In-practice and distance consultant on-call general practitioner supervisors for Australian general practice?

Educational initiatives designed to meet Australia’s future medical workforce requirements have increased the number of medical students and junior doctors in general practice, especially in rural areas. General practitioners understand the rationale for these initiatives, and many welcome the new opportunities,1 but it is unrealistic to expect GPs to cope with the large-scale changes involved without addressing the impact of the changes on GPs’ core role and source of income — patient care. Each initiative can seem small, but as all share the same resource — general practice and GPs — their combined impact is substantial. Large-scale change, arising from multiple smaller programs, requires support and consideration of the impact of the changes on current work practices. The potential crisis in GP teaching creates an imperative for innovations that increase capacity without reducing the quality of patient care or training.2

This article outlines the current framework of general practice education within Australia and argues why this is an insufficient model for the demands now being placed on it. One alternative model for facilitating learning in general practice is suggested for implementation and evaluation.

The Royal Australian College of General Practitioners (RACGP) began formal GP training in the 1970s. Registrars started with hospital terms and then worked alongside experienced GP supervisors. New registrars needed an orientation, face-to-face supervision and timetabled teaching, but as they developed independence, their interruptions to the supervisor’s consultations decreased. In addition, undergraduate medical students were placed for short general practice attachments, usually as passive observers. This “apprenticeship” style of training remains essentially unaltered, despite changes to the organisation and governance of GP training created by regionalisation3 and an alternative qualification route via the Australian College of Rural and Remote Medicine (ACRRM).

Various programs to place learners in general practice have been created (eg, the Prevocational General Practice Placements Program).4-9 Each learner comes to general practice with an expectation of direct patient contact but with different skills and experience. Institutional support for GP supervisors varies — from paperwork and the offer of honorary academic posts to practice grants and paid teaching time. There is limited correlation between the amount of support offered to the supervisor and the educational needs of the learner.

Initial trials of distance supervision10 have been consolidated by the Remote Vocational Training Scheme,11 and off-site supervision occurs for doctors registered under area-of-need provisions12 and in the ACRRM Independent Pathway.13 Distance supervision injects experience into isolated areas, but also creates more demand on busy GP supervisors and requires reliable equipment and connections, as well as effort to engage learners.14

An alternative model of consultant on-call GP supervisors (CoGs) could coordinate education and training within a practice team as well as supervise senior general practice registrars at a distance (Box 2). This would overcome many of the problems cited above and provide much-needed additional training capacity. CoGs would be freed from their own clinical load and their prime responsibility would be proactive and reactive facilitation of junior doctors’ work-based learning. Most of the on-call work would be during the day, when general practices are open. Options for night cover would include reverting to current arrangements or having a reduced number of CoGs supporting a larger number of juniors.

CoGs would enact Kilminster and Jolly’s definition of clinical supervision:

CoGs would need to be expert clinicians. They would be accredited through the same mechanism as that used for GP supervisors and would require training in teaching and supervisory skills. GPs recognise the benefit of teacher training,26,27 but have cited the need for dedicated time and financial support to study.28 CoGs would maintain currency and credibility as GPs by doing part-time clinical work.

CoGs would be involved in recruiting and placing potential trainee doctors, planning practice-based teaching, actively monitoring the quality of patient care and seeking doctors’ blind spots (eg, by audit or video observation). CoGs would support juniors faced with an on-site medical emergency, but responding to off-site emergencies would be limited to advice only. Good emergency skills would be a prerequisite for a doctor under distance supervision. Using fair and transparent systems, CoGs would collate feedback from the health care team and patients about learners and would encourage direct informal communication and learning among team members. CoGs would liaise with learners, educational institutions, colleges and employers, and learners would understand the rationale that this was best for patient safety and their long-term career.

Patients would be reassured that seeing the junior in a practice was a safe option, and the CoG’s involvement might help to preserve continuity of care.29 The CoG model could provide senior doctors with the flexibility and career progression needed to sustain them in the workforce30 and prevent their early retirement and loss of their wisdom from general practice. The CoG role might rotate between senior doctors in one practice or across practices in a town or region. In a rotating system, one CoG would be designated as a learner’s main supervisor/mentor.

Funding this model will require resources from the education and workforce sectors and is a potential sticking point, but without extra resources the investment in medical school places and junior doctor programs is a potential waste. Educational funding should flow to the site of the education — general practice.

The salary for CoGs should be set at the GP consultant level. The MABEL (Medicine in Australia: Balancing Employment and Life) survey showed that average earnings were $316 750 for specialists and $177 883 for GPs in 2008.31 A salary set at $250 000 for CoGs would recognise the consultant nature of the role as well as covering some practice overheads, but it would still be lower than the average salary earned by procedural rural GPs. Assuming each CoG supervised four learners, the cost of providing the 76 000 training weeks that were required in 201032 would be $91 million. Although this sounds exorbitant, it reflects part of the true cost of quality supervision in general practice. This amount is still less than the over $100 million required for the Australian General Practice Training program.

Should funding be redirected into general practice from program administrative and governance costs? The ideas of Thistlethwaite and colleagues30 on pooling separate funding streams provide a sound basis on which to begin some difficult yet important discussions about funding for CoGs and provision of information technology, training and infrastructure support.

A model of consultant on-call GP supervisors and an expansion of distance supervision of senior general practice registrars could address many of the issues facing general practice education. Funding, information technology and detailed evaluation of this innovation would be needed to test its ability to provide effective educational supervision and quality patient care. Australia’s investment in increased medical student places will be an expensive folly unless general practice teachers are supported.