GP training dilemma: a more complex picture

The pressing challenge of securing highly-skilled GP medical specialists in Australia.

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.

Source: Medical Journal of Australia