The rise and rise of academic general practice in Australia The Heads of General Practice are excited about partnerships with GPs and the community Kerrie A Lawson, Mabel Chew and Martin B Van Der Weyden |
MJA 1999; 171: 643-648 | ||
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→ Other articles have cited this article Introduction -
The struggle for identity -
Standing as an academic discipline -
Role of academic general practice -
Divisions of General Practice -
Evidence-based medicine -
Improving GP morale -
The way forward -
Authors' details
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| Introduction |
Fifty years ago, a general practitioner was described by Lord Moran
(personal physician to Winston Churchill) as someone who had fallen
off the ladder of specialist training. Nowadays, general practice is
increasingly recognised as a "specialty" in its own right that
requires specific training, and "some specialists might be regarded
as people who have not been able to get onto the ladder of general
practice", according to John Marley, Professor of General Practice
at the University of Adelaide.
This change has accompanied the development of general practice as an academic discipline in Australian medical schools -- all schools now have at least one Professor or Associate Professor of General Practice and an academic unit called General Practice, in most cases a standalone department. We talked to the Heads of these departments and units to discover how academic general practice is faring and what role it takes. We also asked their opinions on some of the challenges facing general practice today. | ||||
The struggle for identity | |||||
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Academic general practice has had to struggle for its place in
Australian medical schools, and the struggle may not be over.
According to Max Kamien (University of Western Australia), general
practice was to some extent "foisted" on the universities in the 1970s
by the Karmel Report, which called for the establishment of
departments of community medicine. In the beginning, his department
had difficulty obtaining staff and curriculum time from the
university.
The community medicine departments included general practice in their concerns, but not necessarily as a focus, and many underwent metamorphoses and name changes, commonly with the addition of public health. In 1979, Kamien's department was the first to become a standalone Department named General Practice. Only in the 1990s have others emerged and, while "the last eight or nine years have seen a real upsurge within academic general practice", according to Alex Thomson (Tasmania), many Heads commented that academic general practice is still fairly young in this country. "We are all running relatively small units, many of whom have quite divergent, non-complementary interests", commented Richard Hays, from the new medical school at James Cook University. "Other academic departments have wanted to assume responsibility for academic general practice at times, mostly when it has been the target of external funding," he added. | |||||
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Opinions on the need for a standalone department vary. Doris Young
(Melbourne) is looking forward to gaining the identity of her own
department in 2001, when General Practice splits from Public Health.
In contrast, Chris Del Mar (Queensland) says his unit made a "rational
decision" to stay within the Department of Social and Preventive
Medicine. "You need a critical mass of academic GPs to do productive
work, but I don't think it really matters how you group them. Remaining
in the population health care arena enables interesting blends of
disciplines, as well as economy of scale." Mark Harris' unit (NSW) has
resisted moves to become a separate department for similar reasons.
In Tasmania, the struggle for identity is not over. After repeated restructurings and renamings, the department is expected to be downgraded, with possible loss of the Chair, as the university "rewrites its strategic plans", said Thomson. | |||||
Standing as an academic discipline | |||||
| A barrier to the rise of academic general practice has perhaps been a lack of standing in the eyes of other academics. According to Young, one reason her medical school was last to appoint a Professor of General Practice (in 1997) was probably the erroneous "perception that general practice lacks an academic focus". This was especially a problem at Melbourne, which is "very focused on biomedical research". | |||||
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However, nearly all the Heads felt that general practice is now respected as an academic discipline, as evidenced by their departments' representation on key university committees, in administrative positions and in the curriculum. "I don't feel that I need to go out and sell general practice on a day-to-day basis in the medical school any more", said Marley. A major factor in this rise has been the recent dramatic curriculum changes at many medical schools, with the adoption of integrated, non-discipline-based courses that use problem-based, self-directed learning. The effect is especially evident in the new graduate-entry schools: for example, at Sydney, "the new graduate program undertook to embrace general practice as a key clinical discipline", said Michael Kidd. In addition, "in the last 10 years, Australian academic general practice has made important research contributions that have at last been recognised by other disciplines", said Del Mar. Although "general practice research is still evolving", said Kidd, "the departments are building up a core mass of GPs with research skills, master's degrees and doctorates". The achievements of individual departments have also contributed to respect. For example, WA has been "a pathfinder" of Aboriginal health, rural medicine and palliative care (Kamien), Monash has made "valued contributions to educational innovation and curriculum development" (Leon Piterman), and Flinders is "a useful conduit for the school to establish community links for research and teaching" (David Weller). And in northern Queensland, where the James Cook medical school is growing from the University of Queensland's northern clinical school, "general practice in rural health is in a sense the major discipline", explained Hays. Indeed, he has been appointed Foundation Dean of the new school. However, according to Thomson, "scratch the surface and the old attitude is still there", as evidenced by Tasmania's current problems. And the new respect for general practice is not necessarily reflected in financial support: general practice is particularly disadvantaged by university funding formulas that favour departments associated with hospitals or research institutes, said Kamien. According to Hays, a greater credibility problem than that with other academics is probably with the "bag-carrying doctors". "It is very difficult as an academic to work more than two or three sessions of clinical practice a week. I think the profession of general practice has difficulty understanding that there are models other than the full time 10 or 11 sessions a week clinical model." | |||||
Role of academic general practice | |||||
| In the medical education programs, the departments do not see their role as turning out general practitioners (GPs) -- "vocational training is the next step that takes graduates to a desired standard of competence and confidence, so that they can practise independently," said Kamien. Rather, the departments wish to give true balance to the "undifferentiated" doctors that the medical schools are required to produce, turning out not "hospital specialoids", but doctors with "a broader view of the task of medicine". | |||||
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This broader view includes "an appreciation of the importance of patient-centred care and of the role of the patient and family in both the determination and outcome of clinical conditions", said Piterman. It also includes "an appreciation of the need for doctors to respond not just to individuals' health needs, but to those of communities, and to be able to work cooperatively with other health professionals", said Harris. Although not aiming to turn out GPs, "we want our graduates to gain a solid understanding of how medicine is practised outside a hospital setting and to have some active general practice role models", said Kidd, "so even if they never return to general practice, they understand where patients are coming from, both in urban and rural settings." Also mentioned were the desire for graduates to develop regard for "the expertise of GPs and their role as gatekeepers to the healthcare system" (Weller) and to recognise that general practice is "a legitimate and rigorous discipline of its own" (Dimity Pond, Newcastle). A further aim, particularly in the more rural states, is to challenge students to provide better care for those disadvantaged in obtaining healthcare, including Aboriginal and rural people. | |||||
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Contributions to the curriculum vary but fall into three main areas:
teaching of communication and clinical skills, problem-based
learning tutorials, and urban and rural general practice
placements, both compulsory and elective. All departments recruit
GP teachers, but have little way to recompense them beyond clinical
titles, access to university resources (such as information
technology) and relatively token payments. Many of the Heads were
hopeful that the new Practice Incentives Payments will recompense GP
teachers more realistically.
An emerging concept is that much medical school teaching could take place in general practice. For example, Flinders students can elect to spend a year in rural practice in the Riverland, learning all disciplines there. This has been "an unqualified success", said Weller. "Their exam results are just as good as, if not better than, those of the town-based students, and it sends a strong message that GPs are just as capable of teaching medicine as hospital-based doctors." Another major role of academic general practice is to conduct research: "We need to develop a rigorous academic basis for defending our positions as GPs, to analyse general practice's peculiarities and characteristics", said Pond. General practice research has "embraced the understandings from disciplines such as sociology and more qualitative methods", explained Thomson, and has the capacity to stretch beyond "the basic biomedical model" and "to ask the harder questions about health". According to Marley, more use should be made of the enormous clinical richness in general practice. He cited the 2nd Australian National Blood Pressure Study, "a major outcome study of hypertension being done entirely in general practice", as an example of the research that is possible. | |||||
Divisions of General Practice | |||||
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A major development in Australian general practice this decade has
been the Divisions of General Practice. Almost all the Heads were very
enthusiastic about the Divisions' potential to improve healthcare
and many aspects of general practice, while acknowledging that they
are in their infancy and "vary enormously in how well they function"
(Hays).
Most Heads stated that Divisions have many potential and actual benefits. By grouping GPs together, Divisions have helped "give them a voice" (Kidd), and provided "a forum for exchange of ideas" (Pond). They allow general practice to be approached as an entity (eg, to negotiate shared-care with local hospitals) and facilitate links with other healthcare providers. Divisions also offer an opportunity for GPs to have "an impact on health at the community level" (Thomson), and are "the best place to deliver education for continuing development of general practices" (Hays). Many departments work closely with Divisions. They are a source of GP teachers and are the "logical place to coordinate student placements", said Hays. However, Harris believes Divisions offer even more to medical education and has set up regional "clinical schools" to involve them in developing innovative ways of delivering community-based teaching. | |||||
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| Divisions are also a conduit for departments and GPs to collaborate in research. For example, Pond is undertaking a randomised controlled trial of the effects of educational and other interventions targeted at GPs on the health of their unemployed patients. Local Divisions informed the design of this project through focus groups and will help implement it. | |||||
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Many of the departments also provide support to Divisions. For
example, at the national level, Melbourne, Northern Queensland and
NSW run Support and Evaluation Resource Units that advise Divisions
on their functions. More locally, Monash was involved closely with
the demonstration project grants that were the forerunners of the
Division system, and now runs a resource unit that works with seven
local Divisions "to identify issues in the secondary and tertiary
health sector that may impact on local GPs, such as early discharge,
hospital-in-the-home and, more recently, evidence-based medicine
and information technology", explained Piterman. "Divisions have
also sought our expertise in developing and delivering educational
programs", he continued.
Many Heads were very enthusiastic about building further links. "Divisions are struggling with the concept of outcome", said Weller. "To work towards achievable, meaningful and balanced outcomes, they will need epidemiological skill and public health knowledge which a unit of general practice such as ours can provide." However, some reservations were expressed. Despite Weller's enthusiasm for "controlled links" with Divisions, he reported that "some academic GPs are concerned that they'll just use us for ideas, inspiration and methodological advice without much in return." "They must take care not to become too politicised and splinter general practice even further", warned Piterman. Further, Divisions may be a conduit for government agendas of change, according to Pond and Thomson, although Pond believes "those agendas can be modified by GPs' reactions in the Division". The most negative view came from Kamien, who argued that Divisions have not put their funds "to good use" and have "a poor track record" in general practice research and "a long way to go" in involving doctors. "They should stick to their original mission statement to get doctors together, provide good services in their local area, and marry curative medicine with public health medicine." Nevertheless, "provided they work closely with university units, both general practice and public health, and address priority areas in health and health system change within the communities they serve, they have the potential to do an awful lot of good", said Piterman. | |||||
Evidence-based medicine | |||||
| We asked the Heads for their views on evidence-based medicine (EBM) and its relevance for general practice. Many pointed out that obviously doctors should use the best evidence available and that EBM is hardly new -- "just a systemised method of obtaining evidence that, like most things, has taken 15 to 20 years to catch on", said Kamien. However, the development of information technology has provided "ways of organising the evidence much more systematically and perhaps more quickly, and of accessing it more easily", said Piterman. It has had an impact on medical schools. For example, Sydney "very consciously teaches continuing lifelong skills of critical analysis and information technology -- how to find the evidence to support clinical decision-making", said Kidd. | |||||
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However, all the Heads spoke of difficulties in applying EBM to
general practice: the evidence may not be available or may not be
pertinent. "Patients in general practice often present with
undifferentiated illness, but to apply the evidence you need a
diagnosis", said Weller. "The evidence, by and large, comes from
randomised controlled trials with populations that little resemble
the person with multiple illnesses and medications seeing the GP. The
best evidence may not be acceptable to the patient or may not produce
the best economic outcome for society as a whole", continued Marley.
Furthermore, there is a fundamental philosophical difference between EBM and general practice, which "regards every patient and illness as unique", said Thomson. "EBM is based on a series of snapshots of life", explained Hays, "while a GP is writing a book about an individual patient and has a longitudinal corporate memory of that patient. We need ways to marry these qualitative and quantitative approaches." | |||||
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Because of these difficulties, "weighing up the evidence should be
only one factor in clinical decision-making for any particular
patient", concluded Piterman. "EBM must be applied flexibly, not as a
rigid straitjacket", warned Harris. Many Heads also commented on the
need for research to underpin use of EBM in general practice. "We need
to translate EBM into 'best accepted practice' for general practice,
taking into account the evidence and also what GPs are telling us",
said Young.
Ultimately, EBM will be "quite liberating" for GPs, suggested Del Mar. "It is just another way of helping doctors and their patients come to clinical decisions. It will reduce GPs' need to consult specialists for advice and give doctors (and their patients) much more power." | |||||
Improving GP morale | |||||
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Recent surveys of Australian GPs have reported that their morale is
poor and that half would not choose general practice again if they
could turn back the clock. We asked the Heads for possible reasons and
solutions for this malaise.
Several pointed out the shortcomings of these types of surveys: low response rates, sampling bias, and lack of a control group. Nevertheless, the Heads agreed there is a problem, with many possible causes. These include the changes that affect the profession as a whole, such as the advent of evidence-based medicine and information technology, and the changing role of doctors, "who no longer hold all the knowledge" (Kidd). Pressures unique to general practice are the increasing expectations put on GPs (eg, to be "great counsellors and do it cost effectively" [Pond]) and their progressive deskilling. However, Pond and Kidd hoped GPs would "embrace the changes". If they "learn to operate within the new paradigm", said Pond, "there are enormous opportunities to develop new and enriching relationships with patients and to become respected, as patient advocates and coordinators of local health activities via bodies such as the Divisions". | |||||
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Many mentioned the discrepancy between the incomes of GPs and
specialists (particularly procedural specialists), and the
relatively poor (and falling) incomes of many GPs. This is combined
with perceived "threats to GP autonomy" from the Commonwealth
(Harris) and the Divisions movement (Hays). Some are hopeful that the
Relative Value Study will improve GP incomes. Others suggested
various alternatives to fee-for-service -- described by Harris as "a
millstone around GPs' necks". These included sessional payments
and, in particular, linking of patients to practices with
capitation, possibly blended with fee-for-service. Whatever
happens, money may not be enough to show GPs they are valued. "There
also needs to be more open and responsive consultation with the
profession", said Pond, and "GPs need to feel more involved in the
change process", said Hays.
Added to these problems is a perceived loss of community respect and devaluing of the GP's role by the media, specialists and even GPs themselves. "GPs don't value each other's clinical abilities", said Del Mar, "and are more likely to seek advice from a specialist than from another GP". Thomson recommended "positive reinforcement for GPs about what we do well", citing a New Zealand postgraduate program that "utilised GPs' own expertise and information, bringing in specialists only to resolve disputes and issues that could not be resolved by the GP group". | |||||
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| Finally, general practice lacks the career path of specialist practice, which provides increasing respect and income, as well as intellectual stimulation. In general practice, according to Marley, "you take extremely bright creative people, they do a medical degree and 10 years of postgraduate training, then beaver away for another 10 years until they're around 45 with another 20 years until they retire, and they're bored witless." A solution, according to Piterman, lies in postgraduate courses in general practice departments, which allow GPs "to recharge the batteries and reflect on their practice and their lives". His graduates have recognised that "professional life can be satisfying if goals are set and practice is varied (eg, by blending clinical practice, education, teaching, research, and involvement with Divisions)". | |||||
The way forward | |||||
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We asked the Heads for their wishlists to enhance their departments.
By far the most common request was more financial support for staff, to
increase the number of GP academics and provide them with more time for
professional development and research.
The need to foster junior GP academics, particularly to provide longer-term contracts and a career structure, was discussed by several Heads. "At Sydney, only a few of our staff are on continuing contracts", said Kidd. "The others need financial security, so they are not all the time trying to find funding to continue their employment, and can focus on our core priorities." Marley sees a dearth of GP academics that will worsen as medical schools shift teaching into the community. "We need to develop a culture and make resources available so that junior GP academics do a higher degree and go on being academics", he said. Piterman was also looking for facilities and funding, as well as closer links with the Royal Australian College of General Practitioners to allow GP registrars to obtain a higher degree as well as a Fellowship. Developing research in general practice was also a priority. Kamien asked for "a series of 'greenhouse' general practices in which to experiment and show doctors what is available and what should be available", while Pond would like "a vibrant general practice research presence to allow students to participate at various levels". Young would like research on healthcare delivery to be valued by the university, with wider criteria than NHMRC grants used when allocating resources. Curriculum development was another priority. At NSW, which is currently reviewing its relatively conventional curriculum, Harris would like general practice to have "sufficiently large blocks of curriculum time -- at least six weeks -- to allow development of skills and change in knowledge and attitudes", as well as "more support for community-based teaching". Pond has larger ideas -- ideally "a 12-month curriculum development process, asking patients, specialists, GPs, and other health professionals what they want from us as GPs" to create "an evidence-based list of what we need to teach". Failing this, she would like the general practice perspective integrated into every section of the course. Thomson goes further still, suggesting "an absolute revolution" in the medical school. He believes that with the development of the Internet, we are moving closer to the time when knowledge-based disciplines like anatomy need not be provided in every medical school, but could be based in a single place in the world. However, medical schools would still need to provide tutors and environments where students can interact with people, learn factual information, and integrate it holistically. "In this situation, general practice would become a critical environment." Academic general practice has come a long way in Australia in the past 30 years, but it is clear that if the suggestions of the Heads of General Practice are adopted, it may rise further still. | |||||
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Authors' details | |||||
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Medical Journal of Australia, Sydney, NSW
Kerrie A Lawson, PhD, Copy Editor; Mabel Chew, FRACGP, Editorial Fellow; Martin B Van Der Weyden, MD, FRACP, Editor. No reprints will be available from the authors. Correspondence: Dr K A Lawson, Medical Journal of Australia, Private Bag 901, North Sydney, 2059. ©MJA 1999 Other articles have cited this article:
Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1999 Medical Journal of Australia. We appreciate your comments. | |||||
Peter R Mudge. Australian academic general practice: looking back, looking forward Med J Aust 2003; 179 (1): 8-9. [General Practice: Past]