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Wonky Health: The complex and changing world of GP training

In the wake of the federal budget, uncertainty about the future is facing many areas in the health sector – and GP training is no exception, writes Dr Tim Senior in his latest Wonky Health column.

By Tim Senior

 

The last ever GP Education and Training (GPET) Convention was held recently in Brisbane, and there was a lively Twitter stream – #GPET2014 – from an enthusiastic crowd.

If you fancy dipping in to this timeline, you may be confronted with a string of acronyms and abbreviations making your Twitter stream look like you’ve just spilled alphabet soup on your computer.

Before getting in to the conference itself, here’s an outline of GP Training in Australia.

General Practitioners (GPs, also sometimes called Family Practitioners or Family Physicians) are medical specialists.

Their speciality is human beings – the symptoms they get which might indicate nothing or serious disease, and the ways of managing this safely. They have expertise in early diagnosis, undifferentiated symptoms, co-morbidity, and chronic disease. They have expertise in the dynamics of a consultation between a doctor and patient, and develop long term, trusting therapeutic relationships with their patients.

In short, General Practice is easy to do badly, and hard to do well.

For this reason, there is a training program for doctors to become fully qualified GPs. A medical student will train at university for anything between 5 to 7 years, then do an intern year as a junior doctor in a hospital, and go on to do further work as a Resident Medical Officer in hospital. During this time, they gain a broad experience working across many in-hospital specialties, such as emergency, paediatrics, medicine and surgery.

Over the last few years, some doctors in these hospital positions had the opportunity to do a short placement in general practice under supervision. This program was called the Post-Graduate General Practice Placements Program and you’ll hear it referred to as PGPPP.

The idea was to give junior doctors some experience and understanding of general practice, otherwise the only opportunity they have is when they choose it as their career! The PGPPP was defunded in the last budget and is not continuing.

GP training itself consists of a year as a Resident Medical Officer, followed by two years in various general practice settings. At this stage of their career, doctors are called GP Registrars. They usually rotate through several different practices, which may include an Aboriginal Medical Service. There are also opportunities to do extra training in particular areas of interest, such as obstetrics, anaesthetics or paediatrics. Some registrars work part time in a university setting on a research project – an academic term.

In total, training is a minimum of three years (including that hospital year) and is completed after passing the Fellowship of the Royal Australian College of General Practitioners exam (FRACGP). Some registrars in rural areas do an extra year of training to gain Fellowship of the Australian College of Rural and Remote Medicine (FACRRM) or the Fellowship of Advanced Rural General Practice (FARGP) from the RACGP.

Once a doctor has either FRACGP or FACRRM (or both), they are deemed competent to work unsupervised anywhere in Australia, and they are entered on to the Vocational Register with Medicare (or a VR GP).

The curriculum for training and the standards for training posts are set by the Colleges – the Royal Australian College of General Practitioners (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM).

The bulk of the training occurs in general practices across the country provided by an experienced GP Supervisor. Other training occurs in Aboriginal Medical Services, in sexual health clinics, in prisons, and in academic GP Units. The training is co-ordinated by one of 20 Regional Training Providers (RTP), under contract to GPET, a wholly owned government subsidiary.

Into this mix are all sorts of representative organisations. The GP Registrars Association represents GP Registrars, the GP Supervisors Australia represent GP Supervisors. Medical educators are GPs employed by RTPs to provide and co-ordinate out of practice teaching.

So, to the Convention. The budget in May announced that GPET would be dissolved at the end of 2014 and its functions taken in to the Department of Health. The number of staff involved would be halved.

On top of this, the RTP roles will cover a larger geographic area (so there will be fewer of them). They will be put out to tender during 2015. It is possible that a range of organisations will tender, including current RTPs, Universities and Medical Schools, private companies or even Medicare Locals will tender for the new organisations.

The sense of uncertainty about the future was a constant presence at the conference – while GP training will be happening, no one knows what structure it will have.

Into this uncertainty strode the opening keynote speaker, Robin Youngson, founder of HeartsinHealthcare. He acknowledged the uncertainty and set the tone for the conference, eloquently setting out a call for compassion in health care.

“Remember,” he told us, “that it doesn’t matter what structures are around you, you can always care.” This message was well received by this group, who generally are motivated by the idea of producing good, compassionate doctors, not just knowledgeable mechanic ones.

Though Youngson was to some extent preaching to the converted, there was a sense that this message needs to be heard. There was evidence presented that a health system that is built to enable compassion results in better health outcomes across a range of conditions, and is also cheaper. This is a message that should be heard widely among policy makers, but is always at risk from the gravitational pull that looks like efficiency.

We heard impressive evidence that compassion from the doctor results in biological and chemical changes in the patient, though this is perhaps a very anaesthetic take on what could be conceived as a moral issue. If treating people with compassion is the right thing to do, does it matter that a gene is upregulated when it occurs?

John Launer, a GP and Family Therapist in London, gave a complementary keynote. His talk was about using narrative techniques in clinical care and teaching. He contrasted a narrative approach with the conventional approach taught to doctors.

At its purest, the medical model assumes there is a set of facts held by the patient about their condition, which the doctor uncovers using a set of questions. While no GP worth their salt uses this approach exclusively, the techniques of doctor and patient jointly build a shared understanding of the patient’s experience of illness.

Themes that overlapped in both keynotes were the importance of being fully present and emotionally available in consultations, and John Launer touched on ways of teaching this too. Perhaps ironically for a conference celebrating GPs as Superheroes, this approach is really about two flawed human beings in a room.

A regular highlight of GPET Conventions continued this year – the imagination of the participants. This ranged from the fancy dress costumes for the dinner, to the flashmob singing, to a session devoted to a series of paper presentation limited to 3 minutes each and a paper outlining the benefits of GP teaching while out walking in the Southern Highlands of NSW – simple and genius!

With a high proportion of young GPs among the delegates, there was a large social media presence, resulting in the conference trending in Australia.

There was little certainty about the future of GP training, but neither was their pessimism. As Professor John Murtagh, the elder statesman of Australian general practice, said: “GP training must continue.”

There’s a committed cohort of GPs who want to do the job well and train others to do it well. Like caring, the structures will change, but the work will continue.

• This is the first of a two-part Wonky Health series; the next instalment will investigate the impact of planned changes to the higher education sector for the health workforce.

• Declaration: Dr Tim Senior received complimentary registration to the conference as he was covering it for Croakey.

Tim Senior and Croakey thank and acknowledge all those who contributed to the crowd-funding campaign to support Wonky Health – more details here. All Wonky Health columns are compiled at this link.