Why are students not pursuing general practice?

IN September, I had the privilege of sitting on a panel with leaders in general practice, including the Presidents of the Royal Australian College of General Practitioners (RACGP), the Australian College of Rural and Remote Medicine and the General Practice Registrars Association, at the General Practice Training and Education Conference (GPTEC) Future Forum to discuss the evolving landscape of their profession. The forum aimed to decipher what the future of general practice holds and what is needed to prepare for it, with topics ranging from the progress of Indigenous health in primary care to the support structure for GP registrars.

And of course, the question that was foremost in everyone’s minds: why are medical students losing interest in general practice?

Last week, Australian Doctor published the dramatically titled article Medical students shun general practice, highlighting figures from a Medical Deans of Australia and New Zealand survey which put only 15.4% of graduating medical students choosing general practice as their first-choice specialty, a decline from 17.8% in 2015. It’s worth noting that general practice remains third on that list, behind only adult medicine/internal medicine/physician (19.1%) and surgery (15.5%). Perhaps it should be asked why only two graduating students were interested in pain medicine, and why only one was interested in addiction medicine.

Looking past the mild clickbait, I’d like to expand on the reality of these numbers and reflect on the teaching of general practice I have received over the years.

Medical students are told from day one that primary care is the front line of health care, and prevention is better than cure. However, this is hugely incongruent with what we are taught, especially in a clinical setting. The majority of our clinical time is spent in hospital, not in primary care settings. In my own 3 years of clinical study, I will spend approximately 10 weeks of compulsory teaching at a GP clinic. Anything more than that, and I would have to actively seek out interest groups such as the General Practice Students Network or via RACGP student initiatives. Even in pre-clinical teaching, general practice is siloed as its own under-represented topic in separate lectures, as if a patient and their body systems in a general practice clinic is an alien compared with the same patient in a hospital.

How much opportunity do medical students have to have positive exposure to general practice if it is being offered as a 5-week supplement to our 40-odd weeks in hospital?

Madeleine Goss, a final year student from Deakin University, recently wrote:

“I completed a longitudinal program in regional Western Victoria, with fantastic GPs who also staffed the local hospital and nursing homes. Nineteen other students in my cohort were placed in similar sites across the state. We came together every six weeks for formalised teaching and exposure to specialties we may not see in our towns. The most common opening line of a specialist who would come to teach was ‘oh, you’re just going to be GPs; I’ll change what I was going to do’.”

This was frustrating to us, because, as medical students, we should be receiving standardised teaching.

However, it was much more insulting to GPs.

It is true that the minutiae of some topics are not relevant to general practice, but this detail is not taught at the medical student level, so why were our teachers changing their lessons? These types of interactions insinuated to my peers and me that doctors choose general practice because they “couldn’t make it” elsewhere and because we were going to follow that path, we needed to know less. As we know, those in the medical profession are often perfectionists and enjoy challenging themselves, so once this idea of “settling” for general practice has been planted, it is difficult to uproot.

Perhaps we would not have such a loss of interest in general practice if this career choice was not looked upon as a “consolation prize”.

When primary and preventive care should be the forefront of what we teach and learn, why are we in an environment where those who want to pursue general practice must defend or justify their decision?

Of course, it would be facetious to lay all blame on how we are taught; we must also consider how we, as students, are looking at our choices. The common misconception that general practice is not a specialty, or is “a consolation prize”, may be planted by others but then is perpetuated by us. I can think of too many times when I have heard from my peers: “What specialty do you want to do? Or do you just want to be a GP?” In a culture of increasing competitiveness to get on to training programs, we are pressured to choose early and then invest in a sunk-cost fallacy to try and pursue that pathway. Switching specialties or looking at generalism no longer seems like a viable pathway once you’ve poured time and energy into CV-buffing from day one of medical school.

I have been lucky enough to have two excellent general practice placements with GP supervisors who were keen to teach and loved by their patients, one of whom sparked my own interest in addiction medicine. It is important that medical students celebrate positive role models in general practice and encourage our peers who are pursuing the field.

Jessica Yang is the President of the Australian Medical Students’ Association, the peak representative body for Australia’s 17 000 medical students. She is a medical student at Western Sydney University. She can be found on Twitter at @YourAMSA and @JessHYang.

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.