General practice ‘denigrated’ to most students: Poll

Jolyon Attwooll

7/07/2023 12:51:37 PM

Survey results highlight the imperative of ensuring the ‘incredibly rewarding’ aspects of general practice are clear during medical studies.

Medical students
More than 1200 poll respondents said they had encountered negative attitudes towards general practice during their medical studies.

More than four in every five newsGP readers have encountered negative attitudes towards general practice during their medical studies, according to a new survey.
Of 1428 respondents to a newsGP poll last week, 86% said they had experienced general practice being denigrated while studying.
RACGP President Dr Nicole Higgins said the results are a source of concern and would like to see the ‘incredibly rewarding’ aspects of a career in general practice emphasised during medical school.
‘Doctors going through medical school and hospital training can sometimes get a sense that general practice is a second-rate choice, and that really couldn’t be further from the truth,’ she told newsGP.
‘It is a career with huge rewards and challenges.
‘I love general practice, it is so professionally fulfilling, I say the same to anyone who asks.
‘There are so many things I love about being a GP, from the clinical challenges to the relationships that I have with patients and their families.’
Chair of the RACGP’s National Faculty for GPs in Training, Dr Sean Black-Tiong, believes the issue is more systemic than connected to the outlook of university medical educators.
‘Generally, the attitude is positive and the good clinicians have a great deal of respect for the good GPs on a personal and collegiate level,’ he told newsGP.  
‘The issues arise at the systemic level where the denigration comes from systematically being treated without respect.’
According to Dr Black-Tiong, healthcare administrators and policymakers rely too much on ‘coercive bureaucracy’ and ‘fail to respect the experience and knowledge of highly trained GPs’.
That, combined that with the way he thinks the healthcare system ‘incorrectly values quantitative procedural work over and above high value clinical care and time spent with a patient’, has a clear impact on the way general practice is perceived, he says.
‘This procedural favouritism then idolises the specialties and sub-specialties that are focused on low-time, high-turnover procedures that generate exorbitant income for an individual and the perception that they are more valuable due to having the highest income,’ Dr Black-Tiong said.
‘That any individual doctor earns over $500,000 per annum is absurd. No individual doctor is worth double or triple the value of another based on specialty.
‘And yet this is what the system conveys, that a full-time GP, or physician or paediatrician, doing non-procedural work earning less than half that of a high turnover surgeon, or anaesthetist or other procedural specialty is less valuable and remunerated less.
‘There needs to be a rebalancing to reduce the extremes of the wage disparity in medicine.’

Dr Sean Black-Tiong says healthcare administrators and policymakers do not respect the experience and knowledge of highly trained GPs.
Like Dr Black-Tiong, Dr Higgins has positive recollections of her medical studies, having previously told newsGP she was fortunate to have strong general practice advocates during training.
‘I was lucky enough that I went through Monash at a time where we had [Professor] John Murtagh and [Professor] Steve Trumble and [other] champions of general practice leading medical training,’ Dr Higgins said earlier this year.
Nonetheless, research carried out in the UK shows denigration of general practice remains a problem – and the results of the newsGP poll indicate that Australia is by no means immune. 
She would welcome the introduction of a ‘no denigration’ policy among health professionals.
‘“No denigration” calls on others to respect the time and hard yakka that it takes to become a GP, and respect the expertise of other specialties – not just doctors, but all health professions – as well,’ Dr Higgins said.
‘It takes at least 10 years to become a specialist GP and governments, medical and health professions often don’t understand the complexity of what we do.’
Federal Health and Aged Care Minister Mark Butler also raised the ‘culture issue’ within medicine in a podcast with The Guardian earlier this year.
‘I speak to GPs and medical graduates all the time about their experience of being in a hospital and expressing to a consultant who might be supervising them, expressing an ambition to be a GP, and being told, “Why would you want to do that? You could be an anaesthetist, you’re smart enough to be a cardiac surgeon, why do you want to be a GP?” he said. 
‘We’ve got to get away from this idea that general practice, the backbone of our healthcare system, is somehow a B grade.’
Tish Sivagnanan, the President of the Australian Medical Students’ Association, addressed the topic in MJA’s Insight+ last month in an opinion piece entitled ‘Changing the narrative of general practice for the better’.
‘The steps taken in the past six months guide me to believe that I am part of a profession that has recognised the need for radical change,’ she wrote.
‘Whether it be through structural reform to medical education or a rebranding of the primary health care system, there is no doubt that the next steps are multifaceted and will likely challenge the status quo of medical education, training, and the health workforce.’
While Dr Higgins urges universities to encourage general practice as a career of choice, she also believes tackling wider systemic issues are key to addressing negative perceptions.
‘Medicare has been neglected for years and years, meaning general practice has also been critically underfunded, and the gap between GPs and other specialties has got wider and wider when there should be no gap at all,’ she said.
‘The Federal Budget in May was definitely a positive step, but there is still more work to be done.’
Dr Black-Tiong points to a predicted shortage of shortage of GPs – analysis carried out by the Deloitte consultancy suggests there will be a shortfall of 11,392 full-time equivalent GPs by 2032 –and says patience will be needed for change.
‘Access to GPs reduces the cost on the health system in the long run by creating an efficient point of entry and wayfinder who can also provide early intervention and prevention,’ Dr Black-Tiong said.
‘If we want the health system to be viable into the future it needs to be primary care focused, with the tertiary system there as the safety net for the medical issues that we cannot prevent or mitigate.
‘Rather than a $3 billion hospital trying to catch the overflow of delayed presentations, we need the money going into nationwide general practice to reduce hospital attendances and preventable diseases/complications.
‘This will take time to come to fruition and the issues we see at present are the result of primary care neglect for decades gone by.’
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Dr Francisco Rodriguez-Letters   8/07/2023 7:09:39 AM

Although I appreciate the general sentiment in this article, the fact remains that money talks. For all the Trekkies out there, the Ferengi law of acquisition number 109 clearly states..."dignity and an empty sack is worth the sack".
Who on Earth wants to study for over a decade, only to work for the same amount of income as a middle management consultant? General Practice is a noble profession, but it is frustrating, difficult work that earns peanuts.
You can't stop people denigrating General Practice until GPs earn more...double at the very least.

Dr Guillaume Louys   8/07/2023 8:31:36 AM

Unfortunately, I think it's patients and the public (not the healthcare system), who value procedural work over clinical care. Patients can more readily understand why a surgical procedure would cost (and remunerate) more than a medical consult. The risks are higher and the results are significantly more tangible.

I believe GPs who move away from procedural work (e.g. skin excisions, biopsies, pap smears, spirometry, ECGs) and even physical examinations, are doing the profession a disservice. How many times have patients complained "the doctor didn't even examine me"? Why? Because these things take time.

Part of the trouble of course, is that so many patients present for administrative issues such as referrals, or psych issues.

A.Prof Christopher David Hogan   8/07/2023 9:33:55 AM

In summary The disparity in remuneration between specialist GPs & non GP specialists in Australia has obscured origins but did not always exist.
* PM John Gorton & the” most common fee”- which was manipulated
* Initially GPs did not have a formal training program but could go straight into practice from University
* Non GP specialists needed a 4-5 year training program in public hospitals - which were paid very poorly. & they had to fund themselves. As compensation they had higher consulting fees when qualified but the life time incomes of GPs & non GP specialists was equivalent.
* In early 1970s all hospital medical staff were suddenly paid a living wage but the disparity with non GP specialists was not adjusted.
*There was a bias to the remuneration of procedures (for GPs & others.)
* Because the training programs for them were now affordable, there were more non GP specialists & they poached GP appointments
* GPs were not organised & not politically active enough - we lost out

Dr Edward Thomas Wu   8/07/2023 10:23:17 AM

Most people acknowledge primary medical service/care (General Practice/Famiy Medicine) reduces the cost on the health system. However only those who have actually experienced on how this is being done understand fully they way to achieve this. How can we explain "what is General Practice (primary medical care)" better to allow improve understanding and modify the way they manage primary medical care resulting in this phenomenon of denigration?
Just whinging about this situation may not induce improvement.

Dr Philip Ian Dawson   8/07/2023 11:33:23 AM

GPs are not paid peanuts, but yes less than many procedural specialists. Still in the top 5% of income earners. Some procedures are quick and highly remunerated resulting in very high incomes eg cataract surgery and TURPs still have high schedule fees dating back to when TURP wasnt done and it was all open prostatectomy. Other procedures take time eg coronary angiography and stents, major surgery, even endoscopy. Relative value studies have been done and anyone can make suggestions to Medicare about imbalances. GP organizations have suggested the main barrier to training more GPs is not "denigration of GPs", although that may be a factor. it is that all other training programs are hospital based with salaries, sick leave, Super, annual and accrued long service leave, whereas GP training isnt. This uncertainty of income and lack of benefits seems to put off a lot of trainees. That is why they are looking at changing to a 'single funder model" of training. will it happen soon?

Dr Ian   8/07/2023 1:40:01 PM

The trained and committed General Practitioner has great diagnostic and treatment opportunities to heal ill-health and promote well being .
Having a welcoming and efficient clinic with good follow up of abnormal results and accurate triage within the chaos of incoming calls and the differing presentations is a great challenge many times well achieved .
Denigration is a far too harsh word .
General Practitioners are highly respected and often liked by their patients .
in the Specialties many times absolutely heroic we still have had scandals with joint replacements releasing toxins cosmetic surgery extravagances unnecessary or too extensive operations .
Turf Wars sometimes approximating primordial tribalism are counterproductive.

Dr Olataga Alofivae-Doorbinnia   8/07/2023 2:11:00 PM

yes - I agree with the comments by senior and experienced clinicians. General practice is a vocation and many GP registrars we have trained were either disappointed that they could not do a subspecialist for whatever reason or like myself chose it because of flexibility or family life and a chance to work in the community. We need more champions in medical schools to show our med students the importance of good general practice and understanding the whole person and their family situation to offer sensible and safe treatment options for their health conditions. We need champions who appreciate the diversity of cultures and populations and why the same problems occur in these communities. Most of the med students we have had have come away with positive reports and would consider a career in GP, and we are not a third work country that does not have GPs let's do this survey again in 12 months after some positive role shifts in our medical schools .

Dr Olataga Alofivae-Doorbinnia   8/07/2023 2:11:16 PM

thank you

Dr John Joseph Scally   8/07/2023 4:57:04 PM

Nothing has changed in five decades. Being tutored by "esteemed specialists" for those clinical years has a very powerful effect on career choice. Probably harder than ever now to encourage a graduate to embrace primary care which can bring great joy but is now suffocating with lack of numbers and burden of regulation and paperwork.

Dr Angela Maree Roche   9/07/2023 2:52:21 PM

Just wanted to make a mention of 2 other great GP mentors , educators at Monash in the 80 s which helped to produce the like of nearly a 50 % turnout of general practice trainees during the 80 s from medical students: Dr Alan Rose and Dr Neil Carson . Dr Alan Rose couldn’t “ cop “ any idea of others self appointed ideas that they were somehow “ better”, or “ more important “ for being a surgeon or practicing in a different area of medicine. We were all DOCTORS.

Dr Paul Jenkinson   10/07/2023 4:11:17 PM

Bulk billing anything that moved with the permission of representative bodies and the government has seen the respect for GP decline over the last 50 years. If you effectively charge nothing to the consumer,you get the respect you deserve really. As well ,because you have to see a lot more patients to make decent money,the overall standard of GP declined as we handed over so many jobs to the limited specialists.
GPs had a choice at one time and I reckon the sooner they again charge what they are worth like anyone else in the small business world ,the sooner that respect will return.

A.Prof Christopher David Hogan   11/07/2023 4:41:22 PM

In reply to the above
There is a correlation between remuneration & respect- unfortunately.
As for Bulk Billing, there is an apt quote from the 1980s “What costs nothing is seen to be worth nothing
The bias for increased remuneration of procedures over consultation arose hundreds of years ago but is still wrong- consultations are usually much harder.
If you wish to see how effective & complex General Practice is might I recommend the 2 articles A sustainable vision for general practice: Addressing the challenges Joachim P Sturmberg Chris D Hogan Karen L Price
AJGP Volume 52, Issue 3, March 2023

A.Prof Christopher David Hogan   11/07/2023 4:52:21 PM

Articles claiming GPs are in the top 5% of income earners must be disputed.
Some look only at the assigned Medicare benefits but make no allowance for the costs that are deducted from this due to significant practice expenses.
Other studies make no allowance for the extra significant costs incurred by GPs in the first 20 years of practice for HECS & HELP debts, the costs of establishment in practice & the extra imposts by state taxes & charges. IMGs have the costs of their education as well as resettling costs.

GPs have always been lacking when explaining & promoting what we actually do .
We must all become our own champions.
Denigration (of GPs) is not too harsh a term. It is too mild.
The “Just a GP” garbage is usually selection bias. As stated all disciplines have issues with underperforming members but hospitalists tended to see only the mistakes of GPs.
The work of Good GPs was invisible until recently when GP numbers dropped & hospitals were flooded.

Dr Lachlan Christopher Fieldhouse   11/07/2023 5:44:20 PM

Just hosted two students last and this week from different med schools and enjoyed blowing their minds and seeing their smiles as they witnessed 'the magic' that is General Practice. More positive med school exposure can't be understated.

Dr Anon   15/05/2024 2:34:09 AM

-GPs are unequivocally treated like the domestic servants of the medical world.
-Public clinics are forever inventing new ways to refuse GP referrals. Many public clinics (psych, derm) refuse to take on complex patients.
-Agree with Dr Francisco, one can regale about how great “some” GP work is, but at the end of the day many GPs go home short changed for the services they provide +/- live paycheck to paycheck. Young GPs have added mortgage stress +/- infants.
-It’s not patients but medicare / government that denigrate GPs: Plans to fast track APHRA reg. of foreign GPs, pharmacy UTI trial, punish GPs charging gap fees by forcing patients to pay medicare + gap fee upfront, triple BB incentive but deceptively spruik like it’s for everyone.. then add payroll tax, no paid maternity leave for female GP regs, no annual PD allowance like trainees/consultants in hospitals to pay exam/conference costs.
-I also notice many “happy” GPs have closed lists / work GP part-time or do non-GP work.

Dr Paul   15/05/2024 3:41:50 AM

With the insidious economic recession and housing / cost of living crisis ramping up and directly impacting younger generations of doctors, one contemplates whether a career with “huge rewards and challenges” but relative poor financial remuneration (for the medical profession) will fly with the newer generations of doctors - taking into account there are similar fellowship exam pressures/costs, they have first homes to buy / mortgages to pay off, weddings and/or cars to pay off, HECS debts to clear and/or young families to support. I completely agree with Dr Black-Tiong, the issue is systemic (insufficient, opaque and/or coercive federal and state government policies). If the goal was ever for truly free universal healthcare then it needs to operate within the realm of a free market economy. To take a leaf from the economist Hayek - Ongoing attempts at central governance by price-fixing (GP rebates for services) will only further worsen access (to GP-driven healthcare).