As the lines between the professionals begin to blur, perhaps it is time that we ensure every Australian health professional has requisite level of skill.
As a medical graduate of the early 1990s, I was one of the first cohorts to do compulsory GP training.
Before then, it was possible to set up as a GP with no further training than an undergraduate degree and an internship, although there were certainly options to deepen your knowledge before “hanging up your shingle”.
Compulsory GP training was introduced to protect the public. A number of governance agencies decided that it was necessary, to ensure every patient with every condition could trust their GP to have a baseline level of knowledge and skill. At the time, keen GPs were already doing this training, but many were not, and some were risking public safety.
As a GP with over 30 years’ experience designing, leading and evaluating training programs for general practice, I’ve learned a few things about training health professionals to tackle the messy, dangerous and unpredictable world of primary care.
Any GP can tell you that patients aren’t always competent in differentiating between “big sick and little sick”. Many patients are over-concerned, and as a rural doctor, I spent a lot of time with patients who weren’t concerned enough about their symptoms.
Because of this, we can’t rely on patients to decide which health professional is safe to see with their undifferentiated symptoms.
Extending scope of practice safely
As the scope of practice in primary care fields changes, it is essential that the public are kept safe by requiring a baseline level of skill for all professions seeing unreferred patients.
Pharmacists are required to train for 90 minutes using an online module to prescribe antibiotics for UTIs. Nurse practitioners do a Masters degree in addition to their clinical experience to take on a number of GP roles, including independent diagnosis and management. The Australian Psychological Society is making a case for psychologists to prescribe antidepressants.
The average Australian is unlikely to know the difference between these, trusting health professionals to work within their sphere of competence.
I am concerned that while there are keen and competent nurses, pharmacists, physiotherapists and psychologists at the moment who are extending their practice into areas traditionally covered by GPs, there are others in their professions who may, frankly, be dangerous.
If there’s one thing I learned leading the remediation of registrars, it is that the danger lies in health professionals who don’t know what they don’t know.
Unlike hospitals, there may be little backup in primary care. Autonomous prescribing means there may be no team behind a primary care health professional and so there is ample opportunity to make errors that are not detected or effectively managed.
Given this uncertainty, should we consider requiring a Primary Care Fellowship for all primary care professionals seeing unreferred patients?
Why consider a Primary Care fellowship?
Having written into the curricula of undergraduate, postgraduate, vocational and CPD training for university and college contexts, there are a few elements of GP training that may not be obvious, but are essential for producing a safe practitioner.
I believe we should include these in a Primary Care Fellowship to ensure all Australians have access to safe primary care.
Supervision
Supervisors in general practice tell me that the most terrifying part of having a GP registrar in their first term is “unconscious unknowing”.
Some registrars never master the skill of working within their safe scope, and GP training has been designed to detect them, remediate them and potentially counsel them out of training, to protect the public.
In GP training, we have learned that it takes 18 months of supervised practice to reliably detect the unsafe registrar. Registrars may perform well on exams, but not sustain safe practice in the real world. I believe intensive supervision by well-trained supervisors is essential to ensure safe practice.
Managing patients with diverse and complex needs
For at least the last 30 years, GP training has required at least 15 hours of compulsory Aboriginal and Torres Strait Islander training, alongside other training incorporating Aboriginal and Torres Strait Islander expertise.
In doing so, the program now has a network of extraordinary cultural educators and mentors who have reshaped and enriched the GP curriculum and training experience of our registrars.
GP registrars are also required to demonstrate safe practice within other diverse communities, especially those who have poorer health outcomes. This includes patients with cultural and linguistic diversity, those with physical, mental and/or intellectual disability, people from the LGBTIQA+ communities, those with low literacy and health literacy, and others.
Competence managing the unique needs of Australia’s most vulnerable is essential to ensure safe practice.
Diagnosing the full range of health conditions across the lifespan
The health professional seeing the unreferred patient needs to be trained to detect the patient who is rare.
It may not be obvious to the policymakers, but we will get an average good outcome getting a less trained health professional to see a young person with fever, because the vast majority of them will have a simple virus, or clearly be sick enough to send to accident and emergency.
The problem is the one in a thousand with early meningitis.
The policy question is whether that one adolescent with meningitis justifies investment in a health professional more highly trained in diagnosis at the triage stage. GPs are not going to detect all the people with meningitis, but with at least 10 years of training, and 50 hours a year of compulsory CPD they are more likely to do so than a pharmacist, physiotherapist or nurse practitioner.
There is deep evidence for multidisciplinary teams managing chronic disease effectively and efficiently. However, there is a lot less evidence for non-GPs coping with the patient with fatigue, breathlessness or non-specific pain.
If we are relying on primary care professionals to manage the deep uncertainty of patients with non-specific symptoms, we need to ensure they are well trained in diagnosis across the vast field of human illness.
Competence in interpreting evidence and the capacity to adapt practice
All health professionals need to be competent in the analysis and application of evidence.
GPs are now required to undertake reflective practice and audit every year as part of their CPD, presumably because AHPRA has decided this is essential for them to demonstrate safe practice.
If this is a reasonable requirement, it should be generalised to all health professionals working in primary care.
Related
Management of professional boundaries
Some therapeutic relationships are challenging. Some are dangerous. Although AHPRA has oversight over all health professionals, and their maintenance of appropriate boundaries, there is a need to ensure all health professionals are well trained in the complex therapeutic relationships that can tax the most competent of primary care professionals.
GPs have used tools like Balint groups, consultation models and family therapy training since the 1950s. It seems wise to generalise this expertise to other primary care professionals.
Confidentiality, consent, record-keeping and quality improvement
If primary care health professionals are to share responsibilities, it seems important to share the same patient safety requirements.
At the moment, there are very different understandings of these requirements across the disciplines, which has the potential to raise risks when care is shared across disciplines.
As health professionals, our greatest responsibility is to protect the public. While the public can rely on GPs to have met the training and examination requirements of a GP fellowship, they don’t have the same assurance when other health professionals see them for unreferred presentations.
As the lines between the professionals begin to blur, perhaps it is time that we ensure every Australian can expect their health professionals to have a requisite level of skill. If we can share responsibility for patients, surely we can work together to write a shared curriculum.
Associate Professor Louise Stone is a working GP who researches the social foundations of medicine in the ANU Medical School. She tweets @GPswampwarrior.
