General Practice – a strong-link or a weak-link profession?

Not long ago I ran into a recently Fellowed GP whom I’d had the pleasure of supervising as a medical student several years ago.  She was exceptional – bright, keen and an amazing communicator who just “got it”.  During her time with me she joined in with my group registrar teaching and exam prep workshops (AKT/KFP and OSCE).  In the mock OSCE she did better than most of the registrars who were about to sit their Fellowship exams.  After three weeks in general practice (as a student) and a two hour session on what the AKT and KFP were about, she passed both written practice exams (which were shorter than but of a similar standard to the real thing).  Mind you, she wasn’t perfect – there were gaps in her knowledge, and nothing can replace clinical experience, but she was safe.  She knew what she didn’t know.  She knew how to find out.  She was a fantastically self-directed learner.

Fast forward the present day.  I asked her how she found GP training, which she had done with a now-defunct RTP.  She started with some generically nice comments but on my drilling down further she admitted that although it was great socially, the education program didn’t really challenge her and she felt it was, in essence, an exercise in box-ticking.

There are certainly many bright registrars who are extended and challenged during GP registrar training,  but she got me thinking, are we going about this the right way?

The “best and the brightest” are chosen for AGPT training.  Meanwhile, there are large numbers of general practice trainees who are working essentially unsupervised and unsupported.  Some of these have gone down this route by choice; however many are doing so because they are either ineligible for AGPT (usually due to their residency/registration status) or failed to get into the AGPT program.  There are some fabulous GPs amongst them, but there are also many that struggle, both in practice and with their Fellowship exams.  The support for these doctors just isn’t there.

While pondering this inequity, I was reminded of a podcast to which I’d recently listened.  It discussed the difference between weak- and strong-link sports.

soccerIn soccer, research shows that the way to maximize wins is to improve the worst players.  Success typically comes to those teams who have better 9th, 10th, and 11th players rather than those who have the best player.  It is argued that this is due to the nature of the sport, being that one player typically cannot create opportunities alone.  Thus it makes sense to invest in making the least talented players better.  Soccer is a weak-link sport for this reason.

basketballAlternatively, basketball is a strong-link sport.  Typically, the team with the best player wins.  It’s a star-driven sport because one player can have an outsized impact on the game despite also having the worst player on the floor as a teammate.  It is nearly impossible to prevent a great player from getting the ball, and/or helping his/her team score.

The question this threw up for me is whether Australian General Practice is closer to soccer or basketball.  Should we spend more time and resources trying to create a climate that maximizes the number and the relative success of already really successful and talented doctors, or should we do more to help those who are unsuccessful?  Obviously both are important, but which approach best defines and strengthens our profession?

Personally, I think we should take the weak-link approach.

I hasten to add that I’m not advocating a drop in standards, nor a regression to the mean.  We will still have our GP stars, and these inspiring individuals will continue to do our profession proud.  They still need (and deserve) support during training.  My point is that their needs are different, and perhaps the standard AGPT program is somewhat wasted on them, or at the very least would be more useful for others.  I would like to see a more tailored approach.

I’m also not suggesting that any doctor, regardless of suitability, should be working in general practice, and supported to do so.  There should be, in my opinion, baseline competencies, knowledge and experience required – a cut-off point, so to speak, below which a GP provider number cannot be issued.  This would require everyone entering general practice, not just those applying for AGPT, to undergo a rigorous selection process perhaps including an entrance exam.

For those who have reached the required standard of entry, I would like to see the distribution and type of support based on the needs of individuals.  It would be fantastic if extra Commonwealth funding was put towards GP training, but that is unlikely to happen. However, I think we could do so much more with what we’ve got. There are limited resources available, but wouldn’t be wonderful to see quality training opportunities given to those potentially great GPs who have the most need for structured and supported training?

Pie in the sky thinking, but a girl can dream…

 (The views expressed are entirely my own and do not reflect those of my employers.)

 

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3 thoughts on “General Practice – a strong-link or a weak-link profession?

  1. Good thoughts, thanks. I would argue that RTPs and practices are in a position to tailor responses now. Pool the registrars, let the leaders lead the learning and work to get everyone up to speed. Every RTP with streams for registrars at different stages or a set number of times they have to do something should think again. Stars shine in the dark, and working with your peers to become excellent doctors is what we all need throughout our working lives.

    • Thanks Sam, I agree. I love the line “stars shine in the dark”. I guess what I would love to see is the support better spread not just among registrars but among all those training / working towards Fellowship in General Practice.

  2. Great blog post! Definitely the two tier system at present is a mistake- the most vulnerable groups working the longest hours with the least support. Conversely there is little incentive for the extension of the top tier registrars……Mind you, is this reflective of the profession as a whole?

    The specialist career path is structured around hospital funded training posts with built-in PhD pathways, and then the options of staff specialist jobs with well funded opportunities for ongoing research, teaching and support from junior staff.

    The general practice career path seems to reach a flat peak immediately post fellowship and after that it is a constant juggle of fee-for-service and portfolios of competing needs.

    Personally I have loved the freedom of the portfolio jobs that are available, but I am sorry to see the lack of support and formal career extension pathways throughout a post fellowship career. The year I got my PhD, there were only another 8 GP PhDs graduating across Australia….out of a profession of 30 000 of us, and compared with orders of magnitude more PhDs amongst specialty colleagues, it is a pity that so many bright, interested, motivated GPs and so many fine, interesting projects don’t translate into more publications, higher degrees and impact on the national dialogue of policy, academia and health system development.

    Surely the primary care equivalent of secondary care staff specialty and academic posts (all funded at staff specialist incomes) is the RTP/RTO. Might we not formalise these jobs, create more rigorous support, career progression and professional recognition of these roles by progressing through academic rungs, focussing on teaching and supervision rigour with an expectation of publications, higher degrees of some description (with adequate encouragement and mentoring) and associated, transferrable, internationally recognised job descriptions (Lecture/SL/AProf/Prof)? This could apply to both MEs and supervisors and create an ongoing culture of improvement, rigour and differentiation.

    Sorry about the brain dump:)

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