This was a favoured concept in the days before college curricula existed (hard to believe, I know). Certainly a gifted teacher can turn any clinical encounter into a multi-faceted learning opportunity (often done on teaching visits). Plus, the self-directed learner will fill in their perceived gaps and GPs are the sort of doctors who can turn their hand to anything (a uni colleague of mine headed out bush after a single RMO term in obstets and delivered babies for years). But those were the good old days and the assumptions were a bit idealistic. The pendulum has swung decisively in the opposite direction.
The question remains unanswered regarding how much clinical exposure / experience is adequate in various areas but this does not stop people making policies. There is the much repeated “ten thousand hours” to become an expert and proceduralists in the US assert that shorter working hours by trainees means that specialty training should be longer. Well, no one is going to win that argument as regards Australian GP training as long as the government is effectively in charge of training.
In GP training clinical exposure varies greatly because of the variability of practices. A registrar might do only 18 months in general practice (or less with ACRRM) and might work in only two locations. Previously we collected end of term registrar feedback data on multiple aspects of the practice experience and could state with confidence which practices were at one end of the distribution curve of older patients or kids, for instance. Sometimes there were surprises. Registrars may do far fewer minor procedures in a rural practice with a part-time surgeon than in a keen urban practice. Sometimes you have to dig deeper than the statistics. All this enabled evidence-based training and was useful in advising choices for subsequent placements – but only if educational priorities are as high as training location priorities. In any case, such data is now lost in databases which are defunct due to the recent changes to training.
Growing with your patients
Still, does it really matter in the long term? Currently, in the climate of doom saying about population demographics and health system “sustainability”, there is a lot of angst around about how registrars see fewer older patients than established GPs. Is anyone surprised? Even BEACH figures showed that younger (Fellowed) GPs see fewer older patients – and someone still needs to see the kids! My second GP job was in an inner city practice whilst still working weekends in ED for two years. I was happy with acute presentations, became something of an expert in STIs and contraception (and some later occupational health) and augmented this by doing the FPA course in my holidays. I left there to move to the suburbs and a group practice to do more “family medicine” in a practice with two GP obstetricians. The years passed and I did some extra dermatology and paeds, a women’s health course and some research into menopause. I didn’t do a lot of extra mental health because I had trained as a social worker and worked as a counsellor. If we had moved to the country I would have upskilled again in emergency medicine. I then did a geriatrics course followed by a PhD on frailty. You can see where this is heading. Some years later, for curiosity, I looked at the demographics of “my patients” – those who generally only saw me (no mean feat given I am part time in clinical practice). Their mean age was 60 – which, fortuitously, was my age!
Let’s face it, aged care will require a whole new set of knowledge and skills in twenty years and GPs will be up-dating most of what they learnt as registrars. Oh dear, all that wasted time learning about how to bill GP Management Plans!
Recognising the curriculum knocking on the door – relevant up-skilling
I have taught aged care for twenty years (and I will talk about teaching aged care in a later post) and am keen on it but that doesn’t mean I think all registrars need to see a lot of it or be as enthused as I am. General practice is dynamic across a lifetime and we need to encourage registrars to recognise community needs and do something about their gaps. They need to know the basics and take responsibility for the patients they see. “Just a script” should be the chance to reflect on polypharmacy, rational prescribing and de-prescribing. Multimorbidity is not limited to older patients so experience can be gained with younger age groups. of course, exams need to be passed.
Registrars all have different back stories and maybe the ex-geriatric registrar actually needs to see more kids and sports injuries. Maybe the ex-orthopaedic registrar needs to do more mental health. Maybe they can be directed to useful extra curricular courses and CPD to set a pattern for lifelong learning. There is nothing like a bit of extra knowledge to open our eyes and help us to see patient problems we overlooked before and to address them more effectively.
As educators and supervisors we have the opportunity to (hopefully) individualise the vast resources that are the curricula and to go a bit beyond the mandatory syllabuses that need to be ticked off.
Given the brevity of GP training, and the breadth and dynamism of general practice, a disposition to ongoing professional development is the crucial priority.