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DESPITE a boom in the number of general medicine trainees in the past 10 years, new recruits are missing out on hospital training positions because subspecialist trainees get priority, according to a leading medical specialist.
Associate Professor Ian Scott, a former president of the Internal Medicine Society of Australia and New Zealand, said the number of trainees doing general medicine advanced training had “exploded” from less than 50 in 2005 to around 500 this year — largely due to the Royal Australasian College of Physicians (RACP) promoting dual training, where trainee physicians learn general medicine in addition to another specialty.
However, Professor Scott told MJA InSight the trend of increasing subspecialisation meant hospitals were geared against providing training positions for generalists despite the increasing calls to boost the number of doctors with a broad skill set.
“The biggest challenge is there’s a limit on the number of advanced training positions we can offer people who want to do advanced training in general medicine”, said Professor Scott, who is director of the department of internal medicine and clinical epidemiology at Brisbane’s Princess Alexandra Hospital.
“If trainees want to rotate through other specialties as part of their general medicine training, that’s difficult because specialists quarantine those positions for their own trainees.”
He was commenting on a “Perspective” article published today in the MJA calling for governments to do more to usher young doctors into generalist specialties, including general medicine and psychiatry, as well as general practice. (1)
The authors wrote that the medical labour market in Australia was characterised by “20-year boom˗bust cycles”, which successive governments had failed to manage.
“Decisions to increase medical school places to meet increases in demand did not take into account expected costs or benefits to the health system of employing more doctors, and failed to consider more potentially cost-effective ways of improving population health, such as changes in skill mix”, they wrote.
The authors called for better information to be made available to young doctors about career options, saying the government should use financial incentives and penalties to “nudge the market in the desired direction”.
“Long periods of training and increasing subspecialism foster inflexibility such that, in times of shortage or surplus, doctors are unable to change specialties or unwilling to move to geographic areas of need”, they wrote.
Professor Scott said although the RACP had invited specialist societies to develop training modules for physicians wanting to practise general medicine, progress had been slow.
“The changes also need to happen at the hospital level [and] at the chairs of the divisions [level]. They have to try to persuade various specialty departments to open up training positions for generalists”, he said.
“Governments can also help by offering more fully funded scholarship positions for generalist training, so that specialties don’t have to cut into their own budgets or quotas in order to offer rotations to general medicine trainees.”
He called on hospital managers to compare clinical outcomes, length of stay and other measures of efficiency among similar groups of patients in different departments such as cardiology and general medicine wards, suggesting generalist services were the more cost-effective.
Professor Richard Murray, dean of medicine at James Cook University, Queensland, and a vocal advocate for generalism in medicine, told MJA InSight Australia had 85 recognised stand-alone medical specialties — a number topped only by the US, and twice as many as Denmark or the Netherlands. (2), (3)
“But it doesn’t make us any healthier as a nation … Excessive specialisation promotes fragmentation of care, drives up costs, and is not linked to health care outcomes”, he said.
“While [subspecialisation] might work in large hospitals, for regional and outer metropolitan hospitals it means parallel rosters for [different subspecialists], threatening the viability of those services and driving up costs.”
Professor Murray agreed the problem was compounded by the lack of any coherent system for allocating training positions. “It’s all down to the vagaries of individual hospital employment priorities, including [rostering considerations] and the relative power of particular medical craft groups with hospital management”, he said.
Professor Nicholas Talley, the RACP president, defended the college’s commitment to generalism, saying it was “the cornerstone of RACP training”.
“Three years of general basic training is required before trainees can progress to further advanced training; which could be in general medicine or another specialty such as cardiology”, he said.
Dr Stephen Parnis, vice-president of the AMA, also played down the turf war between specialties, saying the much greater problem was capacity in the system.
“We have a bottleneck for prevocational and general registrar training places”, Dr Parnis said.
The national agency previously charged with health workforce reform, Health Workforce Australia, was abolished by the federal government in this year’s Budget and its functions will be rolled over to the Department of Health.
The National Medical Training Advisory Network, a body that includes medical schools, medical colleges and state and territory governments, will identify opportunities to expand vocational training capacity and influence medical school intake. (4)
1. MJA 2014: 201: 82-83
2. American Board of Medical Specialties: Specialties & subspecialties
3. Medical Board of Australia: Medical specialties and specialty fields
4. HWA: National Medical Training Advisory Network
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Jack-why is our government bringing general physicians from overseas?
Is it because Australian physicians will not go to rural / remote areas? If not, why not?
In the broader rural area in which I practice, there are a few Australian general physicians, with an ongoing parade of OTD physicians who are recruited to areas of need, who then desert the sinking ship, jumping to greener coastal pastures, where it would seem that the government believes that there are too many of every kind of doctor, including sub-specialist physicians, prompting Tony Abbott to propose a co-payment in the hope that this will stem the tide of value-addded Medicare billing, which presumes that the hapless patient with a palpitation will baulk at a $7 co-payment for the ECG, then exercise ECG, then Echocardiogam, then stress Echocardiom, then myocardial perfusion study, then stress myocardial perfusion study,
The general physician has traditionally managed the palpitaing patient without the battery of Medicare items mandated by the sub-specialsit, and without expensived new medications trumpeted by drug companies.
Is there a cost-benefit analysis comparing general physicians with sub-specialsts managing patients?
Jack – you are in error. The racp doesn’t train candidates to the level of a general physician by the time of the exam. The exam is an entry point to training. Gen med is a specialty in its own right, just like cardiology etc. As a general physician I chose not to be a cardiologist despite being offered a training job. Where I am the cardiology trainees can’t get a consultant job, and can’t get a general job as they don’t have the skills. Your final comment about getting serious is completely right.
Good to hear you are “not dead yet”, Generalissimo. Please ”go forth and multiply”.
We are not dead yet! As discussed we are growing again, but not through careful nuture. Some strange tenacity stopped our extermination (just). We are cost effective and very suitable for both urban and regional centres. We can make good use of resources, including our subspecialty colleagues. With time and a little cooperation from our colleagues, we may flourish and patient care would be better for it. In these leaner economic times we make good sense. Patients like us and we can be good for them. Support a generalist today! Our trainees need subspecialty posts and they are often a welcome addition to the team.
General Medicine died in big urban areas when subspecialisation started to become a force, and Geriatricians took their place. In response to Sue Ieraci’s first comment, her elderly relative would have been best served by being admitted under the aged care team.
Where generalists are sorely needed is in rural and regional centres but they need to be adequately trained in aspects of subspecialisation so that they can provide that needed service.
This would include being adept at procedural medicine including upper GIT endoscopy, bronchoscopy, cardiac echo, etc.
If training in General Medicine allows these skills to be taught, all the better, however in the major urban areas there is no question that subspecialists are more efficient than generalists in managing a problem provided it is a single clinical issue that needs attention.
Gen Med Physician – Jack of all trades, master of fun. Almost all pure Gen Med Physicians in Australia are from overseas. Australian dual trainees do not train in Gen Med because they believe in Gen Med, but because they realise subspecialist practice is completely overcrowded and want some insurance to fall back on when needed. No Government or RACP efforts will change the situation as long as the Australian medical culture continues with the bigoted towards General Medicine. A basic trainee that completed the RACP exam is regarded as a fully trained Gen Med Physician. Gen Med advanced trainees are regarded as losers who did not manage to secure a subspecialist advanced training position. Subspecialists are seen as superior to Gen Med Physicians in professional status, strictly maintaining the archaic British social class system in Australian Medicine. Australia need to do away with the absurd basic training, mid-training RACP exam and then advanced training, which cements in place the inferior position of Gen Med. Subspecialist trainees should not be required to all do Gen Med training first. All training paths need their own entry and exit exams. Subspecialist and single disease practitioners can follow abbreviated courses and attract lower pay, together with nurse practitioners (who is rapidly expanding into subspecialist practise, because it is easy). Gen Med training need to be more intensive and more extensive, with increased remuneration that acknowledge the wide ranging expertise. If this issue need to advance, we as doctors (not the Gov) need to stop beating about the bush and expose the real issues that hamstrung development of Gen Med in Australia.
As a rural GP, the problem that I see is the increasing number of patients with multisystem chronic diseases like diabetes who need a general physician to sort out complex problems, not a subspecialist who can only deal with the endocrine system , kidney, heart, or nervous system, etc. The aging population would benefit from a geriatrician.
Despite this obvious need for the generalist physician, who is far more cost-effective than the four subspecialist physicians each seeing one patient, there is a serious shortage of general physicians and geriatricians in rural areas , and difficulty accessing outpatient appointments, with the resulting burden on public hospital admissions .
This is made worse by public hospitals cost-shifting by referring inpatients to private outpatient subspecialists who then demand a referral from the GP, when referral to a general physician at the public hospital outpatient clinic would be more appropriate and less costly follow-up.
I agree that general physician training should be completed prior to subspecialty training, to supply physicians to rural areas, where they are needed.
Perhaps there is a need for a cost-benefit analysis of management by patient of the common chronic disease patients by general physicians, and of diseases of aging by geriatricians, both in conjunction with the GP, compared with management of the one patient by several different subspecialists .
If common chronic diseases and diseases of aging were managed by generalists, this would make the subspecialist physicians more readily available for appointments for acute and uncommon conditions.
Being a generalist has been terrific(not!) for GPs despite the fact they see every type of undifferentiated malady that exists.Don’t be silly! Become a super specialist in a tiny area of medicine and have a happy life.
“The patients are generalising while the doctors are specialising”. “generally” – that is spot on! Phillip Carson also makes a good point: “generalist training may need to be longer more intensive and complete than the that of the sub specialist.” For prestige to develop, however, both academic kudos and appropriate renumeration for cognitive skill needs to be present.
Like so much else in our Australian community the end result will be determined by the finance available and market forces. Generalists must be come the order of the day with specific specialists arising where the demand lies most.
Training obligations and positions should be determined within the collective teaching hospital framework of that medical community and certainly not by any individual departmental head. If individuals cannot find the sub-speciality training position they seek locally, then travel abroad as many registrars did in the past.
The practice of medicine is not a solo endeavour but one where the common good should prevail. By all means be a fine generalist with a special interest. Similarly, there are few anaesthetists who concentrated exclusively on any specific surgical sub-speciality. However, botox injecting does appeal as one ages.
I was so much hoping to be the last ever “pure” general physician, but sadly my hopes have been dashed in recent years with some of my own trainees opting to follow suit. I have been interested in my work every single day since I commenced as a general physician and I can’t see that I will ever want to retire. I was offered and considered places in several subspecialty training programs but after I thought very carefully about all of them I decided that I didn’t really want to do just one “sliver” of medicine for the rest of my life.
Someone said recently “The patients are generalising while the doctors are specialising”.
I am ever grateful for the expertise which my subspecialty colleagues offer, and it is extremely useful to be able to say to difficult patients that what they really need is a good subspecialist, rather than me!
I too am an advocate for a strong broad scope medical workforce with much of the care being delivered by doctors practicing across the broad scope of their specialty, in cooperation with and with support from more narrowly focused sub specialists. The two are not mutually exclusive in the same person ie a doctor practicing across the broad scope of their specialty and requiring support from subspecialist for difficult cases may in turn have particular expertise that others will seek from time to time.
A major modern stumbling block is local accreditation and medico legal concerns. Without good will and eye on the big picture, sub specialists and their societies, credentialing committees and institutional managers can be afraid to embrace doctors practicing across a broad scope.
Bill,the trouble with tacking the sub specialty training on the end of a broad initial training ( which is the traditional model) is that it sends a signal that the specialty training is the ultimate and desirable end point and carries more prestige (‘back when I was a general…, now…’) If a doctor is only ever going to practice in a small specialty area it can be argued they need shorter and less training that those committed to practicing across a broad scope. Thus the generalist training may need to be longer more intensive and complete than the that of the sub specialist.
In my view, excessive sub-specialisation not only goes contrary to the needs of the community (an ageing society with complex multi-system disease) but it also contributes to excessive investigation and isolated decision-making – focussed on a narrow diagnosis rather than patient well-being. I have recently seen this in an elderly relative, where neither of two hospital sub-specialty units were able to make a diagnosis that was clear on history because they were overly focussed on the test results. This is a real problem in NSW, where general medicine is essentially non-existent in the big cities. It makes the attempt to admit patients from the ED both difficult and frustrating, as one is forced to seek a diagnosis-of-best-fit for the admitting team, not for the patient. Sub-specialisation also increases risk-aversion, where each sub-specialist feels the need for consults with all the other body-part or system specialists, even though the parts are all connnected.
To my mind sub-specialisation is putting the cart before the horse. The divide between basic and advanced training should be abolished. There should be high level entry criteria into specialty training (this should be both time-based and competency based). All specialist trainees should train in general medicine and be able to meet criteria for registration as a general physician BEFORE they can consider undertaking sub-specialisation. Succesful completion of general physician training should be time and competency based – assessed by multi-component EXIT examination. Then IF they wish they can “apply” to undertake sub-specialisation – which should again be assessed by exit examinations.
BUT as the status quo is unlikely to change substantially then the Colleges should look at the ‘criteria’ for determining where training can occur (both geographically and hospital infrastructure) – it seems to me many are quite archaic and do not reflect what is happening in terms of service provision; i.e where the patients are that need care. This may increase training place availability.
Ironically, in general surgery, as increasing subspecialisation has occurred the true generalist has become more valuable and sought after, especially once you leave metropolitan areas and go out to peripheral city hospitals, and of course in regional and country areas where these skills are vital. The RACS is well aware of the importance of training versatile general surgeons who can manage a wide range of surgical problems as well as the emergencies in other disciplines. We cannot all practice in central city areas where superspecialists are available: in all disciplines of medical practice good generalists are worth diamonds.
I predict that one day you’ll need a diploma to do the podiatry of the middle toe of the left foot.