The Australian Government will provide $275 million over 4 years to general practice infrastructure across Australia with the rollout of 31 General Practice Super Clinics.
One of the core objectives of these Super Clinics is to support medical education.
Several studies have demonstrated that the major barriers to teaching in general practice are time, space and money.
We argue that General Practice Super Clinics can provide a responsive, flexible work culture; and improved payment and targeted resources to support the need for increased teaching capacity, and to attract and retain workforce for general practice and primary care.
support the future primary care workforce by providing high quality education and training opportunities supported by infrastructure for trainee consulting rooms, teaching rooms and training facilities to make general practice attractive to students, new graduates, GP trainees and registrars and other health professionals.1
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 practice with TLC — Time for teaching, Learnedness in the art and science of teaching, and a Commitment to teaching the next generation of young doctors the art and science of medicine.2
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
Currently, there are no alternative funding streams within the GPSC program to support an expanded teaching role and provide protected time to teach. New models for funding teaching are required to free up more GPs to teach. The current fee-for-service model does not encourage or support activity other than clinical practice. GPSCs provide the opportunity to test new approaches to funding general practice education. Teaching capacity in general practice could be increased by the establishment of dedicated teaching practices funded to ensure financial sustainability while still operating clinically under the fee-for-service model. Remuneration of teaching doctors with salaries, supported by additional funding to education providers, such as universities or regional training providers, is another alternative to afford protected time to teach.
GPSCs will provide some additional space for teaching in general practice through explicitly identified building and infrastructure funding for new teaching space, including extra consulting rooms for students and trainees, and seminar rooms. In addition, the funding can be used for information technology that supports teaching, such as videorecording consultations and electronic learning resources.
With only 31 GPSCs, less than 1% of nearly 5000 general practice clinics in Australia, this space may not make a significant difference to teaching capacity across the country. However, there is the potential to encourage cultures of teaching in GPSCs through the adoption of leadership roles and the provision of necessary resources and support. The additional space could be used to explore more innovative approaches to teaching, including vertically and horizontally integrated models. Clinical and educational teams could be developed to create interprofessional learning opportunities for medical students, allied health professionals, registrars and GPs, established through the GPSC model. However, will this new space be sufficient on its own?
Innovation and flexibility of funding that recognises the diversity of general practice business models is needed to increase the capacity for teaching in general practice. The barriers identified in remuneration for teaching suggest that new approaches are required. To increase teaching capacity in general practice, payment should be a true incentive for teaching, so that GPs will be encouraged to teach in a time of workforce shortage and increasing health demand. Specific payments for teaching, targeted to the GPs and GP registrars who teach, must be addressed to encourage more vertically integrated training and to increase the number of GP teachers.
Improved coordination and communication between and within key medical organisations and practices is vital, given that multiple organisations are involved in education in general practice and other health disciplines. This would particularly facilitate vertical and horizontal integration of training. Adequately resourced GPSCs could be instrumental in the coordination and collaboration of these networks.
Additionally, more flexible approaches for teacher training, such as training opportunities on weekends and after hours or through web-based delivery, are required for part-time GPs and others. These alternative models could be trialled in GPSCs to evaluate their wider acceptability and sustainability.
GPSCs will need to offer education and peer support to GPs who do not teach because of rural location or lack of collegial support. Early evidence from rural clinical schools suggests that this can be achieved with investment in teaching infrastructure in rural and remote areas.16 This, too, would result in more GP teachers and increased retention of younger, older, part-time and female GPs who find the present system too inflexible and costly.
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.
1 Key findings of a survey of Western Australian general practitioners and registrars, 2008
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- 13. Medicare Australia. Practice Incentives Program (PIP). http://www.medicareaustralia.gov.au/provider/incentives/pip/index.jsp (accessed Jul 2009).
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