12 March 2018

Training rethink welcomed, but wider input needed

Education General Practice Hospitals

GP supervisors and registrars are demanding a say in designing a fairer, more relevant pathway to general practice ahead of the handover of training responsibilities to the two GP colleges.

New research has thrown a spotlight on shortcomings in the current system, due to a growing divergence between the experience junior doctors get in increasingly subspecialised hospitals and the skills they need in general practice.

The research, led by Dr Susan Wearne, a GP academic at ANU, found GP supervisors had observed gaps in trainees’ basic clinical knowledge and diminished skills in decision-making and managing multimorbidity, while registrars making the transition from hospitals found it “isolating and scary”.

Dr Wearne said that the general practice and hospital settings had both evolved in many different ways, so that registrars coming from hospital work were increasingly anxious and unprepared for general practice.

Dr Melanie Smith, president of the GP Registrars Association, said she believed many registrars kept their heads down and suffered in silence, just trying to get through their training.

“There is concern about that cohort, because they don’t talk about it to the regional training organisations. They don’t get on social media and make a fuss. The RTOs are concerned about that, too.”

The handover of training control to the RACGP and ACRRM from the Australian General Practice Training program will begin in 2019 and be completed in 2022.  The colleges were handed responsibility this year for selection of the 1500 would-be GPs, split 90:10, respectively.

So far, however, the registrars’ association has not been included in formal consultations about new training arrangements among the colleges, training organisations and federal authorities.

Dr Smith said that situation “desperately needs to change”.

This lack of clarity about the future of training added to the pressures of tougher competition and heavy workloads on junior doctors, she added.

“In the past few years, we’ve seen a lot of change in the training arena, without any clear direction about where it’s going and how that’s changing the quality of training,” she told The Medical Republic.

The Wearne report, published in the current MJA, showed up the dearth of serious research to date into what kind of training was the “right fit” for GP registrars in Australia, Dr Smith said.

“I’m thinking it would be great to look into this more deeply and come up with new and better ways to prepare people for practice.

“Becoming comfortable with the uncertainty of general practice, and knowing when and when not to intervene, are things people coming from hospitals find particularly difficult.”

More research involving Australian GP supervisors and registrars could help guide strategies, including policies to make hospital work more relevant.

Dr Steve Holmes, chair of GP Supervisors Australia, said the evolution of hospital care meant registrars could commence GP training with far less experience in clinical decision-making than new entrants less than a generation ago.

This increased the demands on teaching practices, ramping up the responsibility and time required of GP supervisors to ensure the safety of patients, he said.

“Not only have the number of registrars increased, but the time required to bring them to competency is hugely variable,” he said.

“In large tertiary centres, not only can the acuity of patients be higher, but a junior doctor will have a lot more doctors, specialists and specialist clinics between them and the patient presentation, and then again between the presentation and the agreed treatment path.

“This means junior doctors from these settings are vastly lower on the decision-making tree and often less equipped when they commence their rural terms compared with GP trainees 20 years ago.”

Despite the increasing reliance on GP supervisors, however, support for training required by the colleges and RTOs and funded by the federal department of health had remained unchanged in almost 20 years, he added.

With some 1500 intending GP trainees now entering the system each year, the RACGP has suggested there should be more intern placements in general practice could be an effective solution.

Dr Holmes agreed that having junior doctors rotate through general practice would be an effective strategy for teaching clinical reasoning and decision-making skills early in their careers.

“But, importantly, these experiences need additional supervision,” he said.

Increasing direct supervisor support may lead to “greater efficiencies and more sustainable outcomes”, he said.

“We welcome the opportunity to engage.”

ACRRM President Dr Ruth Stewart said health services needed to rethink the concept of junior doctors in training being the mainstay of the hospital workforce.

“This is one of the reasons that junior doctors working in subspecialty teams in large tertiary hospitals may not be suitable for general practice and the areas they will ultimately be working in,” Dr Stewart told TMR.

“It’s a problem, not just because of the experience they get in hospitals,” she said, pointing out that the rural college needed GPs with procedural expertise as well as cognitive skills.

“At the moment the workforce needs of the tertiary hospitals are driving the training opportunities and therefore what specialties people train for,” Dr Stewart said.

“That has not necessarily been linked to the workforce needs we have in Australia.”

Dr Smith said junior doctors in hospitals were often chasing their tails doing paperwork rather than interacting with patients and thinking up management plans.

She noted the Wearne report’s suggestion that hospital training could be more valuable if junior doctors had the benefit of a general practice perspective.

“That’s the thing we lost with the PGPPP program,” she said, referring to the Prevocational GP placement program, axed in the 2014 budget.

“Junior doctors had some general practice experience and went back to hospitals  and they were probably better able to recognise where what they were doing was going to be relevant to their future practice as GPs.”