General practice training applications have dipped: What can be done?

Doug Hendrie

6/09/2019 2:45:22 PM

Australia’s leading advocates for general practice were recently asked a thorny question.

GP training junior doctors
There have been calls for streamlining of training pathways to avoid registrars having to change employers and locations.

While there are still more applicants for general practice training than positions filled, the numbers have dropped by a total of around 400 since 2015.
So why have the numbers of junior doctors applying to be GPs declined over the last two years?
The question was posed to RACGP President Dr Harry Nespolon, as well as National Rural Health Commissioner Emeritus Professor Paul Worley, Australian College of Rural and Remote Medicine (ACCRM) President Dr Ewen McPhee and other prominent GP panellists at the recent General Practice Education and Training Conference (GPTEC) Future Forum.
Answers ranged from the impending changes to general practice training, to the funding challenges after the Medicare rebate freeze, to the axing of the Prevocational General Practice Placements Program (PGPPP).
Dr Nespolon said he believes the situation will improve once the RACGP officially takes the reins of training pathways.
‘Every year, it seemed there was a change to GP training, and that can lead to uncertainty,’ he said.
‘We hope that now we have training back there will be certainty going forwards.’
Dr Nespolon also said the relatively low remuneration in the early stages of training might be an issue, even though it would be offset during later training years and after Fellowship. 
Dr McPhee agreed with Dr Nespolon’s assessment that the training transition period might be a reason for the current drop.
Professor Worley said a key factor of the historic Collingrove Agreement between the RACGP and ACCRM last year, which laid the groundwork for the National Rural Generalist Pathway, was the ‘single-employer approach’ enabling general practice registrars to have confidence of a job for the entirety of their training.
He called for a return to family-friendly training and a streamlining of training pathways to avoid registrars having to change employers and locations.
GP and medical educator Associate Professor Louise Stone said she believes general practice has a problem of representation.
‘One of the great mysteries is what happens in an item 23. It’s hard to describe what we do,’ she said.
‘If it was simple, it wouldn’t have taken 14 years to learn how to do what I do.’  
President of General Practice Registrars Australia Dr Sama Balasubramanian told the forum that a key issue is that the system is ‘undervaluing’ general practice.
‘We have to reimagine general practice as the cornerstone of our health system. We need to lobby hard,’ he said.
‘GPs will not back down. We will not be undervalued anymore.’
Australian Medical Students’ Association President Jessica Yang said she would just spend five weeks in general practice over her degree.
‘When you consider how much of healthcare is general practice, why is there so little time?’ she said.
In a later GPTEC session, Department of Health First Assistant Secretary for Health Workforce Faye Holden described the drop in GP applicants as ‘something we need to address’.
‘There are a number of medical specialties where the community need for well-trained specialists [is] disconnected with what junior doctors are wanting to choose,’ she said.
‘There are multiple factors, from how the profession is perceived and funding around that. As training transitions to the colleges and with the Government’s Primary Healthcare Plan, over time, that should start to help.’
Asked whether the Government would consider reopening the PGPPP as a way to give junior doctors more GP experience, Ms Holden said it was a common question.
‘We’re trying to understand why the PGPPP was successful and what’s not being met in the programs taking its place,’ she said.

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Michael Albright   7/09/2019 6:39:53 AM

As a final term GP registrar I can tell you it’s all about the remuneration. We’re paid very little and expected to work full time and see just as many patients as fellows with much higher scrutiny of everything we do. It’s the pay. It’s got nothing to do with the RACGP taking over. I commenced RACGP training with 5 other registrars. We’re all finishing early 2020 and we’re all leaving GP. There’s no money to remunerate our hard work, we’re under increasing APHRA and PBS scrutiny, we’re losing a battle against the guild, the public feel we are greedy if we don’t bulk bill and the college is meanwhile wasting millions on ‘specialist in life’ rubbish campaigns. We need far more advocacy and remuneration. It all comes down to the pay.

Nicholas Maluga   7/09/2019 7:04:55 AM

You could try actually paying the registrar’s a wage that can be lived on? The salary is absolute peanuts, even compared to simply staying in the public hospital system, let alone doing other speciality training or locuming. The low salary is also prohibitive to people wanting to switch from other speciality training to GP...

Duncan   7/09/2019 8:16:00 AM

It's not just trainee pay, it's specialist GP income that is also inadequate. All the money is in surgery/anaesthetics/interventional procedures and people happily pay the gap. But we've created an expectation that primary care will be bulk-billed and we need to break that, if the government chooses to not find it. However, I suspect we're falling into a trap where the govt would prefer we're replaced with nurses and pharmacists, add they are easier to control, and cheaper to pay.

Diver Dan   7/09/2019 8:18:23 AM

It’s the money.

mileham hayes   7/09/2019 8:24:42 AM

1. Pay them indexed to politicians' increases
2. Stop anyone other than GPs owning medical practices
3. Stop the Pharmacists trying to be junior doctors but not accepting any responsibility or follow up for complications

Anything else is complete and utter band-aid BS and procrastinating window dressing.

Margot   7/09/2019 9:41:46 AM

It also doesn’t help that GP registrars are only offered 4 weeks annual leave and no professional development leave. We’re expected to take our holiday leave to study and sit exams and have barely any time left to recover from the grueling flow of demanding patients. This is not fair compared to the 5 weeks of annual leave and 1 week or PDL that hospitals offer their registrars. I am yet to meet a fellowed GP that works full time and takes less than 4 weeks annual leave.

Michael Bailey   7/09/2019 10:02:19 AM

As a fellow for 7 years and a registrar supervisor for 3 years I would say the changes to rebates, AHPRA, PBS and registrar pay all make general practice less appealing.

At the moment general practice looks like it is heading for towards nothing. Rebates are not going up, bulk billing is going up, expenses are going up. A switched on prevocational doctor will see that and who is going to want a specialty where income becomes progressively less.

If General Practice made financial sense for registrars now and had a promising future there would be no issue with registrars wanting to do the specialty.

Alfredo Aiello   7/09/2019 10:19:20 AM

The problem is not the training provider.
GPs are poorly remunerated.

Some GPs go rural and love it for a certain number of years, some will stay rural, remote etc forever.
But the majority will go back to cities for different reasons, to be closer to families, they want to support their children who go to university or be closer to entertainment.
Then reality hits: GPs are grossly underpaid unless you are willing to become a Locum travelling all over Australia to make a dollar and lose day to day living with your family or you become a practice owner, do cosmetics etc.

Antony Bolton   7/09/2019 10:26:08 AM

Is Harry Nespolon living in a parallel universe? I'm a final term GP Registrar and I'm still not earning anywhere near as much as I did as a registrar in emergency medicine. And when I Fellow, if I move practices my pay will fall precipitously when I lose my base - and given I have very little choice over placement as registrar despite the RTO claiming the process is open and competitive this is likely to happen.

Elias   7/09/2019 10:37:58 AM

I’ll say it how it is...
1. Medicare pays 37$ for standard consult , 10% goes to medical indemnity and PPD , and 30% - 40 %goes to practice , left with 20-24$ per patient. Now take out of that an extra 10% super , and we don’t get paid when sick or unwell or don’t get holidays that’s another 25% “casual loading” lost , so realistically left with around 15-17$ of income per patient if lucky , we see 4 per hour if trying to do a reasonable assessment (for 60$/hour) or 6 / hour if trying to to make money albeit leave ourselves open to litigation as can’t see someone and take good notes in 10 mins. Dentists make 40 -60 $ to look at someone’s teeth, lawyers charge 300-500$/hour, accountants charge 200$ an hour with way way less responsibility. And add in the fact GPS often get hung out to dry if anything goes wrong by Aphra and the court even if the patient doesn’t do as they’re told, is it worth all the stress for 60 bucks an hour ? With no holidays no sick leave no super no annual leave .

DR. AHAD KHAN   7/09/2019 12:02:27 PM

The Solution needs to quintessentially include these :
1. Insist that all NON-MBBSs wanting to Diagnose / Investigate / Refer to Specialists issue Prescriptions, must FIRST & FOREMOST obtain a MBBS Degree & then undergo the same Training as MBBSs are expected to undergo.
2. Make GP Vocation Financially Lucrative.
3. Demand from the Govt. of the day, PROPER Medicare Rebates for GP Services - if necessary RACGP to organise a Nation-wide One Day Strike of all GPs on a Monday.
Let the Populace know what the GPs are Demanding .


Dr Andrew Coker   7/09/2019 1:01:50 PM

I am a GP and chose general practice after completing a PGPPP rotation as an intern. Over the years I have supervised many registrars and medical students in general practice.
Since I graduated I have seen our income erode on top of more scrutiny, more paper work, and (most importantly) the pressure to bulk bill from both patients and the government. My wife is a GP registrar who is leaving for a job in the public service. She will receive better pay, holiday pay and superannuation. And I have encouraged her to do so!
In my opinion the reason people are not choosing general practice or leaving the training program is due poor remuneration during training and stagnant income as GPs, expensive entrance and exit exams that have low pass rates, a lack of syllabus in the training, and obvious support of pharmacists over GPs for delivering primary health care.

Mark   7/09/2019 1:30:33 PM

Final year GP registrar here. In my opinion it simply comes down to poor remuneration, which from all indicators looks as though it will only get worse in the future. Remuneration of GP registrars and Fellows is poor relative to:
- minimum 11 years rigorous university / hospital / fellowship training
- level of responsibility the job involves (literally making life saving decisions on a daily basis)
- other hospital registrars and non-GP specialists income
- income of non-medical professionals or even trades persons who have spent far less time studying/have far less responsibility in their work
- significant expenses that are increasing (while income is only decreasing) - e.g. income protection
GP training in my experience has been very flexible in terms of work life balance.
Non-GP specialist registrars are willing to undergo far worse training conditions than GP registrars (in terms of flexibility, after hours, duration of training, relocation). Why? Simple. Better pay.

Lindsay   7/09/2019 2:56:44 PM

We are going around in circles here: see my comments earlier this week regarding MBS audits, & its clear that many of my fellow GPs are thinking & saying the same things. We are GROSSLY undervalued by Government, & by the State Health departments who will gladly off-load all their difficulties back to the GP's shoulders, whilst they also demand more, for nothing: following their protocols so I can get my patients seen by a junior who has been in the job 5 years if we are lucky. And dont get me started on the new Centrelink certificate, which takes 15 minutes to complete adequately, without actually looking at the patient.
This HAS GOT TO STOP, otherwise there will be no general practice: everybody will flood into ED, or get no real care at the "stack ém high, sell ém cheap"merchants.
Is it at all possible for the College to really start a proper discussion with State & Federal governments? This is the one thing that will determine what happens to General Practice in the future.

MM   7/09/2019 4:28:43 PM

Let's say its $15 per patient and as junior reg, I can only see 3 patients per hour. That's $360 per day. Approx $80k a year. That would be less than what I make as a resident. I guess, I still wont be going hungry on that pay which was my fate had I stayed in biomed research as a postdoc.

James McLeod   7/09/2019 5:32:56 PM

It's plain and simple. My day job as a rural general practitioner simply breaks people. What I do day in and day out and just accept is a tough job actually makes many of my colleagues break down and cry. We run a privately owned medical clinic that is very supportive of our registrars and employed doctors but the sheer scope of clinical work, quantity of work including the added demands of registrar training, responsibility of inpatient and outpatient conditions we manage, the patient expectations, the poor remuneration through Medicare and the utter contempt some patients treat us with because we're "just a GP" means we frequently find our doctors stressed out and have even had our registrars crying and having panic attacks.
As rural GPs and registrars we are completely overworked, undervalued and underpaid and it's absolutely no surprise people are choosing alternate training programs.
Furthermore the "diversity of practice" rule is absolutely killing rural general practice.

Dana   7/09/2019 9:39:37 PM

Insulting treatment by governments over many years, appalling remuneration, finished off by ‘pretend doctors’ with no comparable training or responsibilities (pharmacists and nurses).
Shame, because most of us love the work.
In my opinion, this is why GPs are leaving the profession and medical graduates are avoiding it.

Jess   8/09/2019 5:47:54 PM

As a registrar on crappy low pay, with high levels of stress and responsibility and attempting to study between work and family.. the thing that has kept me going is the idea that at least my income will increase once I’m Fellowed. But reading these comments I fear I am mistaken and now feel rather depressed!! ☹️

Dr Vinod lal   8/09/2019 6:25:31 PM

My prediction is GP will continue attracting fewer graduates in years to come.Many doctors take up GP only if they cant get into another speciality for some reason.It will only improve if following recommendations are taken up seriously:
1-GP only general practitioners.That is only GPs can open and operate clinics.AMA\RACGP should take this up very seriously and lobby Govt to change.
2-Limit the number of GPs--That is 1 GP for at least 1800 people.Not 900 as it is now which has given the monopoly to non doctor owners
3-Basic wage of at least 250K if you are not the owner
4-Each consultation not less than $70 for 15mins
GP had been degraded to maximum.This needs to be corrected.Cooperates to be dissolved or each clinic owned by cooperated to have doctor as a co-owner as well.Same to apply for non doctor owner cowboys.
Get rid of bulk billing only--patients pay or Govt provides for patients in certain income range who are not earning much.

Mark O   8/09/2019 8:37:14 PM

The health care system is broken, general practice is dying, and the government is steadily dismantling medicare. At every review the number of claimable items is reduced. From day one of medicare, the 'rebate' has not kept place with inflation. It was stated at a conference I attended last year that by 2020 the medicare rebate will effectively be 40% of what it was at it's introduction. GP's have effectively had a 60% paycut not including billable itmes that have been dropped. GPs use about 7.5% of total health budget but are constantly being screwed down. GPs are under increasing pressure to fit the norm. Medical practice can be as varied as the seasons and it is naive and unrealistic to expect every general practitioners billling profile to be statistically in the same range. Why would anyone in their right mind sign up to be a GP? I blame the RACGP and the AMA for idly standing standing by and allowing the govt to steadily destroy the profession.

Stuart   8/09/2019 8:39:35 PM

Attracting registrars involves two main factors: providing a career that is intellectually and personally stimulating, and is also financially rewarding.
The RACGP is hopelessly deluding itself if it believes the federal government will increase Medicare rebates in any meaningful way. The RACGPs failure to advocate and lead the profession regarding appropriate remuneration has played a massive role in the diminishing interest in General Practice as a vocation.
It is time the RACGP started to run advertising campaigns advising the public to stop expecting bulk billing, and to start paying appropriate fees for the expertise we GP provide.

Bware   9/09/2019 11:47:47 AM

Why is this a mystery? Of course Dr's don't want to sign on to the misery of the medicare freeze. GP lifestyle is dead. No sick leave no holiday leave and no pay raise in 10 years. Forget super there's no money left over for that just trying to put food on the table each night. The AMA and RACGP have failed to offer any backbone. Its time for GP's to rise up and cease bulk billing in all clinics wait for patients to flood the ED and then watch the medicare unfreeze unfold.
I would welcome more thought out suggestions here as to how to end the medicare freeze before it ends us.

Joe   9/09/2019 1:49:29 PM

I read the article the other day in 'Brisbane Times' under the heading "LET THE PHARMACIST TAKE THE LOAD OFF GP", written by George Tambassis (pharmacist)"
The way he was advocating pharmacists "sharing the load with GP" was an eye opener.
General Practice is dying and there is no body to advocate for us it appears. It is unbelievable that if GPs take only 7.5% of health budget , why are we not able to promote the valuable services we are providing? I am getting sick of constant comparisons with UK. This is not UK. It's Australia. RACGP is the weakest body and we as doctors are not supporting each other. And Dr Nespolean doesn't seem to care.

Amanda   9/09/2019 2:11:37 PM

I believe the issues relate to the following:-
1) Unsatisfactory income which, for Registrars is much less that hospital Registrars, yet we are needing to pay more for indemnity
2) GP Registrars do not accrue sick leave as they would in the hospitals, so many of us are having to work when we are unwell
3) College exams that do not reflect the type of work we see clinically everyday
4) Registrars are often needing to work in fast-turning bulk-billing practices and often have to work evenings/weekends without having the 5 weeks of annual leave that hospital Registrars are entitled to
5) Limited organisational didactic teaching and education post GTP1 and 2

Joe   9/09/2019 5:08:16 PM

@Bware, could not agree more.

Dr Jennifer Smith   9/09/2019 10:42:04 PM

In light of all the above, WHY OH WHY are we charging people to sit a competitive exam to get onto the GP training program? I was an examiner on the interviews in years before the paid entrance test, and we could tell from that whether someone was suited to GP or not, and make recommendations accordingly. To charge a registrar several hundred dollars to do psychometric testing with no proof of accuracy in a capital city that may well be a long way from where they are working with no guarantee of a training place at the end is ridiculous and will put off those who would otherwise have applied. We need less hoops, and less costs, not more.

JT   9/09/2019 11:03:59 PM

I entered Medicine with the romantic notion of becoming a GP in my local community, looking after generations of families. Reading this has grossly deflated my dream as it seems obvious the role of a GP is grossly undervalued both socially and financially. I’d like to think that my years of sacrifice in time and money spent will be worth it but to be honest, I’m not so sure?!

Colin   10/09/2019 10:42:41 AM

The vast majority of registrar comment is saying the key issue is remuneration. The fact that the RACGP President thinks the situation will improve because the RACGP has now taken over training illustrates how out of touch the organisation is with reality. The TOP issue concerning all RACGP members in RACGP surveys is the Medicare freeze and low GP remuneration. If GP practice owners are not earning well means it is harder for them to pay registrars well.
From the above comments it looks like registrars are begging the RACGP to advocate far more actively for better GP remuneration. The main reason why Specialists earn more than GPs is that their bulk billing rate is much lower. As paying members, we should demand that the RACGP steps up to the plate and leads the GP profession in decreasing the bulk billing rate NOW. If they do not want to do it, or can't do it, we should pay our RACGP membership fees to another organisation who can.

Chris   10/09/2019 3:45:16 PM

The issue is the low rebate for patients. Until they complain nothing will change. The Government does not care about GPs complaining but if enough patients complain then that means votes and problems for the Government. The solution is to reduce bulk billing rates to 70% or less. The rate was 75% when the bulk billing incentive was introduced by Abbot.
Remember that the Libs wanted to introduce a co-payment and their under funding of Medicare is their way of doing it and trying to avoid blame for it. We need to discuss this with our patients and blame the Government as that is where the problem lies.
We can fight this but it needs to be done one less bulk billed consult at a time.

Rodrigo   12/09/2019 8:28:26 AM

There are several reasons for this. Unfortunately the RACGP and its contingent is totally out of reality compared to the GP profession. GPs have to work extremely hard to get enough money. I took a big pay when I left my job as a hospital reg to pursue a career as a GP.
In order for you to make enough money if working in private practice you have to see well over 20 patients, especially if you are bulk billing them, you need to deal with all types of stuff from a broken nail to a patient on the verge of killing themselves. Additionally on top of all this you need to revise a huge amount of stuff for very expensive exams which have over the last few years very hard (KFPs) and are of no educational value and totally not in touch with day to day GP work are failing in ridiculous amounts of registrars which are more than capable to doing the task. Additionally in order for you to get a semi decent pay you must go very remote which really puts lots of people off as well.

Kenny Corbett   14/09/2019 7:35:09 AM

I’ve been a GP for about 20 years and I’ve rarely heard such despondency within the profession, and the future of the profession at that. Additionally, I agree, and empathise with, the vast majority of the above comments. I too, spend much of my day trying to navigate and communicate with the illogical and frustrating public health system , welfare system, PBS, etc, etc. Don’t get me started on the CPD industry of which the RACGP is an avarice player! But yet, and here I risk sounding dangerously smug, I love my job. My secret (apart from the stuff we must pursue outside medicine), is: don’t work for a business that’s not owned by another doctor ; don’t universally bulk bill; don’t try and be everything to everybody, just be yourself and patients will take or leave you; try and teach others; develop a particular interest within the broad church that is GP ( mine is Skin Cancer Medicine, my wife’s is Travel Medicine); don’t ever compare yourself to others. It’s a great career. Enjoy

Pat   14/09/2019 1:39:22 PM

Interesting how the College still believes the axing of the much vaunted Prevocational General Practice Placements Program is part of the problem. As a supervisor my experience of the PGPPP wasn’t great. RMOs on rotations from the hospital sometimes with no interest in GP at all; needing supervision for every case and then leaving after 12 weeks - not good for continuity of care. It seems very clear from the illuminating comments above that pay and conditions of registrars and future prospects are the core of the problem to falling numbers. Our own registrar works part time in our practice and supplements her income with lucrative shifts in the local emergency department at weekends. Say no more.

Chris D Hogan   14/09/2019 8:23:06 PM

As I have said elsewhere I started work in General Practice in 1978 & been involved in medical politics since the late 1980s. I cannot decide if I am cynical or experienced - probably both.
I am convinced that governments of all persuasions only see Medicine as a cost that they are trying to reduce rather than an investment in the health & productivity of the nation.
They seek to turn us into a caste of bulk billing serfs but not content with that they use confusion &!weasel words to scare us into billing the minimum for every consult
We have two choices -stop bulk billing or have all of us become employees - hang on, are not 60% plus of us already employees?

Dr Robert Armstrong   15/09/2019 9:23:40 AM

Dr Nespolon and all the other GP committee men have got it all wrong . All students studying medicine have a degree of altruism .However they are the bright high school achievers and they have an expectation of financial rewards for their hard work as well the "feel good "stuff . As a speciality GP has been ground into the dust by bulk billing . The rate per minute is woeful when one considers all the phone calls made and received , all the advocacy for patients facing long waiting lists to see appropriate specialists or on hospital operating lists , the time taken to find a refuge for an abused women too scared to go home etc etc etc .This social work is not remunerated .So dilute the figures given by Elias in a letter above and blind Freddy would know why any graduate is going to avoid GP . GP will be dead in 15 years - make belief doctors ( ie nurses, pharnacists , and poor quality imports from the third world) will be all that is left .

Eustace   15/09/2019 2:24:35 PM

Allow IMG doctors with limited registration to join the AGPT as Registrars training especially IMGs that have finished their Moratorium and still on limited registration