Focusing on the challenges facing primary care

This issue of the MJA focuses on primary health care in Australia. General practice is one of the most enigmatic specialities in medicine in Australia, as in its very nature of generalist medicine, the boundaries and limitations of care are very hard to define. Most general practitioners are absolute generalists and will see patients for an initial consultation on a variety of issues. The “cradle to grave” care that GPs provide covers acute and urgent presentations, chronic disease management, population screening, immunisations and child developmental reviews, procedures, disaster management, and special interests. Most GPs, depending on their qualifications and geographic area of practice, also handle specific areas in medicine such as women's health, mental health, and skin cancer management.

In this issue of the MJA, Pandeya and colleagues examine the rates and outcomes of melanoma diagnoses in a sample from Queensland, finding that “More than 75% of melanomas were initially managed in primary care” (doi: 10.5694/mja2.51919). In terms of management of melanomas, despite current Australian guidelines recommending excisional biopsy with 2 mm margins as the initial management of lesions, only half were initially diagnosed on excisional biopsy within the analysis. Dermatologists were more likely than other specialists to use shave biopsies for initial diagnosis. GPs continue to be at the frontline for the management of skin cancer in Australia, yet the support offered to them for this is often lacking, as pointed out in the linked editorial by Rosendahl and Clark (doi: 10.5694/mja2.51928). Although dermatoscope use is considered the gold standard in melanoma diagnosis, especially for early lesions, GP trainees do not currently have any standardised method of training available to them in the use of dermatoscopes and diagnosis of skin cancers.

In their research letter, Anderson and colleagues analyse the performance of general practice trainees in their first year of training across two formative assessments: a multiple choice questionnaire as well as an external clinical teaching visit (doi: 10.5694/mja2.51928). Scores for trainees from James Cook University did not differ between regional, rural and remote areas, showing that the quality of training appears to be equivalent in this region across the board. Although outcomes for the Fellowship exam are not known, this article highlights the value of a standardised teaching program for general practice trainees to help manage the broad nature of the specialty. With the Royal Australian College of General Practitioners recently taking over training, this will be a space to watch.

In managing the undifferentiated patient, patients with multiple chronic diseases and patients with complex socio‐economic backgrounds, GPs are more likely than other specialties to manage uncertainty in clinical practice, as pointed out in the narrative review by Scott and colleagues (doi: 10.5694/mja2.51925). The authors note that “Clinicians with higher intolerance of uncertainty may be more likely to avoid certain kinds of patients with complex needs, such as substance users, the poor, older patients and the underserved, contributing to health inequities”. Furthermore, “Intolerance of uncertainty is also associated with more psychological distress and burnout, loss of self‐compassion, career dissatisfaction and disengagement at work, more discomfort dealing with death and grief, more concerns about malpractice risk, less propensity to adopt new and effective clinical interventions, and more limited leadership abilities”. The review offers several helpful methodologies for managing uncertainties in clinical practice, depending on the scenario.

Despite having been at the frontline during the pandemic, general practice continues to be an underappreciated and underfunded specialty in Australia. There has been little change in the Medicare rebate offered to GPs for their consultations over several years, and they continue to manage an increasing burden of patients with complex care needs as costs across the health system escalate (https://insightplus.mja.com.au/2023/9/mental‐health‐generalism‐invisible‐workhorse). The poor remuneration combined with a significant prevalence of burnout in the profession has led to a decline in doctors signing up to train in general practice. A significant proportion of practices in remote and rural areas have either closed due to the declining workforce or switched to a private billing model to stay afloat (https://insightplus.mja.com.au/2023/14/doctors‐need‐more‐say‐in‐fixing‐gp‐crisis). These issues do not seem to be addressed by government in any meaningful way. General practice is the pillar of the health care system in Australia; everyone sees their GP. The declining numbers of GPs will have a significant ripple effect on health care expenditure and acute care service use by patients across Australia unless this problem is addressed adequately. The MJA will continue to focus on these challenges and remains committed to supporting GPs through publishing research and commentary in this area.