An attractive strategy to meet the increasing need for medical education is teaching in community general practice.
General practice will be in a position to meet and sustain this need only if various conditions are met, including:
Teaching is undertaken in general practice at all levels of medical education (medical student, postgraduate years 1–3 and GP vocational training);
Standards and quality of teaching are maintained while the number of sites involved increases;
Further Australian research is conducted into innovative models of general practice teaching and their cost-effectiveness; and
Appropriate remuneration and infrastructure is available to support practices and general practitioners involved in teaching.
Medical education in Australia is facing a crisis. It is estimated that the number of domestic graduates will increase by 81% between 2005 and 2012, and, with the inclusion of international students, Australia will be producing more than 3000 medical graduates annually in 5 years.1
The quality of the teaching experience provided in general practice,2 and the success of programs such as the Prevocational General Practice Placement Program (PGPPP), make community general practice an attractive solution for the education of the increased number of medical students and junior doctors.3
There is no coordinated system for collecting data on general practice teaching in Australia, but Box 1 shows our estimate of the number of teaching practices involved in medical education in 2006 at various training levels; many practices are involved at more than one level, but the degree of overlap cannot be determined. With an estimated total of 3000 medical students, 900 interns and 600-plus registrars requiring placement in general practice by 2012, the numbers seem well short of meeting the requirement, unless more sites are recruited, or larger numbers are trained per site.
Before practices consider undertaking training, they need to be aware of the challenges of community-based teaching.2,7-9 Teaching impacts not only on the trainers, but also on other practice staff, patients and the students, junior doctors and registrars themselves. Summarised below and in Box 2 are the issues that general practitioners in the community face when they undertake to teach, and a range of evidence and solutions that should be considered.
Practices involved in undergraduate medical education have been shown to have better quality premises and significantly better performance on quality indicators.19 In addition, students provided stimulus for the GP trainers, encouraged reflective practice and brought variety to the day-to-day work of the practice.8,20-22
However, teaching students increased the workload, not only through the teaching itself, but also through the administration and preparation required for teaching and assessment, and in addition reduced flexibility in GPs’ working practice.8,10,22
To be involved in teaching, a practice needs to expand beyond the provision of core clinical services, and to make organisational changes to provide both the training and the patient load to sustain teaching. The GPs doing the training need dedicated clinical time for their own patients, as well as time to teach.
Patients’ willingness to participate in medical education is vital for the sustainability of community-based teaching.11 Patients overall were found to enjoy their involvement in teaching, as it provided the opportunity for longer consultations and to learn more about their conditions, and improved their view of their illness.8,23 But teaching can also impact on patients’ relationships with their GPs, and patients must clearly be able to choose when they want to be involved in teaching.12,24
An equally important challenge to providing teaching in the general practice setting in a sustainable manner is the financial cost. Little research has been undertaken on the cost to GPs and practices of teaching, and whether the support provided is adequate to cover this. For practices to be involved in teaching, they require the physical space to allow students, junior doctors and registrars to see patients independently, before presenting to their supervisor.2,8,25
Being taught in the community has many benefits for the learner, including more one-on-one teaching, greater access to patients with chronic conditions, as well as access to patients with undifferentiated illness outside the hospital setting. However, currently fewer than 20% of practices in Australia are involved in teaching. In the face of increasing numbers of students and registrars, the challenge for medical educators is how to maintain the interest of the current group of teachers and to attract new GPs, while still ensuring a high-quality educational experience.
To resolve these issues, community general practice must be more innovative in how it organises and provides teaching. Research in other countries and in Australia suggests a number of solutions. With medical students, registrars and now junior doctors being taught in general practice, it is an opportune time to explore the benefits of vertical integration.14 Evidence from other countries and the hospital setting provides a model where more senior doctors teach junior doctors. Models that work well under vertical integration include DeWitt’s service–learning model, which allows productivity while teaching;15 and the “hub and spoke” model of teaching practices, where a main practice provides core teaching, with linked practices undertaking an ancillary role.26 This allows the involvement of practices that might otherwise have had no role because of lack of teachers, space or patient load. For vertical integration to be effective, key organisations must work together, pool resources, support existing teaching practices and encourage new practices to be involved in teaching.
Another approach is to make better use of other practice staff and health services. Rotations through public health organisations, and sessions with private specialists, pharmacists or nurse-led diabetes or asthma clinics during general practice placements could provide GP trainers with a break from teaching. Other practice staff could also be utilised in teaching. Administrative staff might coordinate “volunteer” patients whose medical problems could be reviewed by students.
These models require practices and associated organisations to think more laterally. However, for these solutions to be effective, practices must have the space to accommodate more than one level of student or postgraduate doctor.
A popular solution to resolving some of the issues outlined above is financial. However, missing from the debate is evidence on the direct and indirect costs of teaching at all levels of training. Existing research has focused on particular programs.18,27 Further research is required to determine what support is appropriate, particularly support for infrastructure.
Teaching in the general practice setting will play an increasingly important role in the training of medical practitioners.3 The increased teaching requirement for general practice provides challenges, but is an opportunity to expose more medical students, junior doctors and registrars to the specialty of general practice. General practice has the potential to provide a greater breadth of exposure to health conditions and unique settings, and to allow the acquisition of new skills.
To allow general practice to maintain current teaching levels and to respond to the increasing load, practices and trainers require support in a number of areas, particularly remuneration of direct and indirect teaching costs. While research on viable models for general practice exist,28 the costs and benefits associated with teaching have not been included in the modelling. Research is needed on models that will increase teaching efficiency. In addition, we need to accurately calculate the level of support required across the teaching continuum in both urban and rural environments. This research would inform the debate and provide evidence for appropriate strategies to accommodate the increased teaching load.
1 Estimated number of practices involved in teaching in general practice, 2006*
2 Challenges for teaching in general practice and possible solutions
- 1. Joyce C, Stoelwinder J, McNeil J, Piterman L. Riding the wave: current and emerging trends in graduates from Australian university medical schools. Med J Aust 2007; 186: 309-312.
- 2. Murray E, Modell M. Community-based teaching: the challenges. Br J Gen Pract 1999; 49: 395-398.
- 3. Martin A, Laurence C, Black L, Mugford B. General practice placements for pre-registration junior doctors: adding value to intern education and training. Med J Aust 2007; 186: 346-349.
- 4. Medicare Australia. Medicare Australia statistical reporting. All Divisions of General Practice (999). Approved practices in the quarterly calculations by activity. Participation in PIP. http://www.medicareaustralia.gov.au/providers/health_statistics/statistical_reporting.html (accessed Jul 2007).
- 5. Royal Australian College of General Practitioners. Prevocational General Practice Placements Program Training Collaboration. http://www.racgp.org.au/Content/NavigationMenu/educationandtraining/vocationaltraining/Prevoc/PGPPPcollaboration/default.htm (accessed Jun 2007).
- 6. Australian Bureau of Statistics. Statistics. 8685.0 – Private medical practices, Australia, 2001–02. http://www.abs.gov.au/Ausstats (accessed Jun 2007).
- 7. MacDonald J. A survey of staff attitudes to increasing medical undergraduate education in a district general hospital. Med Educ 2005; 39: 688-695.
- 8. Mathers J, Parry J, Lewis S, Greenfield S. What impact will an increased number of teaching general practices have on patients, doctors and medical students? Med Educ 2004; 38: 1219-1228.
- 9. Parry J, Greenfield S. Community-based teaching: killing the goose that laid the golden egg? Med Educ 2001; 35: 722-723.
- 10. Larsen K, Perkins D. Training doctors in general practice: a review of the literature. Aust J Rural Health 2006; 14: 173-177.
- 11. Coleman K, Murray E. Patients’ view and feelings on community-based teaching of undergraduate medical students: a qualitative study. Fam Pract 2002; 19: 183-188.
- 12. O’Flynn N, Spencer J, Jones R. Consent and confidentiality in teaching in general practice: survey of patients’ views on presence of students. BMJ 1997; 315: 1142.
- 13. Benson J, Quince T, Hibble A, et al. Impact on patients of expanded, general practice based, student teaching: observational and qualitative study. BMJ 2005; 331: 89.
- 14. Rosenthal D, Worley P, Mugford B, Stagg P. Vertical integration of medical education: Riverland experience, South Australia. Rural Remote Health 2004; 4: 228.
- 15. DeWitt D. Incorporating medical students into your practice. Aust Fam Physician 2006; 35: 24-26.
- 16. Bentham J, Burke J, Clark J, et al. Students conducting medical student consultations in general practice and the acceptability to patients. Med Educ 1999; 33: 686-687.
- 17. Kijakovic M, Parkin C. The presence of medical students in practice consultations: rates of patient consent. Aust Fam Physician 2002; 31: 487-489.
- 18. Worley P, Kitto P. Hypothetical model of the financial impact of student attachments on rural general practice. Rural Remote Health 2001; 1: 83.
- 19. Gray R, Carter Y, Hull S, et al. Characteristics of general practices involved in undergraduate medical teaching. Br J Gen Pract 2001; 51: 371-374.
- 20. Jones S, Oswald N, Date J, Hinds D. Attitudes of patients to medical student participation: general practice consultations on the Cambridge community-based clinical course. Med Educ 1996; 30: 14-17.
- 21. Hampshire A. Providing early clinical experience in primary care. Med Educ 1998; 32: 495-501.
- 22. Walters L, Worley P, Prideaux D, et al. The impact of medical students on rural general practitioner perceptors. Rural Remote Health 2005; 5: 403.
- 23. Howe A, Anderson J. Involving patients in medical education. BMJ 2003; 327: 326-328.
- 24. Williamson C, Wilkie P. Teaching medical students in general practice: respecting patients’ rights. BMJ 1997; 315: 1108-1109.
- 25. Gray J, Fine B. General practitioner teaching in the community: a study of their teaching experience and interest in undergraduate teaching in the future. Br J Gen Pract 1997; 47: 623-626.
- 26. Commonwealth Department of Health and Family Services. General practice education: the way forward. Final report of the Ministerial Review of General Practice Training. Canberra: Commonwealth Department of Health and Family Services, 1998.
- 27. Murray E, Jinks V, Modell M. Community-based medical education: feasibility and cost. Med Educ 1995; 29: 66-71.
- 28. Rural Doctors Association of Australia. Viable models of rural and remote practice. Stage 1 and Stage 2 report. Canberra: Rural Doctors Association of Australia, 2003.
Publication of your online response is subject to the Medical Journal of Australia's editorial discretion. You will be notified by email within five working days should your response be accepted.