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.)

 

Counting our blessings

US dollarsAustralian general practice has been pummelled over the past year. With its proposed co-payment plans, prolongation of the rebate freeze, defunding of Medicare Locals and shake up of Vocational Training among others, the Abbott government has delivered punch after punch.

Understandably, many of us have become disillusioned, angry and distrustful. Some are fantasising about a career change or considering early retirement. Meanwhile, there are unprecedented numbers of medical students and prevocational doctors asking, “Should I even consider a career in general practice?”

When under attack counting one’s blessings does not come naturally, but this is exactly what’s needed. I don’t want to sound like the kind of doctor who tells his patient “Cheer up, it could be worse”, but will briefly reflect on a medical system more broken than ours, despite multiple resuscitation attempts.

According to statistics from the World Health Organisation, in 2012 the US spent more than twice as much on health per capita than did Australia ($8,895 US cf. $4,058 US)(1). Much of this was private expenditure, but even so, government spending on health in the US is higher than in Australia (in 2012, 8.3% of GDP cf. 6.1% of GDP)(2). And what do they have to show for it? Lower life expectancies, higher rates of premature death, unhappy doctors and patients financially crippled by medical bills.

At times of life-threatening illness, having to worry about accumulating massive medical bills is a significant extra burden. I speak from personal experience.

Last December, while on vacation in the US, I developed pyelonephritis and became pretty ill, very quickly. To complicate matters, the infection brought on premature labour. My newborn daughter, Amalie, was rushed to the NICU, and I found myself in a high dependency unit with early sepsis. Three days later, my beloved daughter’s system was overpowered by the E. coli infection, while my body, with the help of modern medicine, was well on its way to recovering from it.

There are no words to describe the pain felt. While the medical and nursing staff did everything they could to comfort, those working in the finance department were not so empathetic. Within hours of losing Amalie, I was presented with hospital bills (not including physician fees or other charges) for over $70,000 US, and told “We expect payment at the time of service.” Salt was rubbed into my already almost unbearable wound.

I couldn’t get back to Australia fast enough.

Many of our current woes are because Australian general practice is so directly and largely dependent on government funding. We GPs are tremendously vulnerable to the whims of politicians whose motives are often self-serving rather than altruistic and whose promises are meaningless. On the flip side, when done well, there are big benefits for patients and doctors alike in government playing such an active role in healthcare funding and regulation. Keeping private health insurers, drug companies and other health-related corporates on a leash helps limit overall health expenditure, and therefore the downstream financial and emotional consequences for vulnerable patients.

I’m not for a moment suggesting that we lie down and take the ongoing beating that’s thumping our profession, or that the proposed changes are not ill thought out and unfair. Quite the opposite. Individually and collectively we need to take stock, remind ourselves of all that is good about Australian general practice, and then use this to further ignite our passion and do whatever we can to defend and strengthen our great profession. Let’s help make it something we can enthusiastically recommend as a rewarding career choice for our best and brightest, without crossing our fingers behind our backs as we do so.

References

 

First published in Good Practice magazine, March 2015