Getting back into the emergency department: diversifying general practice while relieving emergency medicine workforce shortages

Generational and demographic changes among Australian medical graduates are creating imbalances in some sectors of the medical workforce, and a desire for more flexible postgraduate training and career pathways.1 Current estimates indicate that despite workforce shortages, only 27% of Australian medical graduates are choosing a career in general practice.2 This is due to a variety of factors, including competition from other postgraduate disciplines for a limited pool of new graduates, lower Medicare rebates for general practice consultations compared with other specialty consultations, and a perception that general practice fails to offer sufficient day-to-day diversity in practice (Piazza G. Specialist registrar perceptions of general practice training. 2005. Unpublished report to General Practice Education and Training).

Career flexibility is widely promoted as a recruitment advantage in general practice, in particular the ability to work part-time. Time for active parenting and development of other career and personal interests is cited as being an important reason for choosing to train in general practice for graduates of both sexes.1 However, while the “diversity” of general practice is widely promoted, the reality may not always meet the expectations of recent graduates. Although training in hospital and procedural practice is reasonably easy for Australian general practitioners to access (including training in surgery, anaesthesia, obstetrics and emergency medicine), GPs are often limited in their ability to utilise these skills in everyday practice. Barriers to an expanded scope of practice include:

• poor acceptance of procedural general practice by other specialty disciplines (particularly in metropolitan and regional areas, and despite a lack of objective evidence that procedural care delivered by GPs results in poorer outcomes for patients3);

• complex credentialling criteria from state jurisdictions and local hospitals; and

• concerns about indemnity costs associated with procedural practice (although this concern has been substantially addressed in recent years by indemnity insurance reforms).

Further, GPs are often denied access to the provision of hospital and procedural services in geographic locations where specialists choose to practise, but readily accepted in regions where no specialty services exist.3

Concurrent with the workforce challenges facing general practice, it is also well known that many hospitals are experiencing difficulty in attracting senior clinical staff to emergency departments.4 Enrolments in emergency medicine are also declining, despite its reputation for career flexibility.1

Skills in emergency medicine and critical care are essential in all geographic locations, but the nature of the skills required will vary according to the location. For example:

• In remote areas, practitioners require retrieval, resuscitation and stabilisation skills before transporting patients to less remote facilities.

• In rural areas, skills are required in resuscitation and the management of infrequent but significant complications of routine procedures (eg, surgery, anaesthesia and childbirth).

• In metropolitan areas, skills are required in the sophisticated management of critically ill patients for extended periods (eg, severe burns and trauma patients).

Matching these skills to the health care needs of individual populations around Australia is haphazard, and not well aligned with traditional college “silo” programs of training. For instance, Fellows of the Australasian College for Emergency Medicine (ACEM) are well equipped with resuscitation and retrieval skills, but rarely practise outside large metropolitan or regional centres. Those with critical care skills (including intensivists and anaesthetists) are overwhelmingly located in major population centres, meaning that resuscitation and transfer must be performed effectively in rural and remote areas. GPs in rural and remote locations require high-level resuscitation and stabilisation skills, but are unable to utilise these skills if they relocate to regional and metropolitan settings.

I argue that existing programs providing GPs and rural practitioners with the necessary skills to make them safe for practice in emergency situations should be expanded to allow development of a well credentialled and competent generalist emergency workforce. Such programs include the Queensland Health Rural Generalist Pathway,5 and the New South Wales Hospital Skills Program6 and Hospitalist initiative,7 and specific courses such as Emergency Management of Severe Trauma (EMST; provided by the Royal Australasian College of Surgeons) and Advanced Life Support (ALS; provided by a number of organisations). These programs are structured to ensure that generalists working in emergency medicine are highly trained and effectively credentialled for various levels of practice. The failure to implement these programs more widely can be attributed to silo-based attitudes to training and service provision among many specialty colleges, exclusion of GPs from public hospitals in regional and metropolitan centres through complex and inconsistent credentialling processes, and a lack of funding to expand existing programs.

Significant access block occurs in emergency departments due to the attendance of patients with exacerbations of complex and chronic health problems. While usually not in the highest triage categories, these patients require detailed assessment and frequent admission.8 The assessment and management of these patients is a core domain of general practice, and GPs could contribute more effectively to the care of this group. The ACEM states that “after-hours GP services do not address the problems of access block and overcrowding in emergency departments”,9 but this statement relates to the co-location of general practice services to treat low-acuity attendees at emergency departments. I argue that there is great scope for the involvement of experienced GPs in the treatment of high- and moderate-acuity patients, not just the low-acuity category, as part of the emergency department workforce.

Compared with general practice and emergency medicine, other postgraduate vocational streams, including anaesthesia, dermatology, radiology and a number of physician specialties, are seen as offering flexibility during and after training and generally receive more attractive Medicare-based remuneration.

I argue that to attract students and new graduates, the appeal of general practice has to be based on broader criteria than flexibility and diversity of clinical work. It is essential to provide expanded career pathways for GPs and positive general practice role models and mentors to students and new graduates. These career paths need to emphasise the ability to regularly expand an individual’s scope of practice through development of new interests and skills during an extended career. This need is acknowledged by the Australian Government, which states:

The medical workforce can no longer be developed within isolated discipline silos — I believe these silos will become increasingly irrelevant in the current century. Other professional groups, such as the legal and engineering professions, seem to have already recognised the positive benefits of career evolution, and it is time for the medical profession to catch up. Consequently, there must be easy entry and exit options between general practice and other medical career pathways. General practice has great scope to provide desirable options for new graduates, including better opportunities to use procedural skills in practice (including in regional and metropolitan settings as well as rural locations); recognition of prior learning (eg, for graduate students with backgrounds in other health disciplines); and shared and modularised training across specialty disciplines.

Encouraging GPs to work sessionally in emergency departments could have many positive outcomes:

• Emergency department workforce shortages would be alleviated, allowing ACEM Fellows to operate at a true consultant level.

• Participating GPs would benefit from an expanded scope of clinical practice and enhanced career satisfaction.

• The management of a number of complex and chronic conditions that are currently managed within emergency departments and affiliated short-stay admission units could also be improved.

• If “specialists” (ie, those holding a college fellowship) from either discipline should subsequently change career, recognition of skills already attained would allow significantly shortened training periods for the alternative fellowship.

• A re-integration of GPs into this part of the hospital system might also pave the way for GPs to again become involved in other aspects of the care and treatment of patients in hospitals.

Further research is needed among medical students, prevocational doctors and registrars to understand the components of present career structures that act as disincentives to entering general and rural practice. General Practice Education and Training (GPET) has undertaken several such studies, in particular with registrars who chose to enter specialties other than general practice (Piazza G. Specialist registrar perceptions of general practice training. 2005; Bunker J, Shadbolt N. If the job fits . . . the complexity of medical career decision making: a review. 2007. Unpublished reports to GPET). A change in attitude towards the scope of general practice is also required from state bureaucracies, other specialty disciplines, and even from some GPs who have accepted that general practice has been limited to a consultative and referral role.

“Generation X” graduates currently entering practice are well aware there is a workforce shortage and that they have many career options. While they are just as diligent and motivated as previous generations, they appear less likely to want to practise in one area of medicine throughout their careers, or to tolerate unsatisfactory working conditions.11,12 Understanding these generational drivers and adapting our current workforce silos and bureaucracies to enable greater flexibility and scope of practice for the next generation of Australian doctors is essential if we are to meet their career needs and the health care needs of the Australian community.