"Only a GP?": is the solution to the general practice crisis intellectual?

General practice is in crisis. It has a poor status within the profession,1 and general practitioners earn less than other medical practitioners2,3 — even for the same services, they command poorer fees than specialists in Australia.4 Their traditional place is outside the healthcare system (still dominated by hospitals), exerting considerably less influence from the "corner shops" of their private practices. The number of GP registrar applicants is little above the imposed restriction, and is falling (Box 1). Only 392 Australian-trained doctors (about a quarter of the cohort of junior doctors) applied for a GP registrar position for 2003. An additional 35% of applicants were overseas-trained, while only 31% were Australian-born (R Coote, General Practice Education and Training Ltd, Canberra, personal communication, May 2003). The picture is similar overseas.3

The perceived poor state of intellectual activity in general practice is more profound. GPs publish less research than specialists5 — vastly less in relation to their practising numbers.6 GP journals have lower (if slowly rising) citation indices. Compared with general practice overseas, we seem to be always catching up (Box 2).

More important, our patients are losing confidence in their GPs' ability to know them as a whole person (eg, their values and beliefs), to coordinate their care, and to provide it continuously.8 They commonly ask, "Are you only a GP?" — and worse, GPs themselves often reply "yes"! Continuing medical education for GPs is still dominated by specialists.

A competent and self-confident general practice workforce is good for a nation's health.9 Research comparing nations suggests that a strong, self-sufficient, self-assured, and respected primary healthcare sector leads to both improved quality and more cost-efficient care.9 For example, the Netherlands has one of the world's highest quality, most cost-effective primary care systems, while Belgium, until recently, seemed to lag far behind — differences that are surely attributable to the very different structure of their healthcare systems. Britain and Australia seem to lie between these two extremes.

To allow general practice to fail would be serious for Australia. We argue here that the many steps that have been instituted around the world are necessary to improve primary care, but need to focus more on the intellectual side of the discipline.

There are several reasons for the poor status of GPs within the profession. Market forces are obviously important: GPs are just less rare. Access to specialists is restricted by delays and waiting lists in public hospitals. One can usually see a GP in a day or two for a non-urgent problem, even in rural areas (where there is a relative scarcity of GPs). In private practice, specialists are much more likely to charge fees above the Medicare schedule fee. The Australian rate of bulk-billing (direct invoicing of Medicare for a discounted fee) in 2002 was 73% for vocationally registered GPs, 20% for obstetricians, and 9% for anaesthetists.10 General practice expertise is less deep (if very much broader), focuses on process more than content, and is harder to measure and explain to managers and politicians.11 We GPs are more expert at processes of care, such as communication skills, accommodating the psychosocial context, and continuity of care. We are less expert in diseases, leading to undervaluing of our skills.

Possible reasons for the poorer performance of GPs in research and publishing are many. GPs are relatively poorly represented in universities, with higher teaching loads per academic.12 This results not just from academic GPs being the "newest kids on the block", but also from the grander and more dominant status of biomedicine. There are not enough high-profile academic GPs to lead the discipline.13 In the competitive environment of academia, the rich get richer.

Solutions are probably many and complex. Simple responses from government, such as substantially increasing the remuneration of GPs, seem unlikely. However, overt inequities should be addressed, by paying the same amount to doctors of the same seniority for the same services. The costly Relative Values Study reported in 2001,14 but solutions have become mired in politics.

Some very attractive ideas for empowering GPs were initiated in the United Kingdom.15 Firstly, fund- (budget-) holding, and then Primary Care Trusts, put GPs at the core of health resource allocation. Similar schemes were introduced in the Netherlands and New Zealand.16 A crucial feature of these systems was their encouragement of professional autonomy, but GPs were less enamoured, and professional morale slipped further.17 In the UK and the Netherlands this may have been because more responsibility was forced on GPs than they wanted,17 and because resources for general practice decreased while expectations rose. Similarly in the United States, where "managed care" strengthened the gatekeeper role of primary care, a disproportionate share of unpopular cost containment fell to GPs.3 In the UK, the proposed new GP contract offers stepped increases in primary care investment,18 but the profession is still digesting its implications.

Divisions of General Practice are an Australian solution.19 They have helped GPs collaborate to improve local health services and to conduct ambitious projects such as the Coordinated Care Trials.20 This activity will probably continue to improve the status of GPs.

However, we believe that another essential for improving the status of general practice is strengthening its intellectual aspects, through promoting more and better critical thinking among GPs. How can we make that happen?