Time is right to rethink GP training model

Registrars are emerging from hospital work increasingly anxious and unprepared for general practice, says new Australian research

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Future GPs are not learning the skills they need in efficiency-driven, sub-specialised hospitals, according to new Australian research.

The report, published in the current issue of the MJA, sets out a case for changing the training model, saying registrars are emerging from hospital work increasingly anxious and unprepared for general practice.

The investigation 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.

For their part, registrars described the transition as “scary and isolating”, according to the report.

“We set out to find out what questions registrars were asking their supervisors,” Dr Wearne told The Medical Republic.

“As we looked, more and more patterns emerged.  They are always asking about skin, about musculoskeletal, about how I do something in general practice when it’s not how I used to do it in hospital.

“They are faced with conditions in general practice that they didn’t see in hospitals.”

Dr Wearne said both general practice and hospital settings had evolved in many different ways, but the GP colleges’ requirements for hospital training had not yet taken account of those changes.

The findings indicate that the current training regime is sub-optimal in preparing junior doctors for general practice in a number of ways.

“The illness scripts that juniors develop are for a very different spectrum of illness than seen by GP registrars, increasing the potential for diagnostic and management errors as the lower likelihood of serious disease reduced the predictive value of diagnostic tests,” the paper says.

In a welcome step, juniors worked fewer hours than they did some decades ago.  But continuity of care is reduced and there was  less involvement in clinical decisions.

Shift work had eroded opportunities for learning from senior doctors, and those opportunities might be narrowly focused.

“Hospitals have become so much more sub-specialised, “ Dr Wearne said.  “You might learn a lot about the knee, for example, in an orthopaedic term, which might be your only surgical term.”

The paper sketches out possible solutions – some more radical than others.

The UK, for example, is considering “whether medical training needs to be shorter, broader and more geared towards creating generalists who can deal with multi-morbidity”.

Current discussion in the UK was questioning whether hospital training is necessary at all, while Canada had adopted a selective approach, Dr Wearne told TMR.

For example, in Canada it took two years to learn to be a GP, with no internship.  A trainee could learn to deliver babies in the practice, rather than having to do a standard six or 12-month term that in Australia would also be accredited for training as an obstetrician or gynaecologist.

“The general practitioners decide that this is on our curriculum:  while we are delivering babies we will teach within our practice and  (a trainee) will go back to hospital for some things, specifically and efficiently what is needed for general practice.”

Dr Wearne, a practising GP who also serves as a medical adviser to the federal Department of Health, said Australia’s GP training could also be improved in smaller ways requiring little or no disruption.

In the run-up to GP registrar training, junior doctors would benefit from a better understanding the scope of practice to make the best use of their hospital time.

“If you know what you are aiming to do in the end, it will help you target your learning.  While you are listening to someone’s chest you are also looking at their skin. You are learning along the way things that you are going to use in practice.”

Similarly, IMGs unfamiliar with the Australian health system could learn first-hand about the scope of general practice by sitting in with GPs before they began hospital rotations, Dr Wearne said.

“If they have a choice between going to see a rare case or seeing  lots of kids with diarrhoea, they’re actually better off seeing the kids with diarrhoea.”

Clear signposts about the scope of practice, education about the mechanics of Medicare and knowledge of practice computer systems could also take away some of the stress for new GP registrars.

In setting out the case for a GP training rethink, the paper also makes another strong point.  The time is right.

“Given the bottleneck in hospital junior doctor training positions and, and junior doctors’ concerns that that their stressful, demanding workloads are of questionable educational value, it is timely to reconsider the effectiveness of this preparation for general practice,” it says.