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A “RADICAL drop” in the numbers of medical graduates entering general practice between the mid-80s and the early 2000s highlights the critical importance of breaking down the barriers to a career in primary care, say researchers.
Research published in the MJA found that, using Australian Health Practitioner Regulation Agency data of current professional status as of November 2019 of doctors who graduated from 1985 to 2007 from the University of Western Australia (UWA), the number of medical graduates working as GPs had more than halved among those who graduated between 1985–1987 and 2004–2007, dropping from about 40% of graduates to about 15%.
The authors noted that this decline was in line with findings from the 2019 Medical Deans Australia New Zealand report that also showed a decline in the proportion of medical graduates planning a career in general practice.
Dr Karen Price, co-founder of GPs Down Under, said GPs’ crucial, but often hidden, role in prevention was undervalued in the community.
“We are like the back line of a football team, if you like. No one compliments all the goals that you stop, they only compliment the goals that were kicked … so what we do is often unseen and hard to describe,” she said.
Dr Price pointed to research by US physician and health services researcher, Barbara Starfield, showing that investment in primary care could lower the overall health care spend, with improved morbidity and mortality outcomes.
She said Denmark had also reduced the number of tertiary hospitals by reinvesting in and recapitalising general practice, but in Australia, significant earning gaps between specialist GPs and other specialists persisted.
“It’s sad to say that money confers status, but it’s a proxy measure of how people value things,” she said.
Dr Aniello Iannuzzi, a GP in Coonabarabran, NSW, and a regular InSight+ columnist, said, unfortunately, money was at the heart of the problem.
“While it may seem like an inappropriate thing to say, especially [during the COVID-19 pandemic], the main reason is money,” Dr Iannuzzi told InSight+. “[General practice] is still way underpaid compared to other specialties.”
He said there was a community expectation that GP consultations should be bulk-billed, while higher, out-of-pocket fees for other specialist consultations were accepted.
“It’s very hard to break [this expectation], and a lot of GPs are lacking in confidence and morale to escape that bulk-billing trap,” he said.
The MJA authors listed several causes for the reduced interest in GP careers, including: perceived lower status of general practice, the generally lower income provided by Medicare fees, the burden of practice accreditation, and specialist-focused teaching in medical schools.
Lead author Associate Professor Denese Playford, Associate Professor of Medical Education at the Rural Clinical School, UWA, told InSight+ in an exclusive podcast that there were many factors contributing to the “radical drop” in the proportion of graduates seeking out a career in general practice.
“We all know about the erosion of trust in general practice as a profession … Medicare freezes, the fact that [general practice] is not taught as one of the key disciplines in medical schools, and that the other disciplines have quite a high priority compared to their actual composition in the workforce.”
The MJA paper also noted the practice burden of accreditation as a factor contributing to the struggle for new GP recruits.
However, Ms Sonia Miller, Chief Program Officer for Western Australian General Practice Education and Training Limited (WAGPET), said while she agreed that there were opportunities to encourage more junior doctors and medical students into general practice, WAGPET enrolments had increased fourfold in the 13 years subsequent to the study period.
Ms Miller said, although enrolments had plateaued in the past 2 years, WAGPET enrolled 45 registrars in 2007, but this year had 180 registrars.
“Forty per cent of our registrars don’t come from WA universities,” she said. “They come from overseas as well as other states.”
Royal Australian College of General Practitioners (RACGP) president Dr Harry Nespolon said numerous factors influenced a medical graduate’s decision to pursue general practice or another specialty, so “a one-size-fits-all solution” would not be effective.
“My message to medical graduates is simple: I can think of few other jobs where you can so readily see the impact your work is having on people in your local community,” Dr Nespolon said.
“So, the challenge before the RACGP is conveying this to medical students weighing up career choices. If more of them could see how valuable a career path being a GP is, we will be able to reverse this trend.
“However, we must also be mindful that there are challenges facing the profession and that government funding hasn’t kept pace with the cost of providing care; namely the Medicare rebate freeze has had a significant impact on general practices remuneration.
“The RACGP will continue to strongly advocate on that issue because primary care is essential to the health of Australians everywhere.”
In 2019, the RACGP launched the “Become a GP” campaign, targeting medical students and highlighting the key advantages of a general practice career. The campaign’s first phase prompted more than 1700 medical students to register interest with the College.
Dr Iannuzzi said general practice had to do some housekeeping of its own to attract junior doctors. He said the red tape involved in GP accreditation had gone “beyond the pale”.
“[GPs] get so bogged down in wanting to meet accreditation standards that I can see the day – and that day is not very far away – that practices will find it’s actually cheaper and less stressful to not get accredited and forgo the [Practice Incentives Payments] and all the strings that go with it.”
He said general practice was still perceived as a “lesser specialty” by many junior doctors, despite the complex skillset required, particularly in rural practice.
“To do general practice well, in fact, requires the most complete set of skills out of any medical specialty,” Dr Iannuzzi said. “You need excellent clinical skills, procedural skills, and communication and organisational skills; whereas, in some specialties, you can be weak in some of those domains and still do quite well.”
This lack of appreciation for the skills required in general practice was amplified by a dearth of exposure to general practice in medical schools.
“We need to increase the presence of general practice early on in doctors’ careers,” Dr Iannuzzi said. “We need more generalists in teaching hospitals, [to help junior doctors to appreciate] that being a generalist is something that is worthy, interesting and equal to the other specialties in terms of skills and status. Until we get generalists back into those teaching hospitals, I don’t think we are going to address the cultural issue that keeps festering with respect to general practice.”
Co-author of the MJA research, Dr Jenny May, Director of the Department of Rural Health and the Betty Fyffe Chair of Rural Health at the University of Newcastle, told InSight+ that the early exposure to general practice provided by the now defunct Prevocational General Practice Placements Program (PGPPP) was mourned in the profession.
She said the PGPPP exposed the postgraduate years (PGY) 1 and 2 workforce to positive role models within general practice and the opportunity to “try before you buy”.
“The loss of that exposure in PGY 1 and 2 is another reason why I think that this decline will increase unless we start to drill down on the many facets of why it is so.”
Dr Price, whose daughter is a junior doctor in subspecialty training, said the stigma associated with a general practice career was also woven throughout medical education.
“[My daughter] commented all the way through medical school that there was that bias against general practice,” Dr Price said. “It appeared to come from within the halls of academia and hospitals and even from some of the other medical students, [general practice] was just looked down upon.”
She said the “massive” Higher Education Contribution debts carried by junior doctors also played into the career choice, as did the challenges associated with the shift from a state-funded hospital system to the federally-funded primary care sector.
“GP registrars are aware that when they move from a state-funded hospital job into general practice, they suffered a huge loss of income and a loss of benefits like superannuation and leave entitlements, including maternity leave, so they fall off a financial cliff once they come out of hospitals,” she said. “General practice] is relied upon during times of crises with prevention and longitudinal community care most recently and obviously called upon. General practice needs to be rebuilt as a viable vocation to attract our younger colleagues.”
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Any attempts to have GP rebates increased with the current government are going to fail. They are ideologically committed to destroying universal community health care even without obtaining an electoral mandate to do so. Since they could not stop us from high levels of bulk billing they are now attaching the messenger and undertaking corrosive auditors (avoidable by working less hours) and criminally inept interpretation of the billing information and clinical notes you provide. The health bureaucrats are pushing their own agenda to reduce GP wages and have us all recording extensive notes to avoid having individual billings disallowed.
I applaud those who have avoid entering GP training and I hope if they cannot get into a speciality here or overseas that they find an alternative pathway. God may save the Queen but nothing will save general practice. Live long and prosper.
As my accountant said to me 25 years ago, when I was contemplating paying $240,000 to buy into a General Practice, that “it is a lifestyle choice as it is not a good business proposition”. Instead, I bought a house in Brighton with the money which has appreciated much more than the GP ” investment”.
There’s a lot more to the story than just saying that graduates don’t tend to want to do general practice because it’s not sufficiently rewarding either financially or professionally. For my part I’d have been very happy to go into general practice but could not actually get onto the training program when I applied in the mid-1990’s having spent the previous 5 years in a job which had a fair degree of overlap with general practice, but not quite enough to qualify for vocational registration without further study. The feedback post-application and interview was that I should go away and self-study the missing areas and then apply to sit the exams, even though I was actively seeking training and mentoring. There’s no other medical specialty where that attittude to training would fly. In the end I found another career path with fewer obstacles.
Lets hope the Rural Generalist endorsement push is not lost in the COVID shuffle
These comments are somewhat heartbreaking to read, because they are so true. My Dad, a still very hard-working GP in his mid-60s, would echo so much of what has been said (esp by Geoff Chapman) about the erosion of what was once, and still could be, a marvellous and rewarding specialty in itself. No one is a generalist like the GP, nor an ‘expert’ across so many fields. Alas, watching the change in his own practice (loss of obstetrics, loss of procedures in-clinic, an overtaking by mental health, poor remuneration etc), the two children in our family who pursued medicine (myself and my older brother) have indeed chosen to specialise – and I don’t think either of us ever thought otherwise, despite knowing our Dad was an incredibly capable, and overall happy GP. The field of general practice cannot be further lost in Australia, we all know that a good GP is worth their weight in gold, and the Government indeed needs to focus on better incentives for prospective trainees.
The decline in GPs is a global phenomenon, accelerated in places with socialised health insurance, but even the US is not spared:
“it would appear that the marketplace demand for non–primary care physicians exceeds the demand for primary care physicians”.
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.21.5.165
Has anyone stopped to consider whether we are recruiting the right doctors in the first place?
Universities continue to insist on recruiting the academic “best of the best”, even though we ultimately don’t seem to end up with the right demographic of qualified doctors.
Although anecdotal, I have heard many a senior doctor remark that they probably would not have been accepted into Medicine, had they applied in today’s educational environment. Top marks don’t necessarily translate into top clinicians, but they do virtually guarantee University pass rates.
If our future doctors are choosing not to enter General Practice based on the fact that they could be paid 450k + in another specialty vs. 250k as a GP, then we are without a doubt recruiting the wrong personalities.
Relaxing entry standards for rural origin and Indigenous students is undoubtably a risk for higher education providers, but the doctors that graduate through these schemes fill vital gaps in our healthcare system. Increasing the number of alternative pathways such as these and maybe focusing a little less on the academic geniuses, may result in a much richer and more capable fabric of Australian produced clinicians.
General practice is undervalued across the board. There are patients who just see the GP as the necessary conduit to what they want, there are members of the public who believe that general practice is the poor country mouse version of medicine, and that you have not succeeded if you are a general practitioner.
There are also general practitioners themselves who, for whatever reason, do not put their skills into practice and instead opt for the path of least resistance and allow their day to be overrun by single request appointments for scripts and routine investigations in 5-10 minute slots over a 5 day week or those who jump onto every unethical opportunity and give general practice a bad name overall. Of course, we must not omit the Medicare rebate and government restrictions which, while they put a check on the unethical, also reduce the incentive to ensure that your practice is looking out for the whole person and the complexities of chronic illness as these are boxed into paperwork requirements which are time consuming and deflect from the intended purpose of such items. There are a lot of people who really appreciate the care and effort that GPs provide for their patients, and they are the reason I am still in practice. General practice is one of the few specialities where you have continuity of care , an opportunity to holistically look after the health of your patients over a long time. Would I go into general practice if I were studying Medicine today? I suspect I would not, unless I had the advantage of a retrospective insight into my career and the satisfaction of being a general practitioner for over 30 years.
Male aged 67. I have worked in rural/regional General practice for the past 33 years. GP Obstetrics/ Anaesthesia and essentially full time General practice. Obstetric and anaesthetic practice subsidised the much poorer paid General practice consulting.
I have retired from the procedural work in the past 2 years. My income has dropped substantially though clearly not as important at my age providing the ASX 200 comes good!
I work in a reasonably large General practice. It has become clear that the younger RACGP qualified doctors have reduced their consulting hours significantly. Careers are being pursued in Occupational medicine,skin medicine,Cosmetics,Sexual health,Locum weekend services as well as work for State and Federal health instrumentalities.
Increasingly these sub specialisations take talented young doctors away from Family Medicine.
I had always thought that Family medicine was the Bedrock. The trends suggest that this is no longer the case.
Adequate medicare rebates might help re establish Family medicine though the more that young GP`s can avoid the difficult grind the less likely they will be to return.
I may be a voice in the wilderness, but had anyone considered that part of the problem is that up and coming GP’s have other issues. The AMA rules with a rod of iron that gives no leeway to use proven methods not recognised by the AMA. The reason that many things are not evidence based researched even though they have research from the 1970’s (that subsequently were manipulated to bring about a false result) to keep more toxic medication the first option, and dare you as a GP use the other as your license would be taken away. In my opinion, some GP’s prefer to work outside of the system as they just don’t like how health is being manipulated, by very high-up faceless players.
It is nothing but the money issue pure and simple. The observation above about a specialist emphasis in undergraduate training being a factor is just pure unadulterated hogwash, Undergrad training has always been that way well before the survey date of the this study.
Years of Medibank rebate freezes, bulk billing and bureaucratic time consuming irrelevant BS spewing out of Canberra and limitation of practice have brought this incredibly important sector of our medical community to its knees.
Advice: Do pharmacy, become a pseudo-doctor in half the time and earn twice as much.
To Ian Hargeaves’
This has been done: THe PGPPP term ( see above in the article). It was a roaring success according to the residents who undertook the work, the VTO s who had increased registrations as a result , and the hospitals, who could not accommodate all interns who needed a job. The problem was , it was paid at the correct rate, so too expensive to maintain
General practice was a great job, when we did “everything”, particularly Surgery (only the stuff you were good at).
Then a few things appeared.
Medicare, with its Bulk billing. They conned the GPs into suggesting they would never have a bad debt, which used to be about 30% of your billings. The Specialists didn’t fall for it, so by about a 60-40 vote , it came into play, and the Govt paid the full fee—you beauty. That was the bait, then the hook appeared–they stopped raising the rebate with the CPI, so you were locked into Govt. control–stiff cheddar.
Mental health became 40-50% of the general practice. Previously this was a topic handled by Psychologists and Psychiatrists. Would there be a more boring and time consuming part of General practice than this—more so if you weren’t qualified to handle it, yet “the authorities”in their Bureaucratic eyries emphasising how important it is , to general practice.
Removal of General surgery and Obstetrics from your practice, which really produced a large proportion of the practice income. How many GPs nowadays could remove an appendix or fix a Colles fracture ?
The Legal profession–every Doctor’s fear of being sued. So unless you are “an Expert “in your “field”, you are regarded as incompetent. They are producing Lawyers like sausages, and they are all looking for work. Let’s have a chop at the medical profession, whose competence has been questioned time and again, and there are a lot of potential candidates out there.
Just a few of the reasons my kids won’t be studying to be GP’s.
Specialise or forget it. Leave the Referrals to the Casualty section of the Public Hospitals, where they can have GP sections and the Public treated for free.
Failing all this, have a nice day.
Also, us GPs going on our Hands & Knees & begging the Govt. of the day for a higher Rebate, is never going to Work.
GPs seem to forget that we are not Govt. Employees & that the Medicare Rebate is for the Patient to claim.
When the Gap between the Medicare Rebate & the Fees of the GP widens to a point at which the Populace feels a ‘ Pinch ‘, the CRY will then come from the Populace.
Cries from us GPs, no Govt. will pay a heed to – GPs constitute a Miniscule of the Voting Populace.
Cries from the rest of the Populace, no Govt.will dare ignore, as they constitute the Bulk of the Voters.
So, GPs should stop Begging & Crying, by start Billing a PROPER FEES to all but a Select few of the Populace, who deserve a Compassionate Fees.
As much as Patients do not like the Wide Gap between what the Specialist Charges & the Medicare Rebate they get, Patients still Pay the Full Fees to the Specialists !!!
So, stop going on your Hands & Knees & begging from the Govt. for an increase in the Medicare Rebates – leave that Task to the Populace & charge a PROPER FEES.
DR. AHAD KHAN
The Financial Rewards for the Hard-Working GP is ‘ PEANUTS ‘, relative to other Specialities.
No Wonder, each successive Government of the day, has treated us GPs like ‘ MONKEYS ‘.
The Altruistic Nature of us GPs has been thoroughly exploited by each successive Government of the day.
Until this ( the Financial aspect ) is rectified, General Practice will remain least sought after, by fresh Graduates.
It is high time that the GPs en-masse discard Bulk-billing & limit their Compassionate Billing to only a select few of the Populace.
It is high time that GPs lift their Self-image & start Billing each Patient ( bar the select few ) a PROPER FEES for the high Quality of Service that they provide, thereby setting the Stage for future Graduates to seek being a GP.
As I understand it, AHPRA/ Medical boards require all interns to do terms in Medicine, Surgery, and Emergency. There is no requirement to do a term in general practice nor in pathology, and the minimal contact that trainees get with these fields is no doubt the biggest single reason for the dearth in their recruitment numbers.
The token couple of weeks’ attachment is a sop, and could easily be replaced by an entire compulsory year for all medical students to be spent in the general practice setting. A compulsory intern GP term would also be easy enough to implement. (Don’t get me started on state/federal stupidities, just pay them a salary from their primary hospital.)
Personal experience of how general practice works would be useful for all hospital doctors or private specialists in their future careers – this is exemplified in the discussions regarding PPE by senior government medical officers, who seem not to understand that the GP practice receptionist is the first person to be coughed on, and potentially the most dangerous superspreader.
The hospital-trained ‘experts’ were all concerned about the ICU staff treating known COVID patients, not thinking about the person who has short-range contact with perhaps hundreds of sick people per day in a busy medical centre. Last week a theatre sister in full PPE took my temperature before allowing me in the theatre suite, while my GP’s staff were stuck barefaced behind a homemade perspex panel. It’s pretty obvious who is the ‘poor relation’ in the medical family.
It took me my entire medical career to realise I had been on a hiding to nothing, and that from a somewhat selfish and personal perspective, I had, in effect, wasted my qualifications doing general practice, when it came to achieving anything like financial success/security.
However, over all, I enjoyed the work, which I guess is why I persevered, and in my retirement now, I can honestly look back and say I did my best, and my patients reaped the benefit and were appreciative. It’s just that warm fuzzies don’t fund a very plush retirement, more’s the pity. This being a very solid reason why GPs do deserve better.
Clearly the falling numbers reveal that prospective GPs are realising this, and voting with their feet. That is going to be a real worry for the future of primary care, and the vital role it plays in keeping health costs down. If only the people in power, and who could address this, would realise this reality and act on it.
Let doctors enter general practice without vocational registration being required for the higher rebates.
From a retired GP
The under-valuing of GP work is at individual, organisational and government levels.
But just to consider one level – that of remuneration… We know “money talks” – what gets done is what is paid for, what attracts incentives. At a personal level GPs can usually see the value of what they do. But it is difficult to demonstrate to government something negative (a patient does not go to hospital) or an outcome at a distance of time (patient does not go to hospital in the next 5 years). So it is difficult (but not impossible) to construct incentives based on real outcomes (as opposed to surrogate outcomes such as keeping HbA1C in target range). And it is difficult to feed back money saved at the hospital, to the GPs – because it is the GPs who have worked hard over a decade to reduce hospital admissions.
Thanks to Barbara Starfield and her co-workers we have the big picture at population level…we need to build on that. Other countries and other systems are doing it.
Perhaps thanks to this pandemic the real worth of GPs will again be highlighted to the Australian government.
Medicare Rebates for GP services will have to increase to raise the GP’s income to attract more graduates to this Specialty. It must be stressed that General Practice is a Specialty & GPs are Specialists & must be remunerated accordingly. Raising the status of the GP is the key to raising the attraction of General Practice to medical students & graduates.