General Practice Super Clinics — how will they meet their educational objectives?

The Australian Government commitment of $275 million over 4 years for the development of 31 General Practice Super Clinics (GPSCs) around Australia has as one of its core objectives to

Almost 100 years ago in the United States, the Flexner Report on teaching and training recommended appropriate infrastructure and funding, adequate teacher training, and rigorous research to inform evidence-based practice. An editorial in the Journal echoed the current relevance of these observations, asserting a need for

General practitioners enjoy teaching; a report from the Australian Institute of Health and Welfare, General practice activity in Australia 2006–07, showed that 50% of GPs taught medical students and 33% taught GP registrars.3 However, with expansion of medical student and GP registrar places across Australia, further capacity for teaching in general practice is required. The major barriers to teaching and training in general practice have been identified as time, space and money.4

These challenges can be detrimental to the overall culture of a practice and its attitudes to teaching. General practices in which the practice principals or corporate owners do not encourage teaching are unlikely to have medical students. Building this “culture of teaching” within a practice is vital and may be even further challenged in corporate practices, in which issues of space and money will be perceived as paramount.

Given the Australian Government’s emphasis on teaching roles for GPSCs, what is the capacity of GPSCs to respond to Australian training needs? We discuss this on the basis of our own recent research (Box 1) and previous studies on medical education in general practice.

The doubling of Australian medical students, set to begin graduating by 2010, has been well documented.5 In addition, there is a shortage of GPs in the Australian health workforce.6,7 Reductions in GP numbers and work capacity due to feminisation and ageing of the GP workforce, desire for flexibility of working hours and other “work–life balance” factors are expected to present challenges until at least 2015.8

Part-time GPs find it more challenging than their full-time colleagues to meet the demands of their clinical workload and find time to teach. Changes to working patterns, with both male and female doctors reducing their working hours and fewer GPs becoming practice principals,9 will limit capacity to take on greater teaching roles.

Education and training in general practice has traditionally been delivered through clinical placements in private practices. A shortage of GPs and a rapid increase in the number of medical students has accentuated the education and training gap for clinical placements and the time available for GPs to commit to teaching. In addition, the demand for general practice health services has increased. With the ageing of the population, increasing health demand and the continuing GP workforce shortage, we can expect that the demands for time and clinical services placed on general practice will increase over the next 10 years.10,11

The second barrier is physical space to teach. General practices are private businesses providing services as efficiently as possible to ensure good care and profitability. There is a moderate recompense for infrastructure expenditure in GP registrar funding, but none available for medical student teaching. Best models of teaching in general practice require opportunities for students and trainees to conduct their own consultations under supervision.12 This means infrastructure costs to the practice to provide additional consulting rooms for students and trainees.

Practices that teach medical students are eligible for a Practice Incentives Program (PIP) payment from the Australian Government of $100 per 3-hour session of teaching, with a maximum of two sessions per day.13 This financial teaching incentive, despite its name, has been found to be inadequate. It is insufficient to compensate for the income opportunity loss, as fewer patients are treated when teaching.14

We have found that the PIP is perceived by GPs as onerous and too bureaucratic. It usually fails to reach the doctor in the practice who provides the teaching, with the practice either absorbing the whole PIP payment or passing on less than 50% to the individual teacher (Box 2). Furthermore, GP registrars are currently unable to claim a PIP payment in their own right for teaching. This creates a further disincentive for GP registrars to become involved in teaching.15

We suggest that GPSCs are well placed to provide the necessary technological resources, office space and flexibility of hours for teaching. GPSCs will need adequate recurrent funding if they are to play a lead role in the establishment of better teaching practices. A responsive and flexible workplace culture, improved payment, and targeted resources and support are needed to increase teaching capacity, and to attract and retain doctors in general practice. With additional funding and new models of training, GPSCs could be part of the solution to training the new medical workforce in Australia. The GPSCs at present may solve locally the issue of space, but unless they also offer solutions for time and money, their potentially important educational role will be limited.

2 Proportion of general practitioners receiving Practice Incentives Program (PIP) teaching payment, 2008*

* Data are based on a survey of Western Australian general practitioners and registrars, 2008.