roll call of surgeons, specialists and “doctors to the stars” but rarely a practising GP. Those doctors are accomplished, no doubt, but not necessarily more interesting than the GP with a profound grasp of the human condition from the cradle to the grave. I know how easy it is to valorise trauma surgery, emergency rescues and treating cancer but when educators repeatedly recognise their most “niche” medical alumni, they do impressionable students and, indeed, society an unintended disservice.
I feel wistful (and slightly envious) when my GP friend tells me about her baby patient who became a mother and now attends with her own newborn. No other specialty can boast such continuity and the affection and trust linked to it.
I recently told some medical students that if they “really, really” want to help people, then they should consider general practice. To educators and institutions, I say that the next time you are looking for a doctor speaker, think beyond the regulars (yes, that includes me) and invite a GP. It would be eye-opening for your students and changing a few minds could change the fate of entire communities.
After all, we can’t be what we don’t see.
• Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death