HEALTH WORKFORCE CSIRO PUBLISHING
Australian Health Review, 2014, 38, 246–251 http://dx.doi.org/10.1071/AH13203
Perspective
Portfolio careers for medical graduates: implications for postgraduate training and workforce planning Harris A. Eyre1,2,3,8 MBBS (Hons), PhD Candidate Rob D. Mitchell2 MBBS (Hons), BMedSci (Hons), Registrar Will Milford4,5 MBBS (Hons), MRANZCOG, Chair Nitin Vaswani6 MBBS, BSc, Resident Medical Officer Steven Moylan7 BMBS (Hons), MPH, BSc, Clinical Lecturer 1
School of Medicine, University of Adelaide, Adelaide, SA 5005, Australia. The Townsville Hospital, Queensland Health, Townsville, Qld 4814, Australia. Email: [email protected] 3 School of Medicine and Dentistry, James Cook University, Townsville, Qld 4814, Australia. 4 Australian Medical Association Council of Doctors in Training, 42 Macquarie Street, Barton, ACT 2600, Australia. Email: [email protected] 5 Mater Health Services, Raymond Terrace, Brisbane, Qld 4101, Australia. 6 Joondalup Health Campus, Western Australia Health, Perth, WA 6027, Australia. Email: [email protected] 7 School of Medicine, Deakin University, Geelong, Vic. 3216, Australia. Email: [email protected] 8 Corresponding author. Email: [email protected] 2
Abstract. Portfolio careers in medicine can be defined as significant involvement in one or more portfolios of activity beyond a practitioner’s primary clinical role, either concurrently or in sequence. Portfolio occupations may include medical education, research, administration, legal medicine, the arts, engineering, business and consulting, leadership, politics and entrepreneurship. Despite significant interest among junior doctors, portfolios are poorly integrated with prevocational and speciality training programs in Australia. The present paper seeks to explore this issue. More formal systems for portfolio careers in Australia have the potential to increase job satisfaction, flexibility and retention, as well as diversify trainee skill sets. Although there are numerous benefits from involvement in portfolio careers, there are also risks to the trainee, employing health service and workforce modelling. Formalising pathways to portfolio careers relies on assessing stakeholder interest, enhancing flexibility in training programs, developing support programs, mentorship and coaching schemes and improving support structures in health services. What is known about the topic? Portfolio careers are well understood as a career structure in general business. However, in medicine little is known about the concept of portfolio careers, their drivers, benefits and risks. There are significant issues faced by the Australian junior medical workforce such as a need for diversified skill-sets (e.g. increased involvement in research, public health and leadership), low job satisfaction for junior doctors and an increasing emphasis of work-life balance and mental well-being. What does this paper add? This paper critically analyses the concept of portfolio careers in the postgraduate setting by critiquing literature on the international and national experiences in this field. This paper outlines potential benefits of portfolio careers requiring further research, such as a diversification in the workforce and improved job satisfaction. Risks include reducing the health service provision capacity of junior doctors and drawing doctors away from a medical career. What are the implications for practitioners? This paper has substantial educational and workforce implications for medical students, junior doctors and medical managers. For medical students and junior doctors this paper frames the possibilities in a medical career, as well as benefits and risks of aiming for a portfolio career in medicine. For medical managers, this paper suggests strategies for further research, enhancing workforce job satisfaction and potential pitfalls of increasing opportunities for medical portfolio careers. Received 22 October 2013, accepted 23 January 2014, published online 10 April 2014
Journal compilation Ó AHHA 2014
www.publish.csiro.au/journals/ahr
Portfolio careers for medical graduates
Introduction Clinical practice has never been the sole end-point of medical training. Although doctors have always engaged in non-clinical pursuits (e.g. medical education, public health practice, health service administration and research), a broader range of professional activities is now accessible to medical graduates. This has given rise to the concept of a ‘portfolio career’,1–4 a term used to capture the longitudinal engagement of trainees and fellows in diversified fields, such as journalism, the arts and business.5–8 Internationally, the term ‘portfolio’ has been applied to any professional pursuit outside a practitioner’s primary clinical role, either concurrently or in sequence.2 The emergence of this new terminology reflects an evolution in the depth and breadth of clinician involvement in non-clinical pursuits. Although the concept of ‘clinical support’ activities is well established in Australia and overseas,5 this term fails to encapsulate the diversified interests of some doctors. There is no clear distinction between what constitutes a portfolio as opposed to a clinical support activity, but the former generally implies a significant time commitment. Given that professional associations consider that clinical support time should consume up to 30% of a doctor’s professional load, a portfolio may be considered as any activity that extends beyond that threshold.5 Based on these broad definitions, there are a large number of professional activities potentially qualify as portfolios (see Box 1). The list includes traditional areas of clinician engagement (e.g. medical education and research) as well as more novel domains (e.g. health law and consulting). For the purposes of this article, a ‘portfolio career’ refers to any combination of clinical and non-clinical activities, provided that the latter constitute a significant proportion of the individual’s professional life. Although medicine has always had portfolio careerists, they are becoming more commonplace, particularly among younger generations of the profession. This has important implications for postgraduate medical education and healthcare systems in Box 1. Potential portfolios for medical practitioners *
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Research, both laboratory and clinical Medical education Public health, including global health, epidemiology, health promotion and health policy Administration Management and leadership Legal medicine General education Medical device development Pharmaceutical development Business and consulting Technology and informatics Journalism and media (Bio)Entrepreneurship Engineering Investment banking and financial services The arts and culture Military and defence Aero-space medicine Allied health Politics and Government
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Australia, particularly in terms of workforce supply. This article examines international trends in portfolio careers (including drivers behind their emergence), identifies the risks and benefits of trainee exposure to portfolios and makes recommendations for integrating portfolio activities with training pathways. International experience The concept of a portfolio career for medical graduates is well established internationally, particularly in the UK and US. In both these places, various initiatives have sought to support graduates to develop portfolios early in their training. In the UK, the British Medical Journal has recently published case studies of prominent portfolio careerists, as well as guidance for trainees pursuing other interests in concert with their clinical careers.2,6,7 Other initiatives, such as coaching schemes and practicums in health leadership, management and consultancy, have also been established.8–11 One such program is the National Health Service’s Prepare to Lead leadership development mentoring scheme, purposefully designed to run complementary to full-time clinical training.12 The Clinical Fellows Program from the Faculty of Medical Leadership and Management offers a program to learn skills in leadership, management and health policy.13 The program offers a 0.5–1-year course from postgraduate Year 2 onwards. Past programs have included work with the General Medical Council, BUPA, Health Education England and private health providers. A recent conference in London was specifically focused on alternative career development for doctors.14 Academic medicine and global health, another two traditional areas of clinician engagement, have been a recent focus for The Lancet,15,16 which has published career pathways for budding clinician–scientists,15 which compliment other established initiatives, including The Foundation Program’s Academic Training Pathway17 and the UK Academy of Medical Sciences’ Mentoring Scheme for clinical and non-clinical post-PhD trainees.18 In the US, several programs have been developed to facilitate portfolio careers. For example, the American College of Physician Executives (ACPE) supports a Mentoring Program for medical graduates interested in developing their leadership and management skills.19 In addition, ACPE coordinates the individually designed Physician Leadership Development Program, which is designed to run in parallel with relevant curricula of established medical and business schools.20 The US-based Society of Physician Entrepreneurs recently launched their Innovation Scholar Program aimed at offering doctors hands-on bio-entrepreneurship experience through practicums with biomedical companies.21 This program offers a 1-year apprenticeship-type model whereby the junior physician is linked to a biomedical company, a mentor, a university curriculum and a project. The Robert Wood Johnson Foundation Health and Society Scholarship program is offered to individuals from a diverse range of health-related backgrounds.22 This program provides focused training in the skills necessary for effective leadership, program implementation and policy change. The program is offered to post-PhD individuals and involves an intensive 2-year program of seminars, scholar-directed research and analysis conducted with guidance or collaboration with distinguished faculty mentors. Consulting firms, including
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McKinsey & Co., Boston Consulting Group and Bain & Co., have well-established training programs for doctors as business analysts. This also holds true for the major investment banks, which aim to recruit junior employees from a wide variety of backgrounds, including medicine. Many universities in the US have been offering dual MD/MBA, MD/JD and MD/MPH degrees for over a decade. Drivers Despite the focused nature of clinical training, medical graduates develop a broad, metacognitive skill set that is attractive to other industries. This includes leadership of multidisciplinary teams, the ability to train and teach, understanding of complex systems, capacity to work under pressure, the ability to provide rapid assessments, appreciation of sociocultural impacts on human behaviour and multitasking with appropriate prioritisation.23,24 This skills base is an important pull factor in the recruitment of doctors to industries other than health. In keeping with generational trends, greater demand from trainees for flexibility, autonomy and diversity in work arrangements is also driving change.25–27 Most colleges now have provisions for flexible and part-time training, and there is greater acceptance of these models of employment within health services.27–33 Uptake of these opportunities is reflected in decreasing clinical workforce participation among younger doctors.34 Decreasing satisfaction of medical practitioners with clinical practice may also be encouraging the development of portfolio careers. In the US, a 2012 survey of 24 216 doctors found that only 54% would choose medicine again as a career, compared with 69% in earlier studies.35 Comparative figures are higher for Australian graduates,36 although some studies have suggested that trainees experience higher rates of dissatisfaction than senior doctors.36 Increasing litigation and the perceived reduction of prestige and public respect associated with clinical medicine may also encourage doctors to expand non-clinical interests.25,26 Role modelling is another important factor, and the involvement of senior doctors in portfolio careers may have spawned increased interest among recent graduates. Although the extent of senior clinician involvement in portfolio activities is unknown, there are several possible reasons why portfolio careers more commonly develop post-fellowship, including greater professional flexibility due to completion of college speciality training, higher remuneration for clinical work allowing engagement with lower-paying portfolio occupations (e.g. research) and increased peer acceptance. Clinical support activities have long been used as a mechanism to minimise burnout and enhance workforce retention.5,37 Australian experience There has been limited discussion in Australia regarding the role of portfolio development during postgraduate training, and the uptake of portfolios among trainees is unknown. There are, however, a variety of initiatives targeting non-clinical pursuits, including structured training programs, grants schemes, global health placement opportunities and public health courses. Several Australasian colleges provide speciality training pathways towards non-clinical practice. These include the Royal
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Australasian College of Medical Administration (RACMA),38 the Australasian Faculty of Public Health Medicine (AFPHM)39 and General Practice Education and Training (GPET).40 The RACMA pathway enables trainee participation in concurrent clinical roles and placements with public and private health systems, as well as with other areas, such as public health departments, legal medicine, academic medicine, clinical informatics and management and consultancy.38 Both RACMA and the Royal Australasian College of Surgeons have recognised the shared responsibility for health management and leadership between surgeons and administrators.41 The Australasian College of Health Services Management offers a structured mentoring program to foster clinical leadership among health professionals.42 In addition, all Australasian specialist medical colleges have adopted CanMEDS43 Physician Competency Framework, recognising the value in non-clinical skills. The CanMEDs framework is based on seven roles and competences including Medical Expert (core role), Communicator, Collaborator, Manager, Health Advocate, Scholar and Professional.43 An increased focus on these skills may encourage future portfolio careers. The development of academic portfolios has been a subject of recent attention.44–46 This reflects a recognition of the increasing requirement for medical practitioners to add research to their clinical duties, a fact highlighted in the recent McKeon Review of Health and Medical Research.45 Interest in an academic portfolio is high among trainees,44 with up to 40% of Australian medical students expressing some level of interest in including research in their careers.47 Unfortunately, interest wanes as junior doctors progress in their training, which has prompted calls for strategies to enhance the attractiveness of research.48 Several universities now offer dual MBBS/PhD degrees with the aim of strengthening clinical academic training, and GPET has established 12-month academic posts for general practice registrars.49 Strategies to enhance clinical academic pathways for trainees are important given the aging of the existing clinical academic workforce.45 Initiatives focused on leadership in safety and quality have arisen in Western Australia50 and Victoria.51 The Medical Service Improvement Program50 offered by hospitals within Western Australia Health involves approximately 3 months work on a specific quality improvement project. Junior doctors are offered supervision and mentorship throughout, as well as lectures and visits to non-health industry locations. Benefits Trainees, employing health services, the Australian community and institutions offering non-traditional occupations all stand to benefit from greater uptake of portfolio careers, but the specific advantages depend upon the professional context. Generic benefits are listed in Table 1. Benefits for the trainee may include enhanced job satisfaction resulting from a more appropriate work–life balance, greater career autonomy and flexibility. In addition, trainees with a broader skill set may have an expedited path to leadership positions within the healthcare sector. Advantages to health systems are multiple and may include enhanced job performance of trainees. Health services are
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also more likely to attract and retain a high-quality workforce with portfolio-friendly positions. In addition, evidence suggests greater engagement of clinicians in medical leadership roles may assist in improving the performance of hospital units.8 Involvement in medical leadership is necessary given the increasingly complex environment in which 21st century health care is delivered.8 Risks Although the development of portfolios early in a trainee’s career can be of immense benefit to the individual and their community, there are risks associated with their broader uptake. These drawbacks need to be carefully considered and managed, with potential for fatigue, distraction from clinical medicine or impedance of clinical performance, and workforce shortages. Generic risks for the trainee, the employing health service, the Australian community or the institution offering the non-clinical occupation are summarised in Table 2.3,52 Time away from clinical positions may lead to prolonged training and a loss of interest in clinical roles. Although some studies suggest time-limiting clinical exposure can compromise
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learning, other programs have found no difference in training quality between those participating full-time and part-time.7,53 Portfolios may draw medical practitioners out of clinical practice, exacerbating existing workforce shortages and impacting on Australia’s pursuit of self-sufficiency in its health workforce. For the employing health service, there are increased complexities of rostering and job-sharing as the demand for flexible work arrangements increases. The latter has been an impediment in establishing these arrangements to date.29,31 These risks can be mitigated through appropriate workforce planning, at both macro and micro levels. From a macro perspective, Australia-wide workforce research is required to examine existing clinical support time and portfolio career involvement, as well as future interest. Inclusion of these research data into workforce projection models is then necessary to predict the impact on matching future workforce growth to community demand. From a micro perspective, clear, flexible and individualised agreements need to be reached between the health service, the portfolio employer(s) and the medical graduate. Local health services could provide data on how many doctors are currently engaged in portfolio careers. Issues such as risk of fatigue also need to be considered.
Table 1. Potential benefits of enhanced portfolio career opportunities Stakeholder
Benefit
Examples
Trainee
Personal development
Improved work–life balance; improved ability to parent or act as carer Greater job satisfaction due to flexibility and autonomy; new challenges; diversified skill-set; expedited path to leadership positions Diversified and up-skilled workforce; greater workforce satisfaction; reduced unhappiness and exhaustion Partnering with other public and private organisations Enhanced workforce retention Improved doctor job satisfaction and work performance; enhanced social accountability of medical practitioners Benefits of medical skills and knowledge
Professional development
Employing health service
Enhanced clinical practice
Australian community
Mutually beneficial partnerships Recruitment and retention Improved standards of health care
Institutions offering nontraditional occupations
Enhanced workforce
Table 2. Potential risks of enhanced portfolio career opportunities Stakeholder
Risk
Examples
Trainee
Suboptimal training Physical and mental health
Loss of supervision or educational support Over-commitment; exhaustion; ill-suited career path for poor communicators; limited support networks and pastoral care Loss of income and entitlements; unpredictable income Criticism from peers and seniors; loss of interest in clinical role; prolonged training Part-time work of medical staff; potential loss of staff entirely due to loss of interest in clinical role Loss of training costs if training partnership fails Complexities of rostering and agreeing on job-sharing Time off clinical roles causing less clinical capacity for workforce as a whole
Financial stress Professional issues Employing health service
Workforce, recruitment and retention
Australian community
Financial loss Complex job-sharing arrangements Reduced supply of clinicians
Institutions offering nontraditional occupations
Continued dependence on overseas-trained doctors Complex job-sharing arrangements
Complexities of rostering and agreeing on job-sharing
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Recommendations
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Both push and pull factors mean increased numbers of medical graduates are likely to adopt portfolio careers, with important implications for postgraduate training and workforce planning. It is important that training pathways and employment arrangements evolve to accommodate this trend. Necessary steps include:
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assessing interest, whereby data must be obtained to determine the interest of various stakeholders enhanced flexibility of training pathways, whereby ongoing discussions between trainees, speciality training providers and accreditation bodies, health service providers and institutions offering non-traditional occupations are critical. General principles for increased flexibility may include opportunities for breaks in training and allocation of protected time for portfolio occupations, which may be counted towards college training requirements developing structured education programs, mentorship and coaching, with these structures requiring further development to ensure support for interested trainees. Pre-existing models of structured educational programs include the aforementioned Medical Service Improvement Program,50 the Academic Foundation Program,17 the Innovation Scholar Program21 and the Robert Wood Johnson Foundation Health and Society Scholarship Program.22 Potential models for portfolio career engagement will need to be funded on a case-by-case basis, and may involve funding by external sources, health services and possibly by the individual developing support structures in health services, whereby appropriate administrative support must be developed to provide general support, to facilitate rostering and to minimise financial stress.
Increasing numbers of graduates, as well as the demand from graduates for flexibility, diversity and autonomy, mean that the popularity and range of portfolio careers is likely to grow. This is likely to benefit medical graduates, health services and the community alike; however, careful thought and planning are required to mitigate potential risks.
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Competing interests The authors report no competing interests.
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Acknowledgements The authors thank Professor Ajay Rane, Associate Professor Andrew Johnson, Professor Tarun Sen Gupta, Dr Seth Delpachitra and Dr Jolyon Ford for their contributions to this project.
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26 Joyce C. The medical workforce in 2025: what’s in the numbers? MJA Open 2012; 1(Suppl. 3): 6–9. 27 Mahady SE. Adding flexibility to physician training. Med J Aust 2011; 194: 460–2. 28 McDonald RE, Jeeves AE, Vasey CE, Wright DM, O’Grady G. Supply and demand mismatch for flexible (part-time) surgical training in Australasia. Med J Aust 2013; 198: 423–5. doi:10.5694/mja12.11685 29 Henry A, Clements S, Kingston A, Abbott J. In search of work/life balance: trainee perspectives on part-time obstetrics and gynaecology specialist training. BMC Res Notes 2012; 5: 19. doi:10.1186/1756-05005-19 30 Carling PC, Hayward K, Coakley EH, Wolf AM. Part-time residency training in internal medicine: analysis of a ten-year experience. Acad Med 1999; 74: 282–4. doi:10.1097/00001888-199903000-00020 31 Kamei RK, Chen HC, Loeser H. Residency is not a race: our ten-year experience with a flexible schedule residency training option. Acad Med 2004; 79: 447–52. doi:10.1097/00001888-200405000-00015 32 Markwell AL, Wainer Z. The health and wellbeing of junior doctors: insights from a national survey. Med J Aust 2009; 191: 441–4. 33 Shrestha D, Joyce CM. Aspects of work-life balance of Australian general practitioners: determinants and possible consequences. Aust J Prim Health 2011; 17: 40–7. doi:10.1071/PY10056 34 Australian Institute of Health and Welfare (AIHW). Medical labour force 2009. Canberra: AIHW; 2011. 35 Kane L. Medscape physician compensation report: 2012 results. 2012. Available at http://www.medscape.com/features/slideshow/compensation/2012/public [verified 6 February 2013]. 36 Joyce CM, Schurer S, Scott A, Humphreys J, Kalb G. Australian doctors’ satisfaction with their work: results from the MABEL longitudinal survey of doctors. Med J Aust 2011; 194: 30–3. 37 Chambers R, Mohana K, Thornett A, Field S. Guiding doctors in managing their careers: a toolkit for tutors, trainers, mentors and appraisers. Abingdon: Radcliffe Publishing; 2006. 38 The Royal Australasian College of Medical Administrators (RACMA). Home page. 2013. Available at http://www.racma.edu.au/ [verified 22 December 2013]. 39 Royal Australasian College of Physicians. Australasian faculty of public health medicine. 2013. Available at http://www.racp.edu.au/page/racpfaculties/australasian-faculty-of-public-health-medicine/ [verified 22 December 2013]. 40 Australian Government. General practice education and training limited. 2013. Available at http://www.gpet.com.au/ [verified 22 December 2013]. 41 The Royal Australasian College of Medical Administrators (RACMA). Surgeons and administrators working together to bridge the divide. 2013. Available at http://www.racma.edu.au/index.php?option=com_ content&view=article&id=447:racma-racs-workshop&catid=93: workshops&Itemid=108 [verified 22 December 2013].
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www.publish.csiro.au/journals/ahr
Australian Health Review, 2014, 38, 246–251 http://dx.doi.org/10.1071/AH13203
Perspective
Portfolio careers for medical graduates: implications for postgraduate training and workforce planning Harris A. Eyre1,2,3,8 MBBS (Hons), PhD Candidate Rob D. Mitchell2 MBBS (Hons), BMedSci (Hons), Registrar Will Milford4,5 MBBS (Hons), MRANZCOG, Chair Nitin Vaswani6 MBBS, BSc, Resident Medical Officer Steven Moylan7 BMBS (Hons), MPH, BSc, Clinical Lecturer 1
School of Medicine, University of Adelaide, Adelaide, SA 5005, Australia. The Townsville Hospital, Queensland Health, Townsville, Qld 4814, Australia. Email: [email protected] 3 School of Medicine and Dentistry, James Cook University, Townsville, Qld 4814, Australia. 4 Australian Medical Association Council of Doctors in Training, 42 Macquarie Street, Barton, ACT 2600, Australia. Email: [email protected] 5 Mater Health Services, Raymond Terrace, Brisbane, Qld 4101, Australia. 6 Joondalup Health Campus, Western Australia Health, Perth, WA 6027, Australia. Email: [email protected] 7 School of Medicine, Deakin University, Geelong, Vic. 3216, Australia. Email: [email protected] 8 Corresponding author. Email: [email protected] 2
Abstract. Portfolio careers in medicine can be defined as significant involvement in one or more portfolios of activity beyond a practitioner’s primary clinical role, either concurrently or in sequence. Portfolio occupations may include medical education, research, administration, legal medicine, the arts, engineering, business and consulting, leadership, politics and entrepreneurship. Despite significant interest among junior doctors, portfolios are poorly integrated with prevocational and speciality training programs in Australia. The present paper seeks to explore this issue. More formal systems for portfolio careers in Australia have the potential to increase job satisfaction, flexibility and retention, as well as diversify trainee skill sets. Although there are numerous benefits from involvement in portfolio careers, there are also risks to the trainee, employing health service and workforce modelling. Formalising pathways to portfolio careers relies on assessing stakeholder interest, enhancing flexibility in training programs, developing support programs, mentorship and coaching schemes and improving support structures in health services. What is known about the topic? Portfolio careers are well understood as a career structure in general business. However, in medicine little is known about the concept of portfolio careers, their drivers, benefits and risks. There are significant issues faced by the Australian junior medical workforce such as a need for diversified skill-sets (e.g. increased involvement in research, public health and leadership), low job satisfaction for junior doctors and an increasing emphasis of work-life balance and mental well-being. What does this paper add? This paper critically analyses the concept of portfolio careers in the postgraduate setting by critiquing literature on the international and national experiences in this field. This paper outlines potential benefits of portfolio careers requiring further research, such as a diversification in the workforce and improved job satisfaction. Risks include reducing the health service provision capacity of junior doctors and drawing doctors away from a medical career. What are the implications for practitioners? This paper has substantial educational and workforce implications for medical students, junior doctors and medical managers. For medical students and junior doctors this paper frames the possibilities in a medical career, as well as benefits and risks of aiming for a portfolio career in medicine. For medical managers, this paper suggests strategies for further research, enhancing workforce job satisfaction and potential pitfalls of increasing opportunities for medical portfolio careers. Received 22 October 2013, accepted 23 January 2014, published online 10 April 2014
Journal compilation Ó AHHA 2014
www.publish.csiro.au/journals/ahr
Portfolio careers for medical graduates
Introduction Clinical practice has never been the sole end-point of medical training. Although doctors have always engaged in non-clinical pursuits (e.g. medical education, public health practice, health service administration and research), a broader range of professional activities is now accessible to medical graduates. This has given rise to the concept of a ‘portfolio career’,1–4 a term used to capture the longitudinal engagement of trainees and fellows in diversified fields, such as journalism, the arts and business.5–8 Internationally, the term ‘portfolio’ has been applied to any professional pursuit outside a practitioner’s primary clinical role, either concurrently or in sequence.2 The emergence of this new terminology reflects an evolution in the depth and breadth of clinician involvement in non-clinical pursuits. Although the concept of ‘clinical support’ activities is well established in Australia and overseas,5 this term fails to encapsulate the diversified interests of some doctors. There is no clear distinction between what constitutes a portfolio as opposed to a clinical support activity, but the former generally implies a significant time commitment. Given that professional associations consider that clinical support time should consume up to 30% of a doctor’s professional load, a portfolio may be considered as any activity that extends beyond that threshold.5 Based on these broad definitions, there are a large number of professional activities potentially qualify as portfolios (see Box 1). The list includes traditional areas of clinician engagement (e.g. medical education and research) as well as more novel domains (e.g. health law and consulting). For the purposes of this article, a ‘portfolio career’ refers to any combination of clinical and non-clinical activities, provided that the latter constitute a significant proportion of the individual’s professional life. Although medicine has always had portfolio careerists, they are becoming more commonplace, particularly among younger generations of the profession. This has important implications for postgraduate medical education and healthcare systems in Box 1. Potential portfolios for medical practitioners *
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Research, both laboratory and clinical Medical education Public health, including global health, epidemiology, health promotion and health policy Administration Management and leadership Legal medicine General education Medical device development Pharmaceutical development Business and consulting Technology and informatics Journalism and media (Bio)Entrepreneurship Engineering Investment banking and financial services The arts and culture Military and defence Aero-space medicine Allied health Politics and Government
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Australia, particularly in terms of workforce supply. This article examines international trends in portfolio careers (including drivers behind their emergence), identifies the risks and benefits of trainee exposure to portfolios and makes recommendations for integrating portfolio activities with training pathways. International experience The concept of a portfolio career for medical graduates is well established internationally, particularly in the UK and US. In both these places, various initiatives have sought to support graduates to develop portfolios early in their training. In the UK, the British Medical Journal has recently published case studies of prominent portfolio careerists, as well as guidance for trainees pursuing other interests in concert with their clinical careers.2,6,7 Other initiatives, such as coaching schemes and practicums in health leadership, management and consultancy, have also been established.8–11 One such program is the National Health Service’s Prepare to Lead leadership development mentoring scheme, purposefully designed to run complementary to full-time clinical training.12 The Clinical Fellows Program from the Faculty of Medical Leadership and Management offers a program to learn skills in leadership, management and health policy.13 The program offers a 0.5–1-year course from postgraduate Year 2 onwards. Past programs have included work with the General Medical Council, BUPA, Health Education England and private health providers. A recent conference in London was specifically focused on alternative career development for doctors.14 Academic medicine and global health, another two traditional areas of clinician engagement, have been a recent focus for The Lancet,15,16 which has published career pathways for budding clinician–scientists,15 which compliment other established initiatives, including The Foundation Program’s Academic Training Pathway17 and the UK Academy of Medical Sciences’ Mentoring Scheme for clinical and non-clinical post-PhD trainees.18 In the US, several programs have been developed to facilitate portfolio careers. For example, the American College of Physician Executives (ACPE) supports a Mentoring Program for medical graduates interested in developing their leadership and management skills.19 In addition, ACPE coordinates the individually designed Physician Leadership Development Program, which is designed to run in parallel with relevant curricula of established medical and business schools.20 The US-based Society of Physician Entrepreneurs recently launched their Innovation Scholar Program aimed at offering doctors hands-on bio-entrepreneurship experience through practicums with biomedical companies.21 This program offers a 1-year apprenticeship-type model whereby the junior physician is linked to a biomedical company, a mentor, a university curriculum and a project. The Robert Wood Johnson Foundation Health and Society Scholarship program is offered to individuals from a diverse range of health-related backgrounds.22 This program provides focused training in the skills necessary for effective leadership, program implementation and policy change. The program is offered to post-PhD individuals and involves an intensive 2-year program of seminars, scholar-directed research and analysis conducted with guidance or collaboration with distinguished faculty mentors. Consulting firms, including
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McKinsey & Co., Boston Consulting Group and Bain & Co., have well-established training programs for doctors as business analysts. This also holds true for the major investment banks, which aim to recruit junior employees from a wide variety of backgrounds, including medicine. Many universities in the US have been offering dual MD/MBA, MD/JD and MD/MPH degrees for over a decade. Drivers Despite the focused nature of clinical training, medical graduates develop a broad, metacognitive skill set that is attractive to other industries. This includes leadership of multidisciplinary teams, the ability to train and teach, understanding of complex systems, capacity to work under pressure, the ability to provide rapid assessments, appreciation of sociocultural impacts on human behaviour and multitasking with appropriate prioritisation.23,24 This skills base is an important pull factor in the recruitment of doctors to industries other than health. In keeping with generational trends, greater demand from trainees for flexibility, autonomy and diversity in work arrangements is also driving change.25–27 Most colleges now have provisions for flexible and part-time training, and there is greater acceptance of these models of employment within health services.27–33 Uptake of these opportunities is reflected in decreasing clinical workforce participation among younger doctors.34 Decreasing satisfaction of medical practitioners with clinical practice may also be encouraging the development of portfolio careers. In the US, a 2012 survey of 24 216 doctors found that only 54% would choose medicine again as a career, compared with 69% in earlier studies.35 Comparative figures are higher for Australian graduates,36 although some studies have suggested that trainees experience higher rates of dissatisfaction than senior doctors.36 Increasing litigation and the perceived reduction of prestige and public respect associated with clinical medicine may also encourage doctors to expand non-clinical interests.25,26 Role modelling is another important factor, and the involvement of senior doctors in portfolio careers may have spawned increased interest among recent graduates. Although the extent of senior clinician involvement in portfolio activities is unknown, there are several possible reasons why portfolio careers more commonly develop post-fellowship, including greater professional flexibility due to completion of college speciality training, higher remuneration for clinical work allowing engagement with lower-paying portfolio occupations (e.g. research) and increased peer acceptance. Clinical support activities have long been used as a mechanism to minimise burnout and enhance workforce retention.5,37 Australian experience There has been limited discussion in Australia regarding the role of portfolio development during postgraduate training, and the uptake of portfolios among trainees is unknown. There are, however, a variety of initiatives targeting non-clinical pursuits, including structured training programs, grants schemes, global health placement opportunities and public health courses. Several Australasian colleges provide speciality training pathways towards non-clinical practice. These include the Royal
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Australasian College of Medical Administration (RACMA),38 the Australasian Faculty of Public Health Medicine (AFPHM)39 and General Practice Education and Training (GPET).40 The RACMA pathway enables trainee participation in concurrent clinical roles and placements with public and private health systems, as well as with other areas, such as public health departments, legal medicine, academic medicine, clinical informatics and management and consultancy.38 Both RACMA and the Royal Australasian College of Surgeons have recognised the shared responsibility for health management and leadership between surgeons and administrators.41 The Australasian College of Health Services Management offers a structured mentoring program to foster clinical leadership among health professionals.42 In addition, all Australasian specialist medical colleges have adopted CanMEDS43 Physician Competency Framework, recognising the value in non-clinical skills. The CanMEDs framework is based on seven roles and competences including Medical Expert (core role), Communicator, Collaborator, Manager, Health Advocate, Scholar and Professional.43 An increased focus on these skills may encourage future portfolio careers. The development of academic portfolios has been a subject of recent attention.44–46 This reflects a recognition of the increasing requirement for medical practitioners to add research to their clinical duties, a fact highlighted in the recent McKeon Review of Health and Medical Research.45 Interest in an academic portfolio is high among trainees,44 with up to 40% of Australian medical students expressing some level of interest in including research in their careers.47 Unfortunately, interest wanes as junior doctors progress in their training, which has prompted calls for strategies to enhance the attractiveness of research.48 Several universities now offer dual MBBS/PhD degrees with the aim of strengthening clinical academic training, and GPET has established 12-month academic posts for general practice registrars.49 Strategies to enhance clinical academic pathways for trainees are important given the aging of the existing clinical academic workforce.45 Initiatives focused on leadership in safety and quality have arisen in Western Australia50 and Victoria.51 The Medical Service Improvement Program50 offered by hospitals within Western Australia Health involves approximately 3 months work on a specific quality improvement project. Junior doctors are offered supervision and mentorship throughout, as well as lectures and visits to non-health industry locations. Benefits Trainees, employing health services, the Australian community and institutions offering non-traditional occupations all stand to benefit from greater uptake of portfolio careers, but the specific advantages depend upon the professional context. Generic benefits are listed in Table 1. Benefits for the trainee may include enhanced job satisfaction resulting from a more appropriate work–life balance, greater career autonomy and flexibility. In addition, trainees with a broader skill set may have an expedited path to leadership positions within the healthcare sector. Advantages to health systems are multiple and may include enhanced job performance of trainees. Health services are
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also more likely to attract and retain a high-quality workforce with portfolio-friendly positions. In addition, evidence suggests greater engagement of clinicians in medical leadership roles may assist in improving the performance of hospital units.8 Involvement in medical leadership is necessary given the increasingly complex environment in which 21st century health care is delivered.8 Risks Although the development of portfolios early in a trainee’s career can be of immense benefit to the individual and their community, there are risks associated with their broader uptake. These drawbacks need to be carefully considered and managed, with potential for fatigue, distraction from clinical medicine or impedance of clinical performance, and workforce shortages. Generic risks for the trainee, the employing health service, the Australian community or the institution offering the non-clinical occupation are summarised in Table 2.3,52 Time away from clinical positions may lead to prolonged training and a loss of interest in clinical roles. Although some studies suggest time-limiting clinical exposure can compromise
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learning, other programs have found no difference in training quality between those participating full-time and part-time.7,53 Portfolios may draw medical practitioners out of clinical practice, exacerbating existing workforce shortages and impacting on Australia’s pursuit of self-sufficiency in its health workforce. For the employing health service, there are increased complexities of rostering and job-sharing as the demand for flexible work arrangements increases. The latter has been an impediment in establishing these arrangements to date.29,31 These risks can be mitigated through appropriate workforce planning, at both macro and micro levels. From a macro perspective, Australia-wide workforce research is required to examine existing clinical support time and portfolio career involvement, as well as future interest. Inclusion of these research data into workforce projection models is then necessary to predict the impact on matching future workforce growth to community demand. From a micro perspective, clear, flexible and individualised agreements need to be reached between the health service, the portfolio employer(s) and the medical graduate. Local health services could provide data on how many doctors are currently engaged in portfolio careers. Issues such as risk of fatigue also need to be considered.
Table 1. Potential benefits of enhanced portfolio career opportunities Stakeholder
Benefit
Examples
Trainee
Personal development
Improved work–life balance; improved ability to parent or act as carer Greater job satisfaction due to flexibility and autonomy; new challenges; diversified skill-set; expedited path to leadership positions Diversified and up-skilled workforce; greater workforce satisfaction; reduced unhappiness and exhaustion Partnering with other public and private organisations Enhanced workforce retention Improved doctor job satisfaction and work performance; enhanced social accountability of medical practitioners Benefits of medical skills and knowledge
Professional development
Employing health service
Enhanced clinical practice
Australian community
Mutually beneficial partnerships Recruitment and retention Improved standards of health care
Institutions offering nontraditional occupations
Enhanced workforce
Table 2. Potential risks of enhanced portfolio career opportunities Stakeholder
Risk
Examples
Trainee
Suboptimal training Physical and mental health
Loss of supervision or educational support Over-commitment; exhaustion; ill-suited career path for poor communicators; limited support networks and pastoral care Loss of income and entitlements; unpredictable income Criticism from peers and seniors; loss of interest in clinical role; prolonged training Part-time work of medical staff; potential loss of staff entirely due to loss of interest in clinical role Loss of training costs if training partnership fails Complexities of rostering and agreeing on job-sharing Time off clinical roles causing less clinical capacity for workforce as a whole
Financial stress Professional issues Employing health service
Workforce, recruitment and retention
Australian community
Financial loss Complex job-sharing arrangements Reduced supply of clinicians
Institutions offering nontraditional occupations
Continued dependence on overseas-trained doctors Complex job-sharing arrangements
Complexities of rostering and agreeing on job-sharing
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Recommendations
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Both push and pull factors mean increased numbers of medical graduates are likely to adopt portfolio careers, with important implications for postgraduate training and workforce planning. It is important that training pathways and employment arrangements evolve to accommodate this trend. Necessary steps include:
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assessing interest, whereby data must be obtained to determine the interest of various stakeholders enhanced flexibility of training pathways, whereby ongoing discussions between trainees, speciality training providers and accreditation bodies, health service providers and institutions offering non-traditional occupations are critical. General principles for increased flexibility may include opportunities for breaks in training and allocation of protected time for portfolio occupations, which may be counted towards college training requirements developing structured education programs, mentorship and coaching, with these structures requiring further development to ensure support for interested trainees. Pre-existing models of structured educational programs include the aforementioned Medical Service Improvement Program,50 the Academic Foundation Program,17 the Innovation Scholar Program21 and the Robert Wood Johnson Foundation Health and Society Scholarship Program.22 Potential models for portfolio career engagement will need to be funded on a case-by-case basis, and may involve funding by external sources, health services and possibly by the individual developing support structures in health services, whereby appropriate administrative support must be developed to provide general support, to facilitate rostering and to minimise financial stress.
Increasing numbers of graduates, as well as the demand from graduates for flexibility, diversity and autonomy, mean that the popularity and range of portfolio careers is likely to grow. This is likely to benefit medical graduates, health services and the community alike; however, careful thought and planning are required to mitigate potential risks.
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Competing interests The authors report no competing interests.
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Acknowledgements The authors thank Professor Ajay Rane, Associate Professor Andrew Johnson, Professor Tarun Sen Gupta, Dr Seth Delpachitra and Dr Jolyon Ford for their contributions to this project.
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