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THERE is no more pressing challenge in Australian medical education than the securitisation of highly skilled, better distributed, energised and appropriately remunerated general practice medical specialists. Paradoxically, this issue receives very little academic attention and certainly nowhere near the focus required to assure the health and wellbeing of the Australian population.
In April 2020, an article published in the MJA presented the findings from an analysis of the number of GPs using data from 1985 to 2007. The authors used data on the registration category recorded by the Australian Health Practitioner Regulation Agency as of December 2019 for doctors who graduated between 1985 and 2007 – a cross-sectional, not longitudinal analysis. The results suggested a declining interest in the numbers of practitioners choosing a career in general practice. However, while the relative proportions of medical registrations have clearly changed over that time, the absolute numbers entering vocational postgraduate GP training in Western Australia, as elsewhere in Australia, have increased exponentially.
But for the past 3 years, there have been 180 medical graduates entering GP training in WA each year. Given that WA has about 300 medical graduates each year, 180 would seem to be a substantial proportion of that cohort, except that only 60% of those entering GP training in WA studied medicine in WA.
While medical education research studies are always welcome, it is critically important that the methods and findings of any individual study are carefully reviewed, the time frame of the data noted, and any conclusions appropriately tempered. A keen eye on timeliness, relevance and research transfer is recommended. It has largely fallen to Regional Training Organisations (RTOs) funded by the Commonwealth Department of Health through Australian General Practice Training (AGPT) and supported by the GP Colleges, namely the Royal Australian College of GPs (RACGP) and the Australian College of Rural and Remote Medicine, to facilitate policy-relevant research and evaluation for GP education.
For instance, WA General Practice Education and Training (WAGPET) has conducted research to better understand complex training problems such as attraction and retention (over 90% of practitioners completing GP training in WA stay in WA). Our unique access to registrars has enabled the methodological decisions to be better informed by experiences on the ground and key policy conundrums.
In 2018, we initiated a qualitative phase with medical students and doctors in training in WA to design a survey tool to describe how career decisions were being made. One subset study compared GP registrars with registrars in other vocational training programs to elicit key differences between them. We discovered that GP registrars exhibit significantly more positive views about the importance of their role in contributing to community wellbeing and their impact on individual patient outcomes (unpublished data). However, because of their limited exposure to role models and GPs at work, they are less likely to be sure about their career choice than other registrars. GP registrars are generally older on admission to medical school as well as into GP training and more often have dependents.
As alluded to by Playford et al and confirmed by our own work, trends revealed in the most recent Medical Schools Outcomes Database (MSOD) report show that “adult medicine/internal medicine/physician” remains the highest preference. Yet this MSOD report also shows that the four most influential factors for career intention are “atmosphere/work culture”, “alignment with personal values”, “experience of specialty as a medical student” and “intellectual content of the specialty” – all characteristics of contemporary general practice.
Other research has shown wide variation in the eventual percentages of each medical school graduation year enrolling for RTO training (Gill G, Shiu B, Yates A. Did medical school factors influence entry of Australian medical graduates into AGPT training in 2011–2016? RACGP, GP16 Conference presentation, 2016). Nearly 50% of University of Wollongong graduates enter GP training but only 18% of those from University of Melbourne. From 2009 to 2011, only 29% of University of Western Australia graduates did so, with an annual range of 9% to 32%. My colleagues from GPEx have also constructively contributed to greater knowledge by initiating mixed-methods research about medical specialisation choice. They found a well timed GP experience was pivotal to specialty decision making. As they concluded:
“Poor quality medical school placements which were mundane, lacked quality supervision, and did not give the student an opportunity to experience the diversity of general practice were often denoted as the turning point that took participants away from the idea of choosing general practice as a specialty.”
For some time, providers of GP training have realised that marketing general practice as the medical specialty conducive to “lifestyle choice” may have curtailed applicants with the personal attributes and professional drivers necessary for the demands of this challenging contemporary medical specialty. To be sure, the effectiveness and efficiency of Australia’s health care system rests on the bedrock of multidisciplinary primary health care, in which referral, treatment and evidence-based chronic disease management requires the expertise of the GP medical specialist to integrate team care, assess changes in predictive clinical outcomes and remain trusted in the patient’s lifelong journey. Failing to ensure continuity of care to residents in WA will rapidly lead to deteriorating patient outcomes and an unaffordable health care system.
A major investment in medical education research to better understand this complex workforce issue is needed. Otherwise, Australia’s policy in this area will continue to “fly blind”.
More effective performance indicators should be imposed on medical schools. They are the source of medical graduates already somewhat primed, whether deliberately or not, for specific specialisations.
Effective initiatives such as the Prevocational General Practice Placements Program should not be prey to “stop–start” funding decisions by policy makers with no accountability.
There must also be a frank national dialogue about the significant financial disincentives GP medical specialists experience throughout their careers while doing the most critical heavy lifting. Does successful general practice better structured to meet population need now require GPs to cross-subsidise their clinical work with other sources of remuneration such as academic work, public health or emergency roles?.
Even in the coronavirus disease 2019 (COVID-19) pandemic response, why was it that compulsory bulk-billing of the new telehealth was required of GPs but not their non-GP medical specialist or allied health colleagues?
Political power and strategic policy must better align to population benefit.
Adjunct Professor Janice Bell is a GP and CEO of WAGPET. In 2011, she was awarded the RACGP’s Rose Hunt Medal for services to general practice.
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.
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I have a different perspective as a physician sub-specialist in full-time private practice (including hospital practice) in a major capital city. I think that being a good GP specialist is the most difficult job in clinical medicine, because you need broad general knowledge and yet still need to be aware of your limitations, and so know when to refer on. Also, the bureaucratic environment (Medicare) is hostile and unforgiving. The referrals I receive can be categorised into two groups – those that are thorough and helpful, with the GP’s clinical assessment and results of relevant investigations, and those that run to only a couple of lines (e.g, “please see this patient with fatigue”), with incomplete or inaccurate medication lists. The former type of referral almost always comes from specialist GPs (who have their FRACGP qualification) who do not offer universal bulk-billing. The latter type of referral nearly always comes from GPs in practices that bulk-bill every patient and usually do not have their FRACGP. So the answer is to recognise general practice as a specialty deserving of equal remuneration to other specialties, but to also limit bulk-billing to certain types of patients (children, pensioners). Those medical practitioners working in general practice who do not hold the FRACGP or equivalent should be required to upgrade their qualifications over the next few years or lose access to Medicare billing.
I doubt that many GPs are seeing 6 patients per hour and private billing them.!
Most GPs are seeing 4 patients per hour and bulk billing about 3/4 of them so earn gross $225 an hour and paying themselves about 65% of that after practice expenses so earning about $168 per hour which is way below other specialist /partialist earnings.
We need to be paid and acknowledged as primary health care specialists who deal with more complexity than any of our partialist colleagues that I know of!
I think we still have a tainted brand
“Are you going to specialise? Or be #justaGP?”
Attitudes from Govt, public and partialist colleagues can still carry strong taint of the notion that either
– general practice is for those who washed out of another training programme
– general practice is a low skilled job dealing with colds and sniffles and sick notes
– general practitioners can set up shop with minimal training
None of these are true
I wonder if re-branding as ‘primary care specialist’ would help re-focus attention on the core skills of the well-versed community-based practitioner, practicing her skills as a public health clinician, internal medicine physician, women’s health expert, mental health practitioner, paediatrician, ENT and skin specialists and so on….
But until we re-brand as ‘primary care physicians’ the brand remains on-the-nose.
#justaGP
Lone Ranger said: “If they have private billing, and seeing 6/hour, they’re already billing at rates equivalent to specialist face-to-face consultations per hour.” I believe that it is not possible to provide quality care in general practice with 10 minute appointments, so to me all that this statement says is that GPs can earn more by providing lower quality care. That is not news to anybody.
Lone Ranger didn’t mention the higher Medicare benefits and fees charged for surgical and other procedures that are performed mostly or in some cases exclusively by non GP medical specialists.
“Their problem is poor management of expenditure = the costs of running a practice.” In my 41 years of experience including some years as Chair of the RACGP’s South Australian Practice Management Committee, general practices are for the most part run efficiently and thriftily, partly because they have to do that in order to stay open.
Not surprising doctors graduating do not wish to become GP’s, considering how inadequate is the retribution for the complexity and responsability of GP’s duties. How derisory are our Medicare rebates if compared with the cost for a simple haircut of at least $ 38!
If they have private billing, and seeing 6/hour, they’re already billing at rates equivalent to specialist face-to-face consultations per hour.
Their problem is poor management of expenditure = the costs of running a practice.
We get zero education in our University courses or via our Colleges CPD in small business management, practice structures, and cost-effective care initiatives.
General Practice is a more difficult job than many specialist jobs. We need to know not just something about everything, but with the increasing problem of fewer specialists bulk billing and increasing gap payments, patients cannot afford to see specialists. Therefore more patients are asking their GP’s to take them much further into treatment and diagnosis than ever before. This is extremely stressful at times. Then we are audited for increasing diagnositic tests and longer consultations.
Despite more doctors graduating , they state do not wish to become GP’s- too difficult and too poorly paid”.