I READ Dr Aniello Iannuzzi’s two most recent contributions to MJA Insight – General practice: where the problems lie and General practice: some ways forward – with much interest. He covers a topic of great importance without holding back. While I agree with his general sentiments, I do not agree with his supporting arguments, and I would like to outline why I feel that they were flawed.

Membership fees

In his first article on general practice, Dr Iannuzzi writes “with a membership fee of close to $1000 per year …”.

The RACGP full current membership fee is $1525 for a full-time GP working 20 hours or more per week (RACGP, 2018). There are discounted fees for different types of membership. But the statement “close to $1000 per year” comes across more as a conjecture.

RACGP assessment process

Dr Iannuzzi writes that “many registrars feel the RACGP training and assessment process is inadequate and many supervisors feel that graduating Fellows are not ready for independent practice and that the exams remain too easy to pass”. It is unclear on what basis, perhaps other than anecdote and personal belief, Dr Iannuzzi bases this claim.

Many dedicated doctors work hard to attain the fellowship of the RACGP – and despite that, the current pass rate for the three exam components hovers around 60–70% for the Applied Knowledge Test; 53–70% for the Key Feature Problem Test; and 80% for the Objective Structured Clinical Examination (RACGP public exam report, 2016–2017). This is not an expected pass mark for an easy exam, particularly for a group of intelligent, hard-working doctors who would have passed many assessments and examinations before even qualifying to sit the RACGP examination.

Low value care

Low value care, as the term is used in medicine, is defined as “care that confers no benefit or benefit that is disproportionately low compared with its cost [which] potentially wastes limited resources” (Scott and Duckett, 2015). Dr Iannuzzi cannot simply say that “it has many meanings to many parties”.

Furthermore, the examples he uses for low value care, such as completing a disability parking permit form for a 90-year-old or creating a care plan for a 4-year-old with autism disregard the benefits to the quality of life each patient could gain as a direct consequence of those forms being completed correctly. This is not low value care – completing these forms is potentially the most impactful action a doctor could perform for these patients in desperate need.

Dr Iannuzzi writes that “[NDIS paperwork] has taken GP low value care to new depths,” but only a GP can complete those forms and they have a profound impact on the life of the patients. To dismiss it as low value care is essentially devaluing the profession, in my opinion.

RACGP training

Dr Iannuzzi writes: “Some simple measures that could be easily and rapidly introduced include: a logbook of patient numbers, caseload and procedures; written exams that demonstrate competence in writing reports, referrals and patient advice; viva voce exams that also include long cases; and a mini-thesis demonstrating an understanding of the Australian health system and primary care”.

As a recent Fellow of the RACGP, having attained my fellowship in 2015, I have to point out that each one of those measures that Dr Iannuzzi has suggested are actually in place. RACGP registrars have to maintain a logbook that includes everything that he has suggested, as well as billings. The written exams as they stand are comprehensive and on par with other similar exams in countries with equivalent health care systems, including the United Kingdom. The Objective Structured Clinical Examination of the RACGP actually has a mix of clinical cases, two long cases and viva voces. All trainees have to submit a research project or equivalent project as approved by their medical educator.

Public perception

Dr Iannuzzi writes: “There is a perception among some members of the public and other medical specialists that GPs are simply paper-shufflers and blood pressure checkers”.

Several studies have shown that public trust in GPs remains high. Hardy and Critchley in their 2008 MJA study showed that “GPs were deemed more trustworthy than specialists or hospitals”.

No system is perfect, of course, and there is much that can be done to improve general practice in Australia. Dr Iannuzzi specifically, and in my opinion, also correctly, points out some areas that are in dire need of intervention. I appreciate his courage and strength of character to openly speak about the need for change, and I have immense respect for his valuable contributions to rural general practice. But respectfully, I disagree with the substance of some of his arguments.

Dr Ajay Chennamchetty BSc, MBBS, DCH, FRACGP is a GP practicing in Wyong, NSW.

 

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 MJA InSight unless that is so stated.

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One thought on “General practice: another point of view

  1. Peter Bradley says:

    I think to some extent Ajay has missed the point. Or at least Aniello’s definition of ‘low value care’.
    For example, when he describes completing a disability parking permit form for a 90-year-old or creating a care plan for a 4-year-old with autism, as low value, I take him to mean that the need for those things is so blindingly obvious, that it should not need a Dr to be involved in applying for it. An example I often quote myself is, why can’t the clerk behind the desk approve a disabled parking permit when someone rocks in in a wheelchair, missing both legs.
    It is examples like that, which reduce us to basically rubber stamps, certifying often to what is verbally relayed to us from the relevant carer in any case, that begs the question, surely someone else could have done that. That is the sort of thing I also categorise as low value care, from a Dr’s perspective, even though all would agree it is high value as far as the patient is concerned.

    I keep finding myself, in these last years of my career, feeling more and more we have been shunted into a role of very often being the conduit for the patient to get from point A, to point B, in order to access something other than what we can provide, with all that anybody is interested in being our signature on the bottom indicating we have taken responsibility for the process, but no-one actually interested in what we actually think or could offer ourselves.

    I see that as an insult to us, as professionals, especially considering the time, money, amount of training, and study efforts rightly pointed out by Ajay, we must put in, in order to be what we are.

    We are also subjected to actions by the powers that be that effectively say they regard our care as low value. Examples abound, but to quote a few.

    1. The Authority medication time and money-wating system, where if we but say the right words, (after wasting significant time) a clerk with no medical knowledge gives us the magic number.
    2. The restrictions on certain imaging, because clearly they don’t trust us to exercise discretion, yet in my experience the specialist waste far more because they feel they must order expensive imaging to justify the fee they’ll charge. The ultimate recent example being the restriction of rebated mpMRI prostate to specialists only.
    3. The absurdly strict requirements now with respect to male HRT – ultimately requiring urology approval, at one and the same time, insultingly reducing the urology specialist to virtually a rubber stamp.

    One could go on, but what’s the point, who listens..? However, without question, each of these restrictions limits the value of the care we can provide.

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