Advertising


Opinion

Consultants of sting: Attitudes towards primary care in dire straits


Sasenie Jayanetty


6/09/2024 11:23:22 AM

As a final-year medical student, Sasenie Jayanetty shares her insights on the future of general practice from the perspective of a next-generation doctor.

Sasenie Jayanetty.
University of Tasmania medical student Sasenie Jayanetty.

As I have been embarking on the final year of my undergraduate medical training, deciding on my future career path has been a constant deliberation in the confines of my mind.
 
Will I be a neurosurgeon performing intricate 10-plus hour surgeries? Or will I be an interventional radiologist chemo-embolising a liver lesion through a femoral artery? Or will I be a neurologist with a special interest in Parkison’s Disease? Or will I be a respiratory physician? Or an anaesthetist?
 
A gynaecologist? A pain specialist? Maybe a paediatrician?
 
Or will I be ‘just a GP’?
 
Growing up in a regional town in New South Wales, the local GP was the port of call for many in need. A beacon in the community that dealt with the complaints of any and all that walked through the sliding doors of the sole medical centre in town.
 
From the straightforward and simple like formulating an asthma care plan, diagnosing reflux or excising an early BCC, to the confronting and complicated like de-escalating a suicidal patient from a mental health crisis to managing a child in acute DKA.
 
In my eyes, GPs were truly the Swisse army knives of the medical system – ready to face whatever, whenever.
 
To find out that this is not the commonly accepted way of thinking in the healthcare sector and the broader public was a baffling realisation that dawned on me as I progressed through my clinical placement years in hospitals.
 
GPs seem to be the defenceless punching bags of the medical world that all other specialties land their hurtful uppercuts on.
 
‘Of course a GP made this referral’, ‘Do GPs manage anything these days?’, ‘Another GP who’s done more harm than good!’ are all platitudes I’ve heard mumbled from the mouths of consultants, registrars, interns and nurses as they roll their eyes and bitterly scoff at their notes.
 
Though on the surface it seems like a throwaway criticism, the damaging attitude it carries is profound; especially in the minds of the vulnerable patient, their family members and the impressionable medical students joining them in the treatment room.
 
This seemingly harmless microaggression triggers a monumental cascade of detrimental effects. It breeds distrust and undervaluing of primary care in the psyches of both the public and the emerging generation of junior doctors.
 
This has been a well-documented issue in general practice for a considerable amount of time.
 
In a 2008 study on enhancing general practice as a career choice, testimonials from registrars and medical students highlighted the misconceptions about GP that has existed for decades; ‘General practice was somehow seen as an inferior type of choice’, ‘I feel like they don’t get a lot of respect from the rest of the medical profession’. 
 
Nearly 20 years later, after reflecting on my own experiences and conversing with my colleagues about their future career choices, these sentiments still ring resoundingly true.
 
‘What’s the point of studying for this long to only do GP?’; a phrase too commonly repeated in the clinical school.
 
Other potential reasons that consolidate the lack of appeal in GP include the overwhelming time pressure of short consults, unfair remuneration in terms of Medicare rebates, sizeable pay cut when joining the program compared to registrar jobs in other specialties, decreased ability to receive multi-disciplinary support, and the overall lack of prestige in the medical community.
 
On the whole, interests of medical students in joining primary care are plummeting astronomically fast.
 
A survey conducted on medical graduates by Medical Deans of Australia and New Zealand found that in 2017 only 16.7% of final year students listed GP as their first preference. This had dropped to 14.7% in 2021 and to 13.1% in 2022.
 
This is a stark contrast to the outlook of those who graduated 20–30 years ago, wherein which nearly half the cohort had considered GP in their highest preference as a career path.
 
Over 80% of Australians visited a GP in the last year with 96% of those aged over 85 years old making up a considerable amount of that percentage.
 
More than 160 million GP attendances were billed in the 2022-23 period. That’s nearly 500,000 appointments per day.
 
With a growing and ageing population on the rise in Australia, these numbers are only going to increase. General practitioners are going to become a desperate necessity in both urban and regional towns.
 
Without enough junior doctors going into general practice, the primary care sector of the nation will crumble. This can manifest in the forms of longer waiting times, higher costs for consults, decreased access to resources for those in rural areas, and increased burden to the healthcare system due to higher hospital admissions.
 
So, what can we do to fix this? Is it too late?
 
There is no solution that will resolve the issue at hand overnight, but interventions can be implemented to hopefully replenish the interests of junior doctors in general practice.
 
A little can certainly go a long way in terms of attitudes we have towards GPs in medicine.
 
Unlearning negative sentiments on primary care and repainting it in a light that highlights its importance will cause less people to think of GP as an inferior career choice.
 
Medicine is fundamentally a team sport; cooperation and harmony at a multi-disciplinary level is a must. These inter-speciality relationships must be nurturing and symbiotic, not breeding grounds for resentment and competition.
 
Otherwise, patient care will be sorely compromised, and the future of healthcare will be clouded in a veil of uncertainty, with threats of privatisation and inaccessibility seeping through the cracks.
 
Fairer financial compensation is another factor that can motivate the upcoming generation of doctors to be redirected towards primary care. This has already been put into action to some degree with the increased Medicare rebate scheme in 2023, offering a 34% increase in major cities and 50% increase in regional towns for standard bulk-billed consultation rebates.
 
Though this is certainly a start, it is undeniable that more needs to be done. Increased rebates are simply a Band-Aid on a bullet wound without providing proper parity of working hours regulation, accounting for the lack of salary benefits and maternity leave in comparison to their in-hospital training colleagues.
 
It seems the tides are slowly yet surely beginning to change.
 
In 2024, the RACGP reported that 91% of their new GP training places were filled, with 114 incentivised training placements successfully filled in areas of workforce need – many of which had not had a registrar for many years.
 
Hearteningly, interests for rural generalism among junior doctors have also risen considerably, as it now takes 6th place overall in recent graduates’ career pathway first preferences.
 
As I approach my graduation, I am still incredibly uncertain about what the future holds in terms of my trajectory as a doctor, which has left me excited and simultaneously petrified of entering this new chapter of my life.
 
Medicine has always been something I have held in high regard, admired deeply and felt drawn towards strongly.
 
Though I understand that there are indisputably more pressing issues in the healthcare sphere that requires urgent attention, to know that I am about to enter a sector where there is much infighting and unpleasantness; in a field renowned for its rectitude and nobility, has been an off-putting experience.
 
I want to advocate for a less hostile work environment, for a health system that places society’s most vulnerable at its centre and not the egos of higher-ups, for a career that fosters good patient care and safe professional boundaries, instead of one that constantly belittles and treats unfairly those that play such a pivotal role in it.
 
I hope attitudes towards general practitioners change and fair reformation in the domain of primary care comes swiftly, before it reaches a point of no return as more and more are deterred away from it for a plethora of varying reasons.
 
And I hope more people think about the dedication, care and significance involved in general practice before they ever again dismiss a doctor for being ‘just a GP’.
 
I know I certainly will.
 
Sasenie Jayanetty is a final-year medicine student at the University of Tasmania.
 
Log in below to join the conversation.


medical student workforce shortage


newsGP weekly poll Would it affect your prescribing if proven obesity management medications were added to the PBS?
 
89%
 
8%
 
2%
Related



newsGP weekly poll Would it affect your prescribing if proven obesity management medications were added to the PBS?

Advertising

Advertising

 

Login to comment

Dr Jennifer Jean Brownless   7/09/2024 8:43:25 AM

er ...34% increase in medicare rebates in metropolitan area in2023? The bulk billing incentive only applies to certain patients, not across the board.


Dr Michael Lucas Bailey   7/09/2024 9:14:57 AM

I think that GPs we don’t sell what we are good at and don’t tend to openly criticise the bad decisions and mistakes of other specialist. We are too busy seeing patients and getting good clinical outcomes for such nonsense.

If we have to sell General Practice then the simple fact is that our specialty is the hardest and most complicated of all clinically, socially and psychologically .

GPs are the expert diagnosticians who can take an undifferentiated complaint and find the diagnosis from something as simple as ear wax to early stage malignancy. We need to have a breadth of knowledge that is unequalled by any other specialty.

Our management skills are not just procedural or pharmacological but often rely heavily and the relationship we can develop with a patient. This is the only way to make lifestyle interventions or took convince patients to take a medication.

That’s all before we talk about rapport, communication and all the hospital mistakes we fix as well!


Dr Mo Nasir   7/09/2024 9:14:59 AM

Trained well, GPs will be the the jack of all trades and master of diagnostician. I can never transpire this to the rest of medical community and government enough, however I know my next patient booked in deserve the best care from whoever doctors they see and GP kickstarts the solution.


Dr Elizabeth Jenkins   7/09/2024 9:17:18 AM

Thank you for making many really important points, particularly highlighting a medical student current perspective. The other factor which is important to mention is the difficulty of GP- it is probably one of the hardest specialities. This point always seems to be missed. Imagine you are a first term registrar on your first day - you sit down in your office with a list of patients to see. You have to build rapport, assess the patient including history and examination and make the right decision for their medical management in likely 10 minutes. You don’t have tests in front of you, you don’t have the luxury of a team or a met call button or people around you. You are it. You also then have to bill that patient appropriately- you need to be across the billing system and how Medicare actually works, not remain oblivious to the money that is being spent in a huge hospital system. There are so many elements to GP, it’s complex, it’s a real challenge and this needs to be appreciated.


Dr Christine Linnette Troy   7/09/2024 9:32:51 AM

Beautifully written Sasenie. When I was a medical student over 30 years ago, GP bashing in hospitals was prevalent, as you outlined, and unfortunately continues. GP's are not in hospitals to defend themselves, so the myth continues.
GP as a career has grown in expertise in the last 10 years in particular and the quality of the GP is exceptional, it is unfortunate that the remuneration is back in the pay grade of 20 years ago.
General Practice does need to have some prestige and much better financial security to maintain the numbers of GPs. Allied health are being paid $150 to $195 and hour on NDIS - this is twice as much as our hourly medicare worth. It is very frustrating.
Money isn't everything and that is why there are still GP's. General Practice is soul food and so rewarding with its rich variety of medical issues and mental stimulation, the connection to patients and the feedback of a job well done. (But money is necessary!)


Dr Annette Hackett   7/09/2024 11:38:59 AM

Sasenie - well spoken! I've been a GP for almost 40 yrs, and in that time have 'specialised' in obstetrics, anaesthetics, general medicine, youth health, homeless care, retrieval medicine, ED, palliative care, aged care and nursing home work, and teaching (at UTAS!). Of course none of them were 'specialties' in the accepted sense, and I was never a consultant as they are described. But I've had the freedom to change, to choose different things, to adapt as my family grew up and I changed. I'm so glad I chose the GP path. All the best for your decision making - I'm only a little biased in saying GP is the way to go:).


Dr Angela Maree Roche   7/09/2024 12:02:22 PM

Very well written however, I would like to clarify that the Medicare Rebate itself was never increased. This is what we need to happen. What was increased was the “ bulk billing incentive payment “ - a small payment that is attached if someone is bulk billed . That small payment was increased - and NOT - increased across the board . It was only increased for children, pensioners and concession card holders therefore leaving out the majority of the population. It was a perfect political move - do something- as little as possible- then confuse and conflate it with seeming like you have actually increased Medicare Rebates themselves Across The Board


Dr Gaston Hubert Marie Boulanger   7/09/2024 1:18:18 PM

Every medical student has to do an at least 8 week rotation during their internships at a GP clinic. Preferably the GP rotation is the last. The interns are than able to integrate the clinical knowledge they gather during specialists rotation and put it all back into perspective. And learn there is another world outside the hospital. I was chocked when I recently found out that a GP rotation is not part of the curriculum (I am trained in Europe). That probably explains this article.


Dr Scott David Arnold   7/09/2024 2:21:05 PM

As a GP who no longer works in GP I share these hopes and concerns.

My fear is that in 10 or 20 years time the only people want to work in primary care will be pharmacists and nurses. All medical decisions will be made by "specialist" and remunerated accordingly. Medicare will be bankrupt. Perhaps then the government and the profession will realise they killed the goose that lay golden eggs.


Dr Roderick Graham Bain   7/09/2024 2:56:55 PM

It is all about communication between the Federal Government of the day and the medical representative body principally the RACGP. If the government is not clear as to exactly what is required and a time frame to solve this problem then nothing will improve. The Health Dept. is fine but the Minister involved must be very clear through RACGP face-to-face consultation and constant personal communication with College board members regarding what needs to improve and be changed. Nominated members must walk the walk with constructive demands and make the general public aware of their ongoing efforts to achieve improvement. I work with the DVA and have been around the block for Veterans.


Prof Max Kamien, AM. CitWA   7/09/2024 2:58:41 PM

This was written 5 years ago.
1.Aust Fam Physician. 1999 Jun;28(6):576-9.
Doctors badmouthing each other. Does it affect medical students' career choices?
Kamien BA1, Bassiri M, Kamien M.

2. Specialists know a lot about a little. They are highly critical of GPs who don’t know a lot about their little.

3. Prof Richard Hays – observed that in some exams the care-based clinical scenarios began with a patient misdiagnosed or inadequately treated by their GP who now presents to the Teaching Hospital for management by the exam candidate.


4. Dr Ed Bateman

4a Many patients use GPs same way as they use a free 7Eleven
The joy and usefulness of continuity of family care becoming less common.
In my last decade of medical practice I spent a lot of time with the elderly whose multiple pathologies were each under the care of a specialist who was disinterested in the patient’s other problems.


Dr Lee-Wuen Meakin   7/09/2024 3:34:19 PM

This is such an excellent article ! It made me feel more proud to be a GP. I would also highlight the massive role primary care played in the COVID Pandemic. Some of my most rewarding experiences were visiting my elderly patients masked up to do their flu vaccinations on their verandahs, or getting a Video Telehealth tour of their house as well as a consult.
In General Practice we have the great privilege of really getting to know our patients or generations of patients. It is a privilege I am so grateful for.


Dr Pradeep Samarakoon   7/09/2024 3:43:52 PM

Arn't we just rubbing this on our own eyes coining this "just a .." thing? Is this our professions own inferiority? How many people get to med school and isn't that enough to be proud or content with? Are other professions bothered by just an MP, just a lawyer, just a plumber or just a bin man? We all do very useful jobs for this society. There was one person who asked me what work I do and said " j.. . .." I dont even know who he is. I am content with where I am, thats all that matters to me. Regarding GP trainee recruitment, yes, more needs to be done and we all could do our part by giving medical student a great experience in GP.


Dr Brendan Sean Chaston   7/09/2024 5:14:03 PM

The health department has a similar view to our specialist colleagues in regards to general practice. That’s why they are outsourcing it to pharmacists and probably nurse practitioners. The future of general practice is currently very uncertain. My advice is to avoid it until there is some clarity. General practice is currently the least attractive of any medical discipline.


Dr Nadine Elise Perlen   7/09/2024 5:31:01 PM

Well done Sasenie! You nailed it!! Hopefully your enthusiasm is infectious. General Practice is truely a challenging and rewarding career. Those hospital specialists forget that you will be the future GP’s referring to them - or not. You have a bright future in medicine which ever path you take.


A.Prof Magdalena Simonis   7/09/2024 6:16:41 PM

Thank you Sasenie for your article. It’s been my experience too, as a mature doctor after all these years I’m still hearing ‘Oh, you’re just a GP’ from colleagues and in social settings. On my international travels also, there is an even greater divide and prejudice against GPs / Family Physicians. Their body language and interest change and often their default response is to ask for ‘free’ medical advice.
People don’t understand how complex and necessary expertise in generalism is. To bridge this knowledge gap, I suggest that each specialty should incorporate a day per year / triennium, shadowing a GP as part of their CPD.
My med students invariably leave my rooms asking ‘how do you do it? They describe the work as diverse, complex, fulfilling yet unrelenting!
I wish you every success and happiness in whichever path you choose for your future.


Dr Josh Saunders   7/09/2024 9:11:32 PM

Huge shout-out to whoever wrote the headline for this article. It’s been a long week, and a cheeky Mark Knopfler reference was just what the doctor ordered!


Dr Deepthi Hemamali Goonaratne   7/09/2024 10:47:15 PM

Thank you very much Saseni for a well written article and your appreciateion of the work done by and support for the GPs.


Dr Pradeep Samarakoon   7/09/2024 11:54:07 PM

Arn't we just rubbing this on our own eyes coining this "just a .." thing? Is this our professions own inferiority? How many people get to med school and isn't that enough to be proud or content with? Are other professions bothered by just an MP, just a lawyer, just a plumber or just a bin man? We all do very useful jobs for this society. There was one person who asked me what work I do and said " j.. . .." I dont even know who he is. I am content with where I am, thats all that matters to me. Regarding GP trainee recruitment, yes, more needs to be done and we all could do our part by giving medical student a great experience in GP.


Dr Hayden Kenneth Elderfield   8/09/2024 6:53:30 PM

Sasenie,
Your article is most heart warming and spot on. Unfortunately, this culture has been around for more than 50 years, when I gave up a specialty for General Practice. Although the poor income and and lack of respect from Specialists and Government, is increasingly damaging.

Early in my practice I joined the College's Practice Management Committee and worked hard to improve our reward and efficiency. It saddens me that after all this time, that the balance is worse than ever.

If it wasn't for the appreciation of our patients, and the satisfaction I felt, I would have retired a cranky old man.


Dr Mark Strelnikow   10/09/2024 8:39:12 AM

I tell our registrars that GPs are the real doctors. The specialists are sub-contractors that we hire for specific jobs


Dr Richard Mark Smith   14/09/2024 11:33:03 PM

I like Fisher-Z's Perfect Day - " something I know, something I know, please don't tell me something I know, I close my eyes and I go to sleep, you say you'll change but desire is weak "
Evidence
1) there exists a societal benefit for Primary Care - strong
2) cost-benefit of Primary Care service - variable
3) comparative efficiency of Primary Care service delivery - limited data
4) values of GP roles within case management scenarios - limited
5) the crumbling NHS in the UK fallout - strong evidence for financial viability
There's a fraction too much friction - Tim Finn (1984) - how prophetic