EXPERTS are calling for a rethink of general practice vocational training, questioning the educational value of time spent in a hospital environment that was now “poles apart” from the general practice experience.
Writing in the MJA, Associate Professor Susan Wearne, a GP and academic at the Australian National University, and coauthors said that in the years since the beginning of formal general practice training in 1973, there had been significant changes in general practice and hospital medicine, but the requirement for hospital experience before commencing GP training had remained.
“Given the bottleneck in hospital junior doctor training positions, and junior doctors’ concerns that their stressful, demanding workloads are of questionable educational value, it is timely to reconsider the effectiveness of this preparation for general practice,” they wrote.
Dr Bastian Seidel, president of the Royal Australian College of GPs (RACGP), said that the college had been calling for a rethink on GP training for some time, and the impending transfer of training responsibility back to the RACGP and the Australian College of Rural and Remote Medicine from 2019 provided an ideal opportunity to consider these issues.
“There is certainly an appetite here to rethink how we can improve general practice training for it to meet the needs for our future GPs,” he said.
“Realistically, the general practice environment is a very different environment compared to the hospital environment. How can the training that you get in a high-tech, tertiary care environment, which is full of safety nets, be transferred into a low-tech general practice environment? There are some learnings for doctors in the hospital environment initially, but we really need to look at how relevant it is in the scheme of things.”
In an MJA InSight podcast, Professor Wearne said that the hospital and general practice environments were now “poles apart”.
She said that shorter hospital stays, greater reliance on high technology, and increasing involvement of specialists in clinical decision making in hospital practice had had an educational consequence for junior doctors.
“It’s not that hospitals are failing juniors … but are there things that hospitals and juniors who work there could be thinking about differently to ensure that they do feel well prepared to come into general practice?”
The authors offered a range of suggestions to better tailor the current system to GP registrars’ needs, including raising awareness of clinical knowledge needed by GPs, direct observation of GPs and of hospital staff, and involvement in relevant outpatient clinics.
They said that increased exposure to general practice during training was needed, noting that the new Commonwealth Rural Junior Doctor Training Innovation Fund (RJDTIF) should enable more exposure to general practice in the early postgraduate years.
The authors further pointed to GP training in Canada and the Netherlands, where registrars were based in the community and worked in hospitals for “specific terms with defined learning outcomes”.
They acknowledged the major structural change that would be required to implement such a system in Australia, but said that it may prove more “efficient and effective” than the current approach.
Dr Seidel said that the MJA article provided a good starting point, but the conversation needed to be broader. The RACGP’s 2018–19 pre-budget submission highlighted the potential role for general practice in taking on more interns.
“We are hearing increasingly that interns are missing out on hospital placements, in particular in smaller states,” Dr Seidel told MJA InSight.
“There is no reason why interns can’t be placed in general practice. It would be great exposure early on … that would help them to become confident and capable GPs in the future. And even if [interns] later want to become a cardiologist or a neurosurgeon, the exposure they have to general practice is going to help them understand the complexity we are dealing with on a daily basis. So, it’s going to make them better doctors.”
It was also important to improve the consistency of medical student exposure to general practice, he said, which could vary from just a couple of weeks to a year.
GP supervisor Dr Linda Mann said that the MJA article made valid points, but failed to mention the successful, but now defunded, Prevocational General Practice Placement Program (PGPPP), which addressed many of the authors’ concerns.
“I absolutely agree with the scenario they paint of superspecialist consultants who are obliged to be decision makers, leaving little decision experience for junior staff,” Dr Mann told MJA InSight.
“The PGPPP was fantastic. It led to huge interest in general practice. Every single person who took part in it reported improvement in their subsequent general practice experience.”
The PGPPP was axed in 2014, due to the cost of the 12-week program.
Dr Mann said that the PGPPP was worth revisiting, and the potential for overseas models, such as the Canadian and Dutch community-based approaches, should also be explored.
“If I had to vote, I would vote for the giant change that’s happening overseas,” she said.
Professor Claire Jackson, Professor of General Practice and Primary Care Research at the University of Queensland, agreed that it was time to apply “fresh eyes” to the first 6 months of general practice training.
She said that the suggestions for change in the MJA article were a good start, but further consideration would be needed to the practicality of some ideas.
“A number [of suggestions] are impractical given the [junior house officer’s] already very busy work schedule,” Professor Jackson said.
She said that the Commonwealth RJDTIF would boost exposure to general practice.
“The RJDTIF is particularly useful as good preparation and early training and mentorship, and requires resources, fiscal and human.”
She added that programs such as the University of Queensland’s Urban LinCc program were promising.
“Programs like Urban LinCc – a longitudinal GP experience for students over years – offer great promise in establishing students for a career in general practice, but are resource intensive. Measuring the impact in time and intensity on registrar training would be very interesting,” she said.
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