I am a general practitioner, are you? When a patient says they need or want to see a general practitioner I put my hand up. But so do a lot of other people. Some of those people are better general practitioners than me and some are not so good, but what if the people who are putting their hand up are not general practitioners? Are PGPPP doctors general practitioners? I think not. Do patients know when they are seeing a PGPPP doctor? Almost always. Are GP registrars general practitioners? Not yet. Do patient’s know when they are seeing a GP registrar? Sometimes. What about the other doctors working in general practice?
The situation in general practice is now much like that in hospital. There are many types of doctors at varying levels of experience and qualifications working in general practice. The following types come to mind in order of qualification:
- International medical graduates that have not passed the clinical AMC (Intern level exam) and working on the basis of exemption from Medicare restrictions
- Australian graduates doing prevocational experience in general practice who are interns (PGPPP – will cease from Jan 2015)
- International medical graduates who have the full AMC and working on the basis of exemption from Medicare restrictions
- Australian graduates doing prevocational experience in general practice who have full registration (PGPPP – will cease from Jan 2015)
- International medical graduates with full AHPRA registration working on the basis of exemption from Medicare restrictions
- Doctors training to be a specialist general practitioner or a specialist rural generalist
- Doctors who have VR based on experience in general practice including grandfathered Australian College of Rural and Remote Medicine Fellows (FACRRM)
- Doctors who have completed their Fellowship assessment by the RACGP or their Fellowship assessment by ACRRM
The only clearly discernible group of doctors, from the public’s perspective, who have completed and passed an objective assessment by their peers (and so demonstrating that they meet a standard of care necessary to provide a quality general practice service) is doctors with the Fellowship of the Royal Australian College of General Practitioners (FRACGP). There is another small group who have completed formal assessment, the graduates of ACRRM, but these are not distinguishable from those given the qualification based on experience.
I believe the public has the right to know if they are seeing a specialist general practitioner or rural generalist who has completed formal assessment. I understand that there are many reasons why this is not transparent to the general public, but this needs to change. I suggest that we reserve the name ‘general practitioner’ for those doctors working in primary care who have their FRACGP and ‘rural generalist’ for those who have an assessment based FACRRM (FARGPs could use rural general practitioner?). The reserved name may be “specialist general practitioner” and “specialist rural generalist” if that suits but it needs to be meaningful to the public. Other doctors need to be presented in a way that the public can discern the role and qualifications attained. We can set a deadline for this in 5 or 10 years to give people a chance to be formally assessed, but after that, doctors who have not been formally assessed should not use the reserved name. After all, you cannot call yourself a dermatologist because you work in a dermatology unit; in fact you might well be taken to court.
This may all appear to be in my own self interest; I have the FRACGP and I want to see change. But how on earth do we argue for the value of training in general practice and rural generalism unless the outcome and benefit is available and visible to the people of Australia. Statements like “I will never see a doctor from overseas ever again” or “I just saw a rubbish GP” are increasingly common where I work and unpleasant to respond to. To be fair to all doctors I need to explain to this patient that there is a huge variety of doctors working in general practice and that a blanket statement like this is not appropriate. When the patient asks me how to tell if the doctor is OK, I say, “The only doctor you can be sure of based on their qualification is one with the FRACGP”. Do you have a better idea?
I am not sure if everyone is aware of the potential professional crisis for specialist general practitioners if the Department of Health and Ageing decide who is providing training for general practice in 2016. That is the stated aim, presumably not with advice from experts in health care delivery.
The Department contributes public money to primary care and so can decide who has access to what rebates and other financial assistance. This is the case for all specialist training. During the Howard government a shortage of trained specialist general practitioners developed due to a failed policy to limit health care spending by limiting numbers of doctors. The ensuing GP shortage in outer suburban, rural and remote areas led to the government opening the door for doctors to work in primary care without the qualifications from the RACGP or ACRRM. These qualifications have been developed to distinguish specialist general practitioners; the FRACGP has never been granted without submitting for the Fellowship exam, or equivalent international qualification. If the value of the FRACGP is not recognised by the community, then value in training to achieve Fellowship is also depleted. This is the crux of the issue and has led to the profession being at a precipice.
We specialist general practitioners understand how to deliver evidence-based sustainable primary health care across the broad range of community settings found in Australia. It is our space, not one invented by governments. Innovations and responses in our profession are not determined in Canberra. We are proud professionals delivering high quality care despite the limits of Medicare. I have worked in the NT for over 20 years and understand the issues with workforce distribution; I am keen to work with anyone who wants to ensure that all Australians have adequate access to primary health care. However the proposed takeover of our training by the Department of Health is unacceptable.
Universities and other large providers will no doubt see this as an opportunity. We will see massive conflicts of interest paying dividends to various agencies to meet workforce needs, fill departmental coffers or bring money to other organisations. Our new registrars have been learning on dolls and out of textbooks for years, and it shows. They want to be able to do doctoring – not be doctors. We have more to do than ever to prepare our registrars for delivery of the services our patients’ need. We need to do better at it.
I have a 7 principle approach to success:
- The College must determine if placements are suitable for learning specialist general practice
- The College must determine if supervisors are suitable for training registrars seeking to become specialist general practitioners
- Our Fellowship must be seen as the hallmark of quality primary care, the doctor with FRACGP as the go to professional to provide primary ongoing medical care and lead the primary care team
- The College must robustly represent and support our Fellows, particularly our supervisors, and our Members who are working towards Fellowship
- The College should work hard for all Members to gain Fellowship and all Fellows to improve their standard of practice
- Doctors with Fellowship should be recognised and promoted as specialist general practitioners and be expected to deliver a higher standard of care
- The College should be the custodian of knowledge relevant to our professional practice and pathways to providing new and improved services to our communities.
The RACGP needs to advocate strongly for our Fellows (especially our Supervisors) and Members seeking Fellowship while working closely with ACRRM and GPRA to ensure that our profession and quality primary health care thrive.
It is our training and those training with us should feel that we are supporting them in their endeavour.
I am pleased with the attention our President of the RACGP is giving to the issue of prescribing Roaccutane.(isotretinoin). It is a serious drug that is used to treat a common condition. Liz Marles is advocating that the prescription should be made in general practice.
There are good reasons for this. First, at least in my experience, if I refer for this purpose to a dermatologist they invariably prescribe. Second, contraception and adherence is something we know about and is the main argument for specialist review. Third, NZ GPs have been doing well since being able to prescribe the drug in 2009.
I would argue that, where such regulator concerns exist, at least in the first instance, Fellows of the RACGP should be able to prescribe the medication as specialist general practitioners. This provides evidence to regulators and patients that the GP has reached a suitable standard to take such action and monitor progress. I understand there are good doctors working in general practice without Fellowship, some no doubt far better than I. However, when actions demand high standards of care it seems reasonable to initially back doctors who have put themselves through assessment by their peers to ensure they are suitable for independent practice.
I would go further and promote those specialist general practitioners, their training and commitment to standards. Does the general public understand what Fellowship means? Do politicians? Do they understand that no one has been grandfathered by the RACGP?
Does your practice draw attention to Fellowship and what this means to your patients? Do they have a right to know?