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For Primary Care| View from the ground

My Portfolio Journey

View From the Ground, by Dr Punam Krishan

Over the past decade, I have been a salaried GP, a GP partner, and now I work as a portfolio sessional GP. This journey has not been easy, and my job continues to evolve. For some, the thought of undergoing so many changes may cause anxiety; for me, exploring the options along my path in life, but within a job I love, has kept me excited and enthusiastic about primary care.

I work really hard, and one thing’s for sure—through each phase and transition of my career, I know that every day I have made a positive contribution to general practice, much like every GP in this country.

What’s prompted me to say this, you may be wondering? Well, it’s because I am fed up of the negativity coming from a small but significant cohort of GPs who feel that they are more hard done by because they consider themselves to be making a more significant contribution to primary care than their portfolio sessional peers. They pass judgements because of a perceived entitlement that comes from holding a permanent position of work.

As a portfolio sessional GP, it’s deflating and upsetting to feel attacked and judged in this way. I reiterate that it is a minority, but it’s enough to make folk like me second-guess the positive work that we do.

Often, such vitriol is hidden in closed social media groups, but other times, it’s shared in generalised, ill-informed, and biased Twitter rants, which—let’s be frank—aren’t wholly professional. I wonder where the anger and resentment stems from? If a GP declares that they are happy or shares their work online, they are accused of altruism, of not working hard enough, or of only being interested in fame and money.

Most GPs who have arrived at the decision to work as a locum haven’t done so lightly. They have made an informed decision based on many factors personal to them, but this rarely gets considered as the push to take up permanent posts repeatedly tops the primary care workforce agenda. 

As I stood at the crossroads 3 years ago, anxiously deliberating on whether to continue feeling miserable as a GP partner or walk away completely, I realised that I couldn’t do the latter. I chose to continue in general practice, but I felt that I had to do it in a different way.

As a partner in a busy practice, I felt burnt out, and one day I decided that enough was enough. Ironically, it wasn’t being a GP that I resented—in fact, that was, and still is, the job that I love. I resented spending most of my days negotiating, arguing, and feeling frustrated with all the paraphernalia that came with being a partner. I didn’t mind the paperwork, staying late for patient-related work, or going above and beyond for my patients, because this is what medicine is about. What I minded was feeling helpless all the time because of business management, politics, and incessant meetings and negotiations that never led anywhere. I felt done in by reviewing contracts that teased but never delivered. I minded wasting time on futile efforts. This was a dark time for me: I felt alone and unsure of what I was going to do.

I started to locum, and as I became more comfortable with this, I realised how much I missed teaching. With years of medical teaching experience behind me, I applied for a teaching post. I also missed the company of fellow GPs, because locum life is isolating and it’s hard to stay in the loop. I have always had supportive appraisers and enjoyed the appraisal process, so I applied and trained to become an appraiser. I thoroughly enjoy both positions.

I tried hard to remain on my local medical committee, but because I was no longer in a permanent role, this wasn’t possible. I learnt early on that there is significant disparity when it comes to sessional representation. I gave up trying. However, along the way, I reconnected with my love for writing, and found myself in the fortunate position to be offered opportunities to work in TV and broadcasting. Never had I considered that this could be possible, but being able to give health advice to a larger audience felt incredible.

I’ve noticed, however, that GPs with diverse careers often face a backlash, again by a minority of GPs—but these people have a significant platform to hide behind. Media medics are especially misjudged. Their choice to work diversely is questioned, and their presumed agendas torn apart by those who know no better. Working in the media is hard work, with little to no financial incentive. So why do doctors do it? Well, many media doctors just really enjoy sharing evidence-based medicine with the public. Not everyone is financially driven or hungry for fame.

Currently, my working week looks like this. I work seven sessions as a locum GP between three practices. I do one appraisal session and one session of teaching. In and around this, I manage my family and my creative passions. Contrary to what some GP principals may think, none of this is easy, and it requires a lot of hard work. I clearly do my share. The downsides are that there is no annual leave entitlement, no sick pay, and as I look at my maternity year ahead, I have no maternity allowance. It is certainly less financially rewarding in comparison to the income of a GP partner, but I’m happy. I love my job, and that’s not what I hear many GP principals say. 

There is a sense of division among GPs. Some feel that they are working harder, staying later at work, earning less, or are less creative or diverse in their work than other GPs, or are more privileged because of their status of permanency within a practice. It’s an endless game of comparisons in which, sadly, sessional GPs are often dismissed as being less important and less valuable an asset to primary care. Surely, we are working towards the same thing? That is, seeing patients, providing them with the best clinical care, and working together to meet rising demands.

Recently, a flippant tweet from an esteemed professor proposed ‘restricting GP appraiser roles to only those GPs who have permanent salaried NHS GP posts or who are GP partners in NHS general practices’. I felt so angry and upset when I read this. It implied that locum GPs are less able and less qualified to do appraisals, when in actual fact sessional GPs are often the best-placed doctors to offer this service. As the trend changes, with more GPs favouring sessional life over permanent GP work, we have to appreciate and value the contributions of sessional GPs. Many locums are senior GPs; many have diverse skill sets, and without such doctors covering practices and holding them up, many more closures would be taking place. Dismissing them is not going to encourage them—only make them quit the vocation altogether, which we cannot afford.

Primary care is currently in crisis. We have a national shortage of GPs, and a recruitment and retention problem that is greater than ever. Attitudes, language, and values need to be reviewed, especially among senior GP principals. Encouraging and supporting one another, and knowing that we are all doing our best in the capacities we work in, is key. Sessional GPs are part of the primary care workforce, and shouldn’t be excluded or shot down.

I love my job: I am a happy GP, and I believe that I have lots of exciting years in practice to look forward to, a vision that I had almost lost. I just wish for a future where we all respect and merit each other’s contributions, and make equal space for one another to do the work that needs to be done.

Punam Krishan

Portfolio sessional GP