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EXPERTS are calling for a rethink of general practice vocational training, questioning the educational value of time spent in a hospital environment that was now “poles apart” from the general practice experience.
Writing in the MJA, Associate Professor Susan Wearne, a GP and academic at the Australian National University, and coauthors said that in the years since the beginning of formal general practice training in 1973, there had been significant changes in general practice and hospital medicine, but the requirement for hospital experience before commencing GP training had remained.
“Given the bottleneck in hospital junior doctor training positions, and junior doctors’ concerns that their stressful, demanding workloads are of questionable educational value, it is timely to reconsider the effectiveness of this preparation for general practice,” they wrote.
Dr Bastian Seidel, president of the Royal Australian College of GPs (RACGP), said that the college had been calling for a rethink on GP training for some time, and the impending transfer of training responsibility back to the RACGP and the Australian College of Rural and Remote Medicine from 2019 provided an ideal opportunity to consider these issues.
“There is certainly an appetite here to rethink how we can improve general practice training for it to meet the needs for our future GPs,” he said.
“Realistically, the general practice environment is a very different environment compared to the hospital environment. How can the training that you get in a high-tech, tertiary care environment, which is full of safety nets, be transferred into a low-tech general practice environment? There are some learnings for doctors in the hospital environment initially, but we really need to look at how relevant it is in the scheme of things.”
In an MJA InSight podcast, Professor Wearne said that the hospital and general practice environments were now “poles apart”.
She said that shorter hospital stays, greater reliance on high technology, and increasing involvement of specialists in clinical decision making in hospital practice had had an educational consequence for junior doctors.
“It’s not that hospitals are failing juniors … but are there things that hospitals and juniors who work there could be thinking about differently to ensure that they do feel well prepared to come into general practice?”
The authors offered a range of suggestions to better tailor the current system to GP registrars’ needs, including raising awareness of clinical knowledge needed by GPs, direct observation of GPs and of hospital staff, and involvement in relevant outpatient clinics.
They said that increased exposure to general practice during training was needed, noting that the new Commonwealth Rural Junior Doctor Training Innovation Fund (RJDTIF) should enable more exposure to general practice in the early postgraduate years.
The authors further pointed to GP training in Canada and the Netherlands, where registrars were based in the community and worked in hospitals for “specific terms with defined learning outcomes”.
They acknowledged the major structural change that would be required to implement such a system in Australia, but said that it may prove more “efficient and effective” than the current approach.
Dr Seidel said that the MJA article provided a good starting point, but the conversation needed to be broader. The RACGP’s 2018–19 pre-budget submission highlighted the potential role for general practice in taking on more interns.
“We are hearing increasingly that interns are missing out on hospital placements, in particular in smaller states,” Dr Seidel told MJA InSight.
“There is no reason why interns can’t be placed in general practice. It would be great exposure early on … that would help them to become confident and capable GPs in the future. And even if [interns] later want to become a cardiologist or a neurosurgeon, the exposure they have to general practice is going to help them understand the complexity we are dealing with on a daily basis. So, it’s going to make them better doctors.”
It was also important to improve the consistency of medical student exposure to general practice, he said, which could vary from just a couple of weeks to a year.
GP supervisor Dr Linda Mann said that the MJA article made valid points, but failed to mention the successful, but now defunded, Prevocational General Practice Placement Program (PGPPP), which addressed many of the authors’ concerns.
“I absolutely agree with the scenario they paint of superspecialist consultants who are obliged to be decision makers, leaving little decision experience for junior staff,” Dr Mann told MJA InSight.
“The PGPPP was fantastic. It led to huge interest in general practice. Every single person who took part in it reported improvement in their subsequent general practice experience.”
The PGPPP was axed in 2014, due to the cost of the 12-week program.
Dr Mann said that the PGPPP was worth revisiting, and the potential for overseas models, such as the Canadian and Dutch community-based approaches, should also be explored.
“If I had to vote, I would vote for the giant change that’s happening overseas,” she said.
Professor Claire Jackson, Professor of General Practice and Primary Care Research at the University of Queensland, agreed that it was time to apply “fresh eyes” to the first 6 months of general practice training.
She said that the suggestions for change in the MJA article were a good start, but further consideration would be needed to the practicality of some ideas.
“A number [of suggestions] are impractical given the [junior house officer’s] already very busy work schedule,” Professor Jackson said.
She said that the Commonwealth RJDTIF would boost exposure to general practice.
“The RJDTIF is particularly useful as good preparation and early training and mentorship, and requires resources, fiscal and human.”
She added that programs such as the University of Queensland’s Urban LinCc program were promising.
“Programs like Urban LinCc – a longitudinal GP experience for students over years – offer great promise in establishing students for a career in general practice, but are resource intensive. Measuring the impact in time and intensity on registrar training would be very interesting,” she said.
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Gosh I love how many comments are about eating our own.
Many procedures are not beyond the skill sets of General Practitioners but beyond the appointment books ability to manage them. Gp is jam packed with chronic complex mulirimorbid patients. We have reduced nursing funding. The mental health nurses got axed and rebates are appalling. We do not have a public outpatients Department and yet as private businesses we are trying to pay our front desk staff and business costs.
There are huge cultural differences in Community medicine versus hospital centric medicine. It seems to me the entire system is under pressure. There are changing demographics of Doctors and of disease spectrums. Let’s adapt to this carefully and slowly as implementation of change is often done poorly.
The next generations of medical students and doctors are under pressure with job insecurity training doubts etc. and pushed via competition and student debt into perverse places attitudes and as we have seen into despair. We need to do better.
I 100% respect my hospital colleagues but context is king. To criticise an academic is poor form. To suggest GPS are 20 years behind is mystifying.
My son (Engineer) recently attended a tertiary hospital ED to be told by the young nurse Tehran he handed in his GPS referral letter and tests that
“She didn’t trust GPs!”
The Gp she didn’t trust came 4th in her graduating class. Unbelievably disrespectful of the General Practice workforce.
General Practice is a unique specialty discipline with many contexts. The solutions are likely to be complex. But two things are for sure
1. We should not fail our next generation of Doctors with incomplete understandings of what is needed for training. Or worse disregard for their health wellbeing and social stability.
2. We should pay more attention to cross disciplinary professionalism and not make casual assumptions (and derogatory comments) based on limited understandings of each other’s many workplace pressures.
Seek to understand.
There is no doubt that the metropolitan hospital system has failed the large cohort of young clinicians who joined the sausage factory on a promise that they would get a shiny fellowship in a sexy specialty one day, sometime in the distant future.
Meanwhile, Regional and rural hospitals continue to offer excellent clinical exposure, opportunities to develop clinical reasoning at an earlier stage and to produce well-rounded generalists (be they family physicians or specialists).
If there is a need to renegotiate GP training then lest accept that GP training in the city is a very different beast from the comprehensive role of a family physician and rural doctor in our regional areas and set up two programs, One for the second that accepts the ongoing need for hospital foundational training where it is still valued and needed.
This is a perfect example of why academics are such clever fools. Susan Wearne writes a great textbook, but don’t let her touch GP training!
I am a recently fellowed GP with RACGP.
I confidently reduce and treat fractures without referring to orthopaedics (because I did a term in orthopaedics, writings notes yes for most of the time, but also watching and doing it myself too).
I diagnose medical conditions and manage most specialty patients without much specialist input (because I did basic physician training for three years, and wasted my time apparently doing ward rounds and being grilled by consultants to perfection).
I perform complex skin procedures and hold my instruments properly (after being bullied into form by my seniors assisting dueing surgical terms).
Susan’s suggestion might make a few more pansy “specialists in life,” but I am my patient’s specialist in medicine. And they come back to see me for it.
Stick to textbooks Susan.
Sorry but Prof Wearne is out of touch, sending PGY1 interns straight from medical school to general practice is a recipe for disaster. It is a recipe to downskill GP’s. It is a recipe for those interns to misdiagnose and not know how to medically manage patients with hundreds of life threatening diseases with atypical, insidious, or complex clinical presentations. It is a recipe to break the spirit of those PGY1 interns when they are thrust into a clinical environment that demands skills beyond what they have learned as medical students. Prior to being allowed to do GP terms, work in acute hospital medicine, surgery, paediatrics, O+G, ED, Geriatrics, psychiatry and some anaesthetic experience should be mandatory. General practice is easy? “Just saying it don’t make it so.”
Oh FFS. Australia has ~715 hospitals of which ~520 are run by GPs. To say we have NO need of hospital based training is beyond ridiculous. The problem however is that new grads are used as workforce fodder by an ever-expanding metropolitan specialist service so they do clerking for cardiothoracic surgery instead of having any sort of a hands-on practical term. Do Metro hospitals even have general surgery or general medicine any more?? Seriously, I’d recommend removing Intern/PGY1 from the cities entirely and let them do diverse/generalist medicine in a regional centre. That is where they will accelerate their learning and can return with a better understanding of what they actually wish to specialise in – and yes that includes PGPPP. There is also good evidence that careers are chosen by registrars along gradients other than intellect yet we seem to be happier training nurse-endoscopists and nurse-anaesthetists than to consider training GPs in these roles. Maybe it is time for a cross-college RPL process whereby we can sit each others exams?
I did 4 years in hospitals before starting GP terms and despite my initially wandering career path regard the experience gained as an essential foundation for what I am now able to do in the rural setting where I now work. Some things are only learnt in hospitals/tertiary centres. This approach will deskill GPs both city and country including the ones who are prepared to extend themselves. It will shift more care to the specialist sector increasing health costs, blowing out already unworkable waiting times for specialists and worsening health outcomes as a consequence. Once skills are lost the GP teachers will have a smaller skillset to pass on . I have major reservations about this approach.
Hospital training at the junior level has never been fit-for-purpose for any career. In 1985 it used to take 20 mins to take a history and examine a patient and a further 30 to write out all the forms by hand. 2 hours to do a ward round, but preceded by 1 hour of pasting results into the notes by hand, and a further hour of handwriting new requests after.
There is nothing special about general practice training requirements. You need to learn some medicine. Not only that, but if you expect GPs to be cost effective (and keep significantly unwell patients at home) then they need to learn directly from critically unwell patients, ie in hospital.
Sure, there is a big difference between the hospital medicine and GP medicine, there always has been. That is because on average a GP is 15-20y out of date. But that is no reason to perpetuate the innate knowledge and skills gaps by not even exposing new GPs to the up to date practice of medicine.
What is a GP with who has learned only from his (out of date) GP tutors? He is a replaceable unit. To be replaced with a nurse or physician’s assistant. The treasury would love that. Cheap at a quarter the price.
I got little value from hospital terms apart from some of the ED terms in regional hospitals and Obstets (9 months without a registrar Heaven) which gave me the rudiments to work but the real training occurred doing X2 rural GP terms (FMP) and working with the best GP in Dorrigo 600KM away from any city hospital. This is a view shared by many of my rural and city colleagues. Hospital training not highly regarded and most learnt fro working in quality GP practices-quality being the key.
If we want to talk about various branches of the profession understanding each other, I would make a plea for anyone planning on training in General Practice (the hardest job in medicine to do well) to spend time at registrar level in the Emergency Department. These days it seems that often the only way for a GP to get their patient into a public hospital is via the ED. It shouldn’t have to be this way but it is. Thus the interaction between the GP and the ED is crucial. Spending time in the ED at a relatively senior level will provide insight into the limitations and challenges of this interface and, at least in theory, improve communication and smooth the patient journey. On the flip side, I’d suggest time in General Practice for those planning a career in hospital medicine, for the same expected benefits.
I would be pleased if GPs would consider that procedures like joint, neurosurgery and cataract surgery are better respected by deferring such surgery while acute skin lesions and acute infections heal beforehand. Will GPs learn these precautions if not serving at least one term in surgery and one term in psychiatry to see advanced disease?
My wife is a product of the PGPPP program that she did in 2011. It enabled her to approach her first GP term as Registrar with a lot of confidence. I was very surprised reading in this article that it has been canned. What a shame!
I agree with Linda Mann – the PGPPP program was a brilliant initiative. I think it should be reintroduced and offered to all second year doctors. For those going in to specialist training it provides an insight into general practice, and will ultimately lead, we hope, to better communication with GPs. For those going into general practice it provides a very well supported first experience. It also frees up hospital terms so another 25% can be offered positions. It’s a good investment and the government should support it
Although the environment is different, the medical skills and knowledge are fundamentally the same. Hospital based training provides concentrated experience in the acquisition of these skills. Sound basic knowledge, enables transition to another practice environment. Patients in general practice still have the common conditions, such as heat disease, hypertension, renal impairment, chronic lung disease etc and these conditions are concentrated in hospital wards and emergency departments.
As a now retired GP my mind is musing about babies and bathwater. The best in General Practice combines broad skills in communication and some skills in counselling, with a sound understanding of major disease mechanisms. The former needs some formal training but these skills grow slowly with experience. The knowledge of basic mechanisms often does not. In over 30 years of practice I came to treasure the 3 years of post-graduation hospital experience, where the daily care of the very ill patients and those with complex and sometimes rare conditions gave me a set of alerts to dangers and therapeutic possibilities which were useful over and over again. My urgent concern is that in dealing with the complexities of new knowledge and consequent changes in professional roles the opportunity for young Doctors to learn about and respond to a wide variety of clinical presentations with the appropriateness that comes from understanding underlying mechanisms will not be lost. My prejudice is that hospital practice is a uniquely valuable context in which to gain such understanding. Otherwise meaningful “generalism” will become a thing of the past.
Society has a problem with “education” creep. We progressively need more and more qualifications to do the same job, yet when we begin, the qualifications don’t seem to have helped us. Nearly all jobs are learnt by doing. Hospital interns have been reduced to paperwork lackeys, the registrars do the jobs of interns and the junior consultants now do most of the registrar work in a hospital. This means the junior jobs no longer provide any meaningful experience. GP’s quite rightly should be frustrated by this – 2 years of form writing and signing adds nothing to any persons training and is now a mandatory tax on all doctors in training that has little to do with preparing them for their long term jobs. The hospitals use this as a cheap slave labour pool – few people would want to work as a junior doctor in the public health system. The hospital doesn’t encourage permanence in these roles, if they did, people would very quickly insist on dramatic changes hospitals do not want to consider! Its not just GPs – every doctor in every specialty as well now has this problem.
EDs already see a great number of patients who need simple management of fractures, wounds, or medical conditions, who are referred by GPs. Then someone looks at the stats and complains that “EDs are full of GP-patients”. You can’t have it both ways, if GPs can manage these then they should do it, if they don’t have the skills then someone needs to accept that they are not “GP patients”.
Yes great idea. We should completely deskill GP’s and just train them all in psychology because that’s all we do as GP’s. Anything tricky like a wound we can call an ambulance.
As part of the training program the doctors need to spend time based in Aged Care. I currently work in the aged care environment and the registrars we come across have limited knowledge on the management of residents with dementia and behavioural issues as well as the management of residents palliating.