In Australia, the general practitioner (GP) is the first point of contact with the primary care model of healthcare, acting as a gatekeeper to specialists as well as delivering whole-of-person care.1 Demand for GP services in Australia rose by 58.4% from 2009 to 2019,2 driven concurrently by population growth and the increase in chronic disease and comorbidity.2 Australian medical student preferencing of GP careers as their first choice for future speciality practice dropped from 14.4% in 2019 to 10.5% in 2023, offset by an increasing preference for rural generalist (RG) careers from 4.6% in 2021 to 7% in 2023.3 Despite this relative recent stability in the total percentage of medical students interested in GP and RG careers, a shortfall of 11,517 full-time equivalent GPs is predicted by 2032.4 To address this shortfall, a robust supply of GPs to the workforce via engagement of trainees with GP training pathways is required.
Over the last decade in Australia, GP training has changed substantially, and since 2023 has been delivered by two vocational training colleges: The Royal Australian College of General Practitioners (RACGP) and The Australian College of Rural and Remote Medicine (ACRRM).5 The Colleges use different methods of delivery; however, they ultimately strive for the same outcome of training vocationally registered (VR) GPs and RGs to work within Australia, with the distinction being that RGs are able to work both as GPs and within the extended scope of practice in their advanced skill area, as determined by their state health jurisdiction.6 Most GP trainees in Australia undertake College-led training funded by the Australian Government via the Australian General Practice Training (AGPT) program. Prior to 2023, multiple alternative training pathways such as the RACGP Practice Experience Program (PEP), the Remote Vocational Training Scheme (RVTS) and the ACRRM Independent Pathway (IP) existed,7 with the RVTS and IP continuing and PEP ending in 2022 and being replaced by the RACGP Fellowship Support Program, a self-funded pathway for international medical graduates who are not eligible for the AGPT pathway.8
The state of Tasmania faces challenges in primary care healthcare delivery including an aged and geographically dispersed population, with data from 2020 and 2021 reflecting that 20% of residents are aged 65 years and over9 and almost two-thirds of the population live in regional areas outside of the capital city of Hobart.10 These aspects are both unique and relevant to other jurisdictions. The success of local training pathways to engage and retain GPs to work effectively within the Tasmanian healthcare context are an important piece of the overall GP recruitment pipeline. Ultimately, if GP training pathways are seen as unattractive and unsupportive, then prevocational doctors might be less likely to undertake GP training and thus attrition of the GP workforce will be experienced. Understanding the function and use of components of Tasmanian GP training pathways can inform the design of effective and attractive pathways both locally and with external relevance.
Aim
This study aims to provide insight into the experience of users of the GP training pathway in Tasmania and to uncover barriers and enablers to engagement. This study adds an understanding of the lived experience of a GP training pathway to provide tangible targets for improvement of current and prospective pathways. The questions that guided this research were: (1) how do stakeholders including trainees, supervisors/medical educators, training providers and supporting organisations experience the current GP training pathway; and (2) what components of the pathway are effective and what could be improved?
Methods
Study design
This research uses a qualitative methodology using semi-structured, individual interviews to explore experiences of interacting with the Tasmanian GP training pathway. The study was approved by the University of Tasmania Human Research Ethics Committee in April 2024 (reference number 30533).
Setting and participants
A purposive sampling strategy was used to ensure a variety of participants located across multiple regions of Tasmania, with a range of experiences and perspectives. Inclusion criteria allowed a diverse and neoteric range of opinions to be included (Table 1).
Recruitment methods aimed to provide a broad representation of participants from across a wide range of locations within Tasmania. Flyers were widely distributed through a variety of mechanisms to reach GP trainees and supervisors in both community and hospital practice. Targeted emails were sent to stakeholders identified to have important and unique roles within GP training in Tasmania. Participants were remunerated for their time with an electronic gift card congruent with their usual hourly earnings.
| Table 1. Inclusion criteria for participants |
| Inclusion criteria 1 (one of these) |
Inclusion criteria 2 |
| Pathway users: current or recent past |
Involvement in GP training in Tasmania within the past 10 years |
| General practice supervisors and medical educators directly involved with the GP training pathway |
| Employees of organisations that provide support to GP trainees or prospective trainees |
| GP, general practitioner. |
Data collection
Semi-structured interviews were conducted between April and June 2024 via the online platform Zoom (Zoom Communications, San Jose, CA, USA) and an interview guide (please contact the corresponding author if you wish to view the interview guide) was developed by two of the authors (SS, JP), shaped by the results of an unpublished 2024 scoping review (authors JP, SS, SP, et al) with questions aimed to stimulate candid dialogue encompassing:
- Tasmanian GP training pathway experience
- enablers or advantages of the pathway
- barriers or challenges within the pathway.
The interviews were mainly conducted by JP (a Master of Public Health graduate) with one interview performed jointly by JP and SP (an experienced mixed methods researcher and statistician with a background in higher education and health service improvement research), both of whom had no prior relationship with the participants and are academics independent of the training pathways. The Zoom audio recording and auto-transcription function were used for transcript creation. The interviewers reviewed the transcriptions immediately to ensure fidelity and remove any identifying features.
Data analysis
Transcripts were uploaded to NVivo 14 (Denver, CO, USA). An inductive thematic analysis was conducted11–13 with coding labels created based on the themes in the data.11 Two researchers analysed each transcript, with four researchers contributing to the process (SS, JP, SP, BW). Two fledgling researchers (SS, BW) are academic GPs with past personal experience of GP training, one researcher (JP) is a currently undertaking a PhD in the healthcare domain and one researcher (SP) is a highly experienced qualitative researcher within healthcare and education. All researchers reviewed the codes and met to interpret the findings. Sample size was determined by the principle of data saturation14 and the ability of the data to provide a rich and nuanced account of the phenomenon studied in line with the aims and scope of our project.
Reflexivity and bias
Three authors have a background in general practice, one in public health, one in health services administration and one in health services research. All authors held academic or professional positions at the same university. Inherent bias was reduced by using an interview schedule informed by prior research, and by conduction of interviews by academics with no involvement in general practice training. Throughout the research, the team considered the influence of their roles and sociocultural standing on data collection, analysis and reporting.
Results
Participants
Eighteen participants completed a semi-structured interview, at which time data saturation was deemed to have occurred. Interviews lasted between 12 and 71 minutes, with an average length of 32 minutes. Participant characteristics are summarised in Table 2 (please contact the corresponding author if you would like to view further information about the participant demographics).
There was consensus across the stakeholder groups around common barriers and challenges to trainees engaging with the GP training pathway. Factors that were identified included professional aspects of GP careers, features of training support and trainee personal characteristics. Each facet involves complex bidirectional relationships between the trainee and professional and personal entities (Figure 1).
| Table 2. Participant characteristics |
| Characteristic |
n (%) |
| Stakeholder group |
|
| Recent past or current GP training pathway user |
10 (56) |
| Supervisor or Medical Educator for GP trainees |
5 (28) |
| Member of supporting organisation |
3 (16) |
| Gender |
|
| Male |
4 (22) |
| Female |
14 (78) |
| Modified Monash Model (MMM) classification7 |
|
| 1, 2 |
10 (56) |
| 3, 4 |
1 (5) |
| 5, 6, 7 |
7 (39) |
| Length of time associated with Tasmanian GP training pathway (years) |
|
| 1–4 |
7 (39) |
| 5–9 |
5 (28) |
| 10+ |
6 (33) |
| GP, general practitioner. |
Figure 1. Relational diagram of factors influencing engagement with the general practitioner training pathway.
Professional aspects of GP careers
Professional influences were dominated by perceptions of the archetypal GP career, including poorer prestige and remuneration compared with other medical specialists and stigma – particularly from other professionals within the hospital system (Box 1). Multiple participants reported negative bias surrounding GP careers experienced at medical school, with these prevocational experiences seeding negative sentiment toward GP careers long before formal engagement with the GP training. This stigma was noted to perpetuate the sense that GP careers are a ‘fall back’ (Trainee [T]2, female, Modified Monash Model [MMM] 5–7) position if a trainee is unsuccessful at gaining a training position in another profession or ‘can’t cut it in the hospital’ (T4, female, MMM 5–7) environment. In addition, most participants noted that doctors were radically influenced by their prevocational clinical experiences and stressed that this should be considered an important aspect of the GP training pathway.
Negative community attitudes towards ‘lazy and greedy’ (T7, female, MMM 1–2) and ‘crap GPs’ (T9, male, MMM 3–4) were assimilated into the perception of GP careers lacking value, a sentiment further perpetuated systemically by a lack of professional opportunities for career advancement within Tasmania, and low rates of remuneration offered for GP trainees.
The ‘appealing’ (Supervisor [S]1, male, MMM 5–7) career endpoints of GP training, such as being valued by patients, flexibility to follow specialised interests and embeddedness in the community were a consideration; however, for RGs, the limited scope of practice that they might experience being employed in Tasmania meant that there was concern that VR GPs might not remain in the state.
| Box 1. Professional aspects of general practitioner careers: Illustrative quotes |
| Still there is devaluing of general practice by other specialists which is a deterrent and barrier to people entering general practice. (S3, male, MMM 1–2) |
| Other sorts of barriers are financial, particularly if people have been senior registrars in the hospital, then it’s often a financial step backwards to come out to the community to do general practice. (S5, female, MMM 1–2) |
| Good placements as a student and an intern … just being in it and experiencing it and knowing that it’s what I liked was certainly a positive factor. (T7, female, MMM 1–2) |
| The next challenge for us as a state is ... What are the opportunities out there for them to practice their skills? If they’re not professionally satisfied, they’ll go somewhere else where they can practice to their full scope. (S1, male, MMM 5–7) |
| MMM, Modified Monash Model; S, Supervisor; T, Trainee. |
Features of training support
Training support components included educational components, social support and the complexity of interaction between the trainee, training organisation, supervisors, medical educators and practices. Many features of training programs discussed by participants acted as both barriers and enablers depending on context (Box 2).
When well supported by the training program, the social network provided by peers could result in supportive tight-knit communities of learners contributing to positive experiences, which is particularly important in rural and regional pathways. Conversely, GP training could be challenging if networks and support were perceived as not available, particularly for those who were not on the AGPT pathway, leading to a sense of discontent with training. In addition, burnout and exhaustion were noted to relate to the rigours of ‘full-time work and life and just how heavily you need to study’ (T3, female, MMM 5–7).
Participants identified that the availability of quality, well-supervised, entry-level placements is limited with the number of practices taking trainees dwindling. Further, there was a sense of some disarray in the placement allocation processes. Models where GP training pathways required registrars to train in at least two different general practices were perceived as the antithesis of what the registrar and the practice desired, whereas a quality placement, supportive relationships within practices and supportive supervisor were highly valued but not always guaranteed. In addition, a practice culture that was nurturing of learners was seen to be an enabler for educational support in addition to support in navigating ethical and emotional challenges and was particularly important for those experiencing significant hardship.
Some participants were aware of the challenges faced by the training organisations in recruiting and retaining supervisors. Not receiving suitable payment was seen to be both a disincentive to become a supervisor and lead to poorer quality of supervision. Providing more financial incentives and support for supervision was seen as crucial to improving training supervision capacity.
There was frustration by pathway users who felt that they lacked support from the training program and medical educators to manage challenges encountered with their practice or clinical supervisors. This apparent lack of responsibility that training programs took in assisting trainees to navigate these challenges indicates a potential breakdown in the multi-pronged relationships across all stakeholders to ensure well-functioning training programs.
A further potential barrier to the optimal functioning of GP training was created by difficulties encountered in online systems used for administrative and educational delivery, with a preference for face-to-face learning.
| Box 2. Components of training programs: Illustrative quotes |
| Training meetings … helped us get to know one another. GP can be quite isolating, and the beginning of training can feel unsupported so having that support from each other and from your medical educators was quite good. (T8, female, MMM 1–2) |
| (AGPT trainees) get more (exam support and) case discussion … but I’m not eligible because they are for local graduates … Sometimes I think Oh, is (an) IMG inferior to a local graduate? Why (are we) put on different training program? Once we get into the system all of us want to be a good GP. (T2, female, MMM 5–7) |
| (the placement process) was quite competitive … and there was a lot of chop and change and people thought that they had a placement and then it would be taken out from under them … people are in tears … when they’ve got nothing or something that they thought was a sure bet has fallen through. (T10, female, MMM 5–7) |
| Everybody wants to stay (but) the registrar still has to move, and so why would the practice have a GPT one, it’s not a recruitment strategy … the registrars don’t benefit because they don’t get continuity … (and they) have to uproot everything … it’s a massive barrier … ACRRM doesn’t do it and everybody seems to survive. (S4, female, MMM 5–7) |
| It was the culture of the place that you could ask people … for help … I felt like they always had my back. (T3, female, MMM 5–7) |
| My attendance was patchy … (I was) feeling guilty about not being able to meet commitments … so what was helpful during that time was being upfront with the medical educator … (she said) you can just take a month (of leave). (T3, female, MMM 5–7) |
| It’s so poorly remunerated and supported, it’s not an attractive thing to do … (supervisors do it) generally because they love teaching. It’s hard on the practice, so a lot of practices don’t like to, and some supervisors just pay lip service ... you don’t know (about the quality of your supervisor) until you start so that’s a barrier. (S4, female, MMM 5–7) |
| (There) needs to be … more support from the colleges… my supervisors have said that they don’t really get any support from ACRRM ... no one checks in to say … how are you going with supervising ... if they get a registrar that is tricky to supervise … then it’s hard to manage that. (T10, female, MMM 5–7) |
| Quite often people don’t feel comfortable to talk to their medical educators if there’s been a problem … the medical educators (suggest) that’s your problem, you have to deal with it, that’s a practice issue, we can’t really help. And the RACGP says you can’t look at any extra support and that can be really hard. (T8, female, MMM 1–2) |
| I didn’t necessarily feel that supported by GP training to fix (problems with my supervisor). I had to … find (my own) solution ... I just didn’t feel like they cared, in a way they had a supervisor, that ticked that box and that was all that mattered. (T4, female, MMM 5–7) |
| People don’t engage with the online stuff, even when they’re forced (into) breakout groups ... it’s such a different dynamic to face to face. (T4, female, MMM 5–7) |
| AGPT, Australian General Practice Training program; GP, general practitioner; IMG, international medical graduate; MMM, Modified Monash Model; S, Supervisor; T, Trainee. |
Trainee personal characteristics
Personal factors were identified by all stakeholder groups as influential and were seen as largely non-modifiable by the time a trainee enters the vocational training stage of their career (Box 3). Personal factors included family commitments, health of the trainee and lived experience of GP interactions via the health experiences of family.
Personal factors influenced trainee choice to engage with the pathway, thus components such as increased flexibility, lower financial costs of training and lower educational demands when compared to other vocational pathways were seen as being attractive.
| Box 3. Personal factors: Illustrative quotes |
| Trying to actually understand individual circumstances like mental health ... the college should focus (more on that). (T8, female, MMM 1–2) |
| They’ve got kids and they can’t travel 2 hours away to do their training. (T10, female, MMM 5–7) |
| The biggest challenge that we tend to encounter is around not so much the clinical load, it’s around the complexities of what’s happening for the registrar outside of practice, like … health conditions that they’re trying to manage or family demands. (S3, male, MMM 1–2) |
| MMM, Modified Monash Model; S, Supervisor; T, Trainee. |
Discussion
The provision of supported and user-friendly training pathways to a VR GP qualification is one fundamental way to strengthen the primary healthcare workforce. A 2024 scoping review of the components of GP training pathways found that training pathways in Australia and internationally face similar challenges.15
This research, which explored experiences of those engaging with the GP training pathway in Tasmania over the last decade during the transition to College-led training, identified many modifiable factors that could be addressed with the aim of improving engagement and retention of GP trainees. Favourable factors identified in this study and in prior research as influencing GP training engagement include flexibility of the role, satisfactory work–life balance, connection with patients, positive general practice role models, job satisfaction and broad scope of practice.16 An important outcome of this research was the significant role of positive GP experiences and role models throughout prevocational and vocational training, a finding that is consistent with other research and has consistently been identified as fundamental to stimulating and strengthening interest in GP careers.16–18 Deliberate strategies to ensure the quantity and quality of these positive experiences should be explored and implemented.
The findings of this Tasmanian research echo findings of other Australian studies that suggest perceived benefits to GP training include shorter duration of training and flexibility during training.19,20 GP training programs can leverage these perceptions to attract and retain trainees. Importantly, for training programs operating across geographically diverse areas, consideration of judicious and effective blended online and in-person learning might be necessary, and these delivery methods should be designed with the learner experience at the centre. Consideration should also be made of supporting trainees across all pathways, potentially integrating the training support for all trainees.
Some modifiable factors were linked directly to the training pathway. These included the complex multidirectional relationships between trainees, practice staff, supervisors, medical educators and training organisations. Ensuring clear expectations of roles and responsibilities was identified as a strategy to improve trainees’ experience and hence engagement. This was not a factor that was identified by previous known research and might provide a focus for future research or intervention. In addition, recognition of the social complexity of GP workplaces and providing support to foster positive connections and cohesion within the workplace would allow trainees to feel more supported and engaged in their training program and potentially lead to longer-term commitment to working in the local community once VR qualified.
Countering these appealing aspects of GP training are modifiable barriers that include the low prestige of GP careers overall, relating to intrinsic factors such as inadequate remuneration for both GP trainees and specialist GPs21 and the limits to scope of practice once qualified,4 an issue that is particularly pronounced for RGs in Tasmania. These aspects have been previously identified22 and require significant systemic change within educational and funding bodies to rectify or alter.
Healthcare and educational systems are increasingly being conceptualised as complex adaptive systems (CAS),23,24 which rely on many individual components to interact and respond to feedback from other agents. These interactions and adaptations result in dynamic and self-organising properties with the emergence of a global structure or system.25,26 Our research identifies GP training pathways as CAS with many interacting components that impact on the initial engagement, experience and ongoing engagement of trainees. The identification of these components using a complexity lens can provide targets for improving or strengthening the GP training pathway to improve GP supply within Tasmania.
Strengths and limitations
This research is the first to be undertaken within the Tasmanian context, exploring contemporary experiences of the GP training pathway. It is a small study, and it is also possible that not all unique experiences have been captured, notably those who are being trained via non-AGPT pathways, and as such, the views presented might not be representative of all GPs and GP trainees. As the project was completed quite soon after the Regional Training Organisations transitioned to College-led training, many participants reflected on issues related to this transition, which might not contribute to ongoing barriers. Caution should be employed in extrapolating the rich and contextual views of the participants to settings and contexts that have limited proximal similarity to the study.
Conversely, as this project comes at a time of transition in the delivery of GP training in Australia, these findings can be used to ensure that any future structural changes are likely to promote a more supportive and retentive program.
Conclusion
This study highlights the complex interplay of personal, professional, and systemic factors influencing engagement with GP training pathways in Tasmania. Addressing modifiable barriers and enhancing enablers – particularly through supportive training environments, positive role modelling, and systemic reform – can strengthen the pipeline of vocationally registered GPs. These findings offer valuable insights for the ongoing development of sustainable and attractive GP training programs, both within Tasmania and in comparable contexts.