GP rotations may be turning med students off

Early exposure to general practice should be one way to attract new blood, but a stretched workforce means they can have the opposite effect.

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When rural GP Dr Hamish Steiner suspected many medical students were getting very little from their general practice rotation, he wondered whether a good rotation was actually an incentive to choose the speciality.

Recently, the Cooma, NSW-based GP posted on Twitter, asking if there was any research on the question, and received a wide range of reviews from students who had completed a GP rotation.

From: “I sat in the corner and watched a bunch of niche lifestyle prescriptions that were more like coffee mornings. I never wanted to be a GP after that.”

To: “City GP was great, I parallel consulted in other rooms and presented histories, felt like I was part of a team, and improved patient flow.”

Their comments came as the Australian Medical Students’ Association (AMSA) last week brought Health Minister Mark Butler and opposition health spokesperson Senator Anne Ruston to a roundtable, along with industry leaders and educators, to discuss how to reverse the decline in medical school graduates intending to enter general practice.

“We have a lot of students coming through our practice,” Dr Steiner told TMR. “Some say they’ve had another GP attachment somewhere and it was terrible – they sat in the back of the room and weren’t allowed to do anything for two weeks. Or the GP told them general practice was a terrible occupation, and they should choose something else.”

Is there strong evidence that exposing med students to GP work makes them more likely to become GPs??
From talking to a number of students , it’s would seem their GP placement is not a great experience….
They sit and watch and do nothing…

— hamish (@CoomaDoc) October 8, 2022

Getting their hands dirty

Lack of involvement was often the reason for a poor rotation experience, one third-year medical student told TMR.

“I think one of the reasons it happens is because the uni doesn’t really screen the GPs,” said the UQ student, who asked to remain anonymous. “Some of them are just there to get that cash and have no interest in teaching, but others are completely different – they’re so interested in education.”

While the student had found their own GP rotation valuable, they had got more out of their hospital experience.

“So many of the [GP] consults are extremely time-pressured and you can’t get through what you want to so there’s not a whole lot of critical medical thinking,” they said. “There’s so much rapport building – and GP is so important in achieving things like preventative healthcare measures – but it’s way easier to see medicine in action when you’re in the hospital.”

One solution could be parallel consulting, according to AMSA president Jasmine Davis. With this approach, the student sees the patient on their own, presents their findings to the GP, then they develop a health management plan together.  

“I’ve been lucky to have done parallel consulting in rural general practice, but we’re not currently seeing that rolled out everywhere because we’re just lacking in the infrastructure and funding for that model to exist everywhere,” Ms Davis said.

“Unfortunately, the incentive payment for GPs who teach isn’t financially attractive compared to how much you could earn if you didn’t have the students.”

Designing a GP rotation

Dr Fiona Robinson, associate professor in general practice at Sydney university, is not entirely surprised by these comments.

“I think it’s been a mistake in the past to have one term, where the students only do general practice, and it’s usually been towards the end of their degree,” Professor Robinson said. “They’ve had all this hospital exposure – the frantic, acute end of medicine – but they don’t have an appreciation of what goes on in the community. And 95% of medicine goes on in the community.

“We’ve introduced a program in year two, as well as year four, with expectations that their year two experience will be more supervised because they’ve only been doing medicine for 12 months,” she said. “From a safety and patient expectation perspective, students are more likely to assist the GP or observe the things that are going on within the practice.”

Once students have become more confident in medicine after exposure to several more specific areas of practice, they do another GP rotation in year four, with eight weeks in practices and in more than just one context.

“Context is everything in general practice,” Professor Robinson said, “so they tend to have four weeks in an urban setting, and then four weeks rurally. If students don’t understand the context in which they’re working, or where their patients are coming from, they’re going to miss a lot of the cues and the reasons behind some of the presentations.”

GP vs non-GP

While some students go into their GP rotation with an open mind, others may have already decided to specialise in another area.

“I think the generation of students coming through, we’re pretty lifestyle-conscious,” the UQ student said. “If you want to have any sort of life, general practice is kind of the one that you can do.

“A lot of people look at themselves in their 30s and they’re thinking about families across the next 10 years and, you know, GP sort of aligns quite nicely with that.”

Many practising GPs would disagree with that, pointing out that the years invested in training and fellowing coincide with peak family-starting time, and that GPs in practices get no maternity or other leave allowances.

However, the next generation also has its eyes on another incentive.

“To be honest, it’s about the money,” the student said. “Why would you flog yourself like that, given your level of education and the amount of time you’d be working? It’s a bit of a no-brainer, I think.”

Movin’ to the country

Exposure to rural practice has always been one of the most significant benefits of a GP rotation, and Sydney University’s program has been very popular overall, according to Professor Robinson.

“There are those who sign up happily and usually have an incredibly good time,” she said. “Then there are those we encourage to go, and when they do they are so surprised. But there are also those who go but drive back to Sydney every weekend and don’t really embrace the community, which is part of the joy of rural general practice.”

While she supports GP exposure being mandatory, Professor Robinson worries about how this might affect the stretched rural workforce.

“If you make every medical student go rural for a certain number of weeks, I am concerned about the workload for the lessening number of rural GPs who can take students,” she said. “Where students have a negative experience, it’s often where the GP is overwhelmed by their other work.

“If a practice understands and is on board with providing education, then that’s not so important, but if you’re a practice with two or three-week waits to see a patient, slowing down to explain everything to a medical student will sometimes add to the stress.”

Counting the cost

“The remuneration for having a student, despite it going up a couple of years ago, is still not really an incentive,” Professor Robinson said.

And according to Dr Steiner, the benefits of remuneration are often in the hands of the practice.

“Some practices keep half the [PIP] money, some practices give it all to the doctor,” he said. “By and large it’s quite varied but it probably doesn’t go to the doctor who’s doing the rotation as often as it should.

“The rural loading means an extra 20% or 30% for us, so it’s like $260 a session. It’s not an insubstantial amount of money and we just incorporate it into the doctor’s normal income. So if the doctor has a student for the day, that’s around an extra $500 added on to their income for the day and they get a percentage from it.

“It’s potentially a benefit for the practitioner as well as the student, but it depends on how the practice handles the money.”