postgraduate training in general practice: the registrar perspective

Postgraduate training in general Practice: the RegistRaR PeRsPective, March 2008

about this rePort

this research report was prepared by Bob Birrell of the centre for Population and Urban Research at Monash University in collaboration with general Practice Registrars australia (gPRa). it presents information derived from a survey of gP registrars conducted during semester 2, 2007 as well as background information about gP postgraduate training, australia’s primary health care needs and government strategies to meet these needs. the report was coordinated by gPRa with funding from the commonwealth Department of health and ageing, the independent Practitioner Network (iPN) and Dr Jerry schwartz through the schwartz Foundation. the purpose of this document is to inform government and stakeholders about attitudes of young gP registrars to their training and career aspirations that will shape the future of health care delivery in australia.

Acknowledgements With special thanks to the the schwartz Foundation, the independent Practitioner Network (iPN) and the commonwealth Department of health and ageing for their support.

Postgraduate training in general Practice: the Registrar Perspective 3

4 Postgraduate training in general Practice: the Registrar Perspective

contents

introduction 5

context overview 6

section 1 - the big Picture 7 the context of general practice training in australia 7 the contemporary setting 8 the vocational training setting 9

section 2 - the gPra registrar survey 11 Registrar survey methodology 11 Who chose general practice and why? 11 What attracted the registrars to general practice? 11 the situation of female registrars 13 career location 15 What attracted registrars to the rural pathway? 16 attitudes to the general practice training program 17 experience with the gP training program 19 the RacgP examination 19 conclusion 21

glossary of terms aPPendix 22

introduction

training the future general practice workforce in australia should be viewed within a broad-brush social, political and economic context if we are to understand how to meet australia’s future health care needs.

there are many factors currently influencing gP vocational training in australia. the most significant of these include the prevailing gP shortage, especially in rural and remote areas; changing demographics among gPs-in-training with a new emphasis on women and international Medical graduates (iMgs); competition for medical graduates from other medical specialties perceived by some to be more high-status and lucrative; and a continually evolving postgraduate gP training program that aspires to elevate the competencies and perceived status of general practice as a profession – all of this, while grappling with the over-arching demands of australia’s health care system.

in shaping future government policy, it is important to take soundings from all the important players. in this report, we have set out to explore the motivations and satisfaction levels of a cohort of people central to the gP workforce debate: registrars currently participating in general practice postgraduate training.

Section 1 of the report outlines the big picture of general practice training and provides a background exposition on the wider social, political and economic setting in regard to training australia’s future gPs.

Section 2 of the report sets out the findings of a survey of gP registrars conducted through general Practice Registrars australia (gPRa).



context overview

the need to attract an increasing number and share of medical graduates into general practice is clear. there are severe shortages of general practitioners (gPs) in australia, particularly in regional australia. the australian government is anxious to alleviate these shortages and has taken a number of steps in this direction. these include the creation of new medical schools and clinical training centres in regional areas and the allocation of medical school places and scholarships to students prepared to serve in regional areas on completion of their medical studies.

if additional resident doctors are to take up general practice, more medical graduates will have to be attracted to the postgraduate gP training program. as with surgeons and physicians, medical graduates wishing to enter general practice must first complete the relevant postgraduate training program. Prior to the election of the current Labor government, the coalition government facilitated this outcome by increasing the number of beginning training places in the gP postgraduate training program from 450 in 2001 to 600 in 2004. the aim is to gradually increase the number of training places to 1200 by 2012.

there is no guarantee that such places will be taken up. it will depend on the willingness of domestic medical graduates and international Medical graduates (iMgs) who have completed their accreditation examinations with the australian Medical council (aMc) to take on gP postgraduate training. this cannot be taken for granted, because there are currently many more training places available across the specialist training programs (including general practice) than the annual

number of medical graduates. in recent years, the gP training program has not been able to fill its quota from domestic graduates. it has drawn increasingly on iMgs to fill its ranks.

if additional resident doctors are to take up general practice, more medical graduates will have to be attracted to the postgraduate gP training program.

in addition, there is no assurance that a significant share of the doctors who complete the gP postgraduate training program will be prepared to practise in regional or other under-serviced areas. again, the previous coalition government took a number of steps to make medical service in these areas more attractive. But whether these actions will be sufficient to attract the required number of doctors to under-serviced areas is an open question.

these are some of the issues that this report addresses. it looks at them through the perspective of the registrars who are currently participating in the postgraduate gP training program. this is a perspective not often heard in the debate about medical manpower issues. the main source of information for this report derives from a survey of current gP registrars. the survey was designed by the authors and administered by general Practice Registrars australia (gPRa), the organisation that represents these registrars.

The context of general practice training in AustraliaPostgraduate training in general practice is not just about preparing medical graduates to serve as gPs. From the government’s perspective, it has also been about managing the size and work location of the gP workforce.

Until 1996 there was no compulsory postgraduate training program in general practice. Prior to 1996 gPs were encouraged to complete a vocational training program run by the Royal australian college of general Practitioners (RacgP), but could practise without this credential. every year prior to 1996, hundreds of medical graduates who were fully registered (that is, they had completed their intern training) took up gP appointments without any postgraduate gP training.

this situation changed at the end of 1996 when the incoming coalition government introduced some fundamental changes to the regulations governing the terms under which gPs could bill on the Medicare system. the new rules were designed to better prepare doctors for general practice and to simultaneously limit the number of doctors entering the field. the first objective was achieved by the ruling that new medical graduates were not permitted to bill on the Medicare system for gP services until they had successfully passed the RacgP training program. the goal of limiting numbers was achieved in the 1996 legislation by the stipulation of an entry quota to the training program of 400 new places each year. this number was well below the actual number of medical graduates who had been annually entering general practice prior to 1996.

until 1996 there was no compulsory postgraduate training program in general practice. gPs were encouraged to complete a vocational training program run by the racgP, but could practise without this credential.

the reason for the restrictive quota was that the coalition government, like the preceding Keating Labor government, was concerned that there were too many doctors practising in australia, particularly in general practice, and particularly in metropolitan areas. this was partly because of an upsurge in the inflow of iMgs during the 1980s. the 1991 census enumerated 4,696 persons who had arrived in australia over the years 1986 to

1991 and who held degree-level medical qualifications. this group included 1,117 from the UK and ireland and 261 from New Zealand,

i who were granted automatic registration to

practise in australia. those from other countries had to first pass the australian Medical council (aMc) accreditation examinations before they could practise. this iMg inflow added to the annual number of domestic medical graduates of 1,200-1,300 at the time.

in 1992 the Keating government acted to limit the entry of iMgs to medical practice in australia, by making it harder for them to gain skilled visas and by requiring all iMgs, including those coming from the UK and ireland, to complete the aMc accreditation examination before they could gain full registration in australia. the government also required the aMc to put an annual quota of 200 on the numbers of iMgs who successfully completed the aMc’s examinations.

this restrictive attitude also affected government decisions about domestic medical training. Both the Keating government and the coalition government (until the early years of this century) adamantly opposed any increase in the numbers of medical school places for domestic students.

the basis for the Keating government’s concerns (and the coalition government that followed) was that the ratio of gPs to patients had increased markedly since the 1980s, as had the number of services delivered per patient and the overall cost to government through the Medicare system. it was considered that the rate of growth of expenditure on medical services was becoming excessive and had to be reined in. the government’s medical manpower advisory body at the time, the australian Medical Workforce advisory council (aMWac) advised that by international standards there were enough doctors in australia to service the population (though it acknowledged some maldistribution favouring metropolitan areas).

ii the attitude within

policy circles at the time was that doctors would continue to be attracted into general practice despite the alleged “surplus”. this was because they could (allegedly) initiate services without patient resistance since it was the government that paid the bill. By implication, doctors were regarded as service generators as well as service deliverers.

as it turned out, the aMc quota initiated by the Keating government did not come to pass because after an inquiry into the matter, the human Rights and equal Opportunity commission declared that the quota was unjust – indeed racially biased. after

section 1 - the big Picture




this judgement, the aMc removed the quota. Partly because of this development, when the coalition government addressed the issue in 1996, it also took the view that there were “too many doctors”. this judgement prompted the decisions previously noted - that is, to make postgraduate training in general practice compulsory and to establish a tight quota on the number of training places.

in addition, the coalition government toughened the access of iMgs to medical practice in australia. it did so by introducing a “ten year rule” (known as the ten year moratorium) which stipulated that iMgs could not bill on the Medicare system (unless they served in an “area of need”) until ten years after completing their aMc accreditation examinations and gaining full registration with a state Medical Board. this measure prevented iMgs from providing general practice services (except in “areas of need”) during this period.

the coalition government introduced a “ten year rule” (known as the ten year moratorium) which stipulated that imgs could not bill on the medicare system (unless they served in an “area of need”) until ten years after completing their amc accreditation.

Furthermore, if they wished to practise as gPs, like local graduates, iMgs had to vie for one of the 400 places available in the training program. after satisfactorily completing the training program they could gain a provider number and bill on the Medicare system but only if they worked in an area of need.

The contemporary settingthe rules put in place in 1996 are still more or less intact. But the government’s judgement about whether there are enough doctors has turned full circle. since the beginning of this century, regional communities have become very vocal about the shortages of doctors serving their people. these shortages have manifested in a decline in the share of gP services that are bulk billed as well as in queues for hospital services.

the federal Department of health and ageing bureaucracy has since acknowledged that it underestimated the rate of growth in demand for medical services and overestimated the supply

of doctors willing to provide these services. another factor sharpening the government’s awareness that it has a serious shortage on its hands is the age distribution of the gP workforce. this applies particularly to australian-born gPs working in regional areas. currently, about 55 percent of gPs in non-metropolitan australia are australian-born. however, far higher proportions are in the 45-54 and 55-64 age groups than is the case for australian-born gPs in the metropolitan areas. For example, according to recently released 2006 census data, of the australian-born gPs living in sydney, 28.5 percent were in the age group 45-54 and 16.3 percent in the age group 55-64. however, in the case of australian-born gPs living in the rest of NsW, 38 percent were aged 45-54 and 16.7 percent were aged 55-64.

iii

the coalition government’s response to these developments represented a complete reversal of earlier policies. a sizeable expansion in medical training was initiated with five new medical schools opened by 2005 and seven more in planning. as indicated, the government also increased the number of gP training places to 600 in 2004. in 2003 it introduced the strengthening Medicare package, which included measures to encourage domestic medical graduates to serve in regional areas. the package also provided financial assistance for the recruitment of iMgs, particularly those entering australia on temporary resident visas. to gain such a visa, an iMg has to be sponsored by a medical employer to a specific medical position in a location defined as an area of need. in such circumstances, the iMg will be issued with a Medicare provider number. Furthermore, the iMg does not have to first complete the aMc accreditation examinations that iMgs holding permanent residence visas in australia have to complete, nor the gP postgraduate training program.

iv

in a complete reversal of earlier policies, a sizeable expansion in medical training was initiated with five new medical schools opened by 2005 and seven more in planning.

Largely as a result of these measures, the number of domestic medical graduates will increase substantially, from around 1348 in 2005 to 2442 in 2012.

v however, it will be several years before

graduates from the new medical schools significantly increase the size of the graduating class. the first impact was felt in 2005 when there were 58 graduates from the James cook University medical school.

On the other hand, the number of iMgs completing the aMc accreditation exams has increased rapidly in recent years. currently, 500-600 are completing these examinations each year and adding to the stock of potential applicants to the general practice postgraduate training program. The vocational training settingFrom the perspective of recent medical graduates, the choice of medical career is much wider than it was a decade ago. the wheel has turned completely since 1997 when medical students went into protest mode about their fears that they would struggle to find a training place. at the time, many thought that they might be excluded from access to general practice, since they faced a restrictive quota of just 400 places should they wish to pursue a career in this field. such fears proved to be groundless.

the general practice training program must vie for medical graduates in competition with other vocational programs. there may be an increased dependence on imgs to fill the ranks of gP trainees, especially if the quota is increased to 900.

Recent medical graduates considering their vocational future now do so in a context where there are more vocational training places than there are domestic aspirants for these places. the number of these training places has expanded much more rapidly than has the number of medical graduates.

vi this reflects

government’s concerns about shortages in a number of specialist fields, including surgery. By 2004 there were 1,782 first year advanced training places available compared with 1,300 domestic medical graduates. there was a further increase in the number of training places to around 1,898 in 2006.

vii

this means that for the immediate future, the general practice training program must vie for medical graduates in competition with other vocational programs. this choice, in turn, will be shaped by the relative attractions of general practice as a career and perhaps the appeal of the general practice training program. in the past there has been fierce competition for places in some of

specialities, including surgery and adult medicine. as the number of places available in these fields increases, this could mean that the general practice training program will struggle to fill its quota of places. in fact, the 21 Regional training Providers (RtPs) that currently conduct the gP training program have not been able to fill the number of places allocated by the government. the number of applicants since 2000 has been around 750 each year. however, the number of doctors accepting the offer of a gP training place after completing the selection process was 560 in 2004, 532 in 2005 and 558 in 2006. these numbers fell short of the 600 quota that has been in place since 2004. however, there was an improvement in this situation for 2007. the number of acceptances to the gP training program increased to 619. Of these, 172, or 28 percent were iMgs.

viii

One implication of these statistics is that in the immediate future there may be an increased dependence on iMgs to fill the ranks of gP trainees, especially if the quota is increased to 900. as noted, the number of aMc completions has grown and many, if not most, of the doctors in question will have an interest in joining the gP training program. the selection process is conducted by general Practice education and training (gPet). this is a national body funded by the australian government which also tenders out the training program to RtPs. gPet appears to be interested in attracting more iMgs. it has extended its marketing program which seeks to attract doctors to the gP training program to overseas sources. it has focused on the UK, where there is currently an oversupply of doctors eligible for training places.

ix

Most of this oversupply consists of iMgs who have completed their UK accreditation examinations but have been unable to secure a vocational training place in the British system. their numbers have recently increased sharply, partly because the number of training places available to iMgs has declined as a larger cohort of UK-trained doctors has entered the vocational training market.

x

the dependence on iMgs within the australian gP training program could be significant in relation to the rural program. Under the current rules, gP registrars can choose to enrol in either a rural pathway or a general pathway training program, both of which require three years to complete, with an optional fourth year for rural registrars. the rural pathway involves a



commitment to 18 months training in rural and remote areas. those undertaking the general pathway have to undertake a much shorter six month period of training in a rural location. as noted, the government has been anxious to increase participation in the rural program, in the hope that those who complete it will choose to practise in a regional location.

an important factor that shapes the choice of a career in general practice and the location of future practice is the sex of medical graduates. the female proportion of all domestic medical graduates has been increasing.

in the case of the registrars accepting places for 2007, some 129 iMgs were selected to the rural pathway, compared with 120 australian trained medical graduates (aMgs). as table 4 shows, the great majority of the aMgs selected the general pathway. Most of the iMgs had no alternative but to enrol in the rural pathway, since those affected by the ten year rule were only eligible to participate in this pathway. it is for this reason that our survey paid close attention to attitudes of iMgs to these arrangements, including their fairness and the willingness of iMgs to stay in regional practice over the long term.

another important factor that shapes the choice of a career in general practice and the location of future practice is the sex of medical graduates. the female proportion of all domestic medical graduates has been increasing. in 2005, the latest year for which data is available, 786 (or 54 percent) of the 1,457 domestic medical graduates were females. there was a much smaller proportion of women among medical graduates in the past. But because the great majority of female doctors have entered general practice (well above the share of their male counterparts), over a third of all gPs are women. By comparison, about 25 percent of specialists are women. this pattern represents both a challenge and an opportunity within the gP workforce. it is a challenge in the sense that the working environment for female gPs will have to adjust to their particular needs for balancing work and family commitments. it is an opportunity in that the flexibility of gP practice may serve as an attraction to female domestic graduates, thus giving the gP training program a competitive advantage in recruiting these doctors relative to the other specialist vocations. the following survey addresses these issues.


Registrar survey methodologyin mid-2007 all members of general Practice Registrars australia (gPRa) were requested to fill in a survey that covered details of their training background and career path into general practice training (whether a domestic graduate or iMg and if so their country of training and immigration circumstances); their personal attributes (age, sex, partner status, children); the reasons for their choice of gP training; and their career expectations as general practitioners. another section of the survey asked registrars about their expectations and experience with their Regional training Provider (RtP) and their overall satisfaction with the training program.

there are around 2200 members of gPra who are currently gP registrars. of these, 365 completed the survey during the second half of 2007, most by using the electronic facility offered by gPra.to assist in designing the content of the survey, interviews were conducted with the board and advisory council of general Practice Registrars australia (gPRa), the peak body representing australian gP registrars. the research process included extensive interviews with several RLOs (Registrar Liaison Officers), who represent and advocate for registrars during their training and who therefore have an excellent understanding of the issues important to registrars.

there are around 2200 members of gPRa who are currently gP registrars. Of these, 365 completed the survey during the second half of 2007, most by using the electronic facility offered by gPRa. gPRa utilised specialist software to accumulate the data, which was then sent to the centre for Population and Urban Research for analysis. the female share of the respondents was 65 percent, slightly above the 63 percent of the registrar population who are females. the rural pathway share of respondents was 49 percent, which is above the around 40 percent level for all registrars (see table 4). in addition, australian-trained registrars were slightly over-represented relative to iMgs.

Because the response rate was low, we caution against using the following results as an accurate representation of all registrars. however, the 365 who responded is a significant number, large enough to provide a good indication of the background, aspirations and training experience of key groups of gP registrars, including those who were male and female and those who were australia-trained or iMgs.

Who chose general practice and why? as noted, doctors trained in australia are in a better position to vie for a specialist training position (rather than in gP training) should they wish to do so than doctors trained overseas who have completed their aMc accreditation exams. thus it is significant that the majority (275) of the respondents were aMgs. the implication is that they took up gP training because they wanted to do so, rather than because it was the only choice available. the other respondents (81) were iMgs. they would have had fewer options for vocational training aside from the gP training program.

the survey results confirm that for most registrars, gP training was their first choice. 80 percent said this was the case. Of those for whom gP training was not their first choice, the most frequently mentioned alternatives were surgery, paediatrics and anaesthetics.

What attracted the registrars to general practice? the registrars who responded were given a set of eight attributes of medical work that it was thought might be important in making their vocational choice. Registrars were asked whether they rated these attributes as an “important factor”, a “minor factor” or “not a factor” in their choice of general practice. the results are shown in tables 1a to 1h for each of the attributes for male and female registrars. surprisingly, only 32 percent said that “wanting to be a gP” was an important factor. Furthermore, just 14 percent said that the income they could earn was an important factor in choosing general practice. Presumably, in making this judgement they were thinking of the income they could have earned if they had chosen a speciality like surgery.

some 86 percent said that “flexibility of work hours” was an important factor. another significant factor was “variety of work”.the registrars said that they were attracted to general practice by certain attributes of the general practice working environment. some 86 percent said that “flexibility of work hours” was an important factor. another significant factor was “variety of work”. 83 percent said this attribute was important in their choice of general practice. also, 78 percent said that “continuing relationships with patients” was important in their choice of general practice. it appears that having chosen medicine as their vocation, most gP registrars are prepared to trade off the higher financial returns potentially available in several of the specialist areas for the flexibility of gP work and for the relationships they think will ensue with their patients in general practice.

section 2 - the gPra registrar survey




Table 1a Attracted by the income gain from working as a GPnumber %

important factor

minor factor not a factor total important factor

minor factor not a factor total

Male 21 65 39 125 17 52 31 100

Female 29 98 108 235 12 42 46 100

total 50 163 147 360 14 45 41 100

Table 1b Always wanted to be a GPnumber %

important factor



Male 42 41 42 125 34 33 34 100

Female 73 89 73 235 31 38 31 100

total 115 130 115 360 32 36 32 100

Table 1c Attracted by the variety of work available as a GPnumber %

important factor



Male 96 25 4 125 77 20 3 100

Female 203 28 4 235 86 12 2 100

total 299 53 8 360 83 15 2 100

Table 1d Opportunity to do procedural as well as non-procedural worknumber %

important factor



Male 90 30 5 125 72 24 4 100

Female 132 75 28 235 56 32 12 100

total 222 105 33 360 62 29 9 100

Table 1e Variety of service arrangements possible (Sole, group, locum, etc.)number %

important factor



Male 64 41 20 125 51 33 16 100

Female 120 79 36 235 51 34 15 100

total 184 120 56 360 51 33 16 100

Table 1f The opportunity for continuing relationships with patientsnumber %

important factor



Male 94 28 3 125 75 22 2 100

Female 188 36 11 235 80 15 5 100

total 282 64 14 360 78 18 4 100

Table 1g Opportunities for building links with the communitynumber %

important factor



Male 64 48 13 125 51 38 10 100

Female 119 96 20 235 51 41 9 100

total 183 144 33 360 51 40 9 100

it was anticipated that general practice might be particularly attractive to female registrars. this expectation was only partially confirmed. there is not much difference between male and female registrars as to the importance they place on each of the attributes listed. however, female registrars were particularly keen on the “flexibility of work hours” attribute, with 90 percent indicating that this was important in their choice of the field. this level is slightly higher than for male registrars, of whom 80 percent made a similar judgement.

The situation of female registrarsWe know that a majority of general practice registrars are women (around 55-60 percent).

xi One hypothesis for this outcome is

that the potential flexibility of hours available in general practice attracts female doctors who want to balance work and family obligations. the length of medical training means that most registrars are young adults. in the case of the female respondents to the survey, just over a third were in their late 20s, with most of the rest in their 30s. the male respondents were slightly older. as a consequence, it will come as no surprise that most of the female registrars (and males) were partnered. table 2 shows the family status of female and male registrars by age group. Only 21.8

Table 1h Attracted by the flexibility in work hours (eg part-time or contractor) number %

important factor

minor factor

not a factor

total important factor

minor factor

not a factor

total

Male 100 18 7 125 80 14 6 100

Female 211 21 3 235 90 9 1 100

total 311 39 10 360 86 11 3 100


percent of all females were single. even among those aged 25-29, only 31 percent were single. Just over half (51 percent) of the female registrars aged 30-34 were partnered with children and 72 percent of those aged 35-39. this information is consistent with the expectation that family responsibilities might be important in the choice of general practice. Further confirmation of this expectation was provided in the answer to a question about the intended work schedule of registrars when they completed their training program. this is shown in table 3. the table indicates that 46 percent of the female registrars indicated that they intended to work part-time, compared with 43 percent who intended to work full-time.

the length of medical training means that most registrars are young adults. in the case of the female respondents to the survey, just over a third were in their late 20s, with most of the rest in their 30s.



Table 2 Sex and family status by age age male female total male female total

numbers %

single 24-29 10 27 37 32 31 32

30-34 10 15 25 22 22 22

35-39 2 5 7 10 12 11

40-44 1 3 4 8 11 10

45-50 2 1 3 20 9 14

50+ 1 1 2 13 33 18

total 26 52 78 21 22 21

Partnered with children

24-29 3 12 15 10 14 13

30-34 22 34 56 49 51 50

35-39 17 31 48 85 72 76

40-44 9 24 33 69 86 81

45-50 8 9 17 80 82 81

50+ 6 0 6 75 0 55

total 65 110 175 51 46 48

Partnered without children

24-29 18 47 65 58 55 56

30-34 13 18 31 29 27 28

35-39 1 7 8 5 16 13

40-44 3 1 4 23 4 10

45-50 0 1 1 0 9 5

50+ 1 2 3 13 67 27

total 36 76 112 28 32 31

total 24-29 31 86 117 100 100 100

30-34 45 67 112 100 100 100

35-39 20 43 63 100 100 100

40-44 13 28 41 100 100 100

45-50 10 11 21 100 100 100

50+ 8 3 11 100 100 100

total 127 238 365 100 100 100

By contrast, the majority of male registrars (72 percent) indicated that they intended to work full-time. table 2 shows that male registrars were just as likely to be partnered and to have children as female registrars. clearly, family obligations and the relationship between these and work choices have different implications according to sex. For women, these obligations place more restraints on their vocational choice within medicine than is the case for men. they also impact on the choice of work location, an issue that is explored immediately below.

clearly, family obligations and the relationship between these and work choices have different implications according to sex.

Career locationBoth the state and federal governments are concerned about achieving a redistribution of general practitioners in favour of regional areas. since there is little possibility that experienced gPs who are settled in metropolitan areas will make such a move, the government has focused on attracting gP registrars to non-metropolitan areas. the first step in this process is to engage them in the rural pathway of the gP training program.

gPet reports that in the selection process for gP registrars beginning their training in 2007, the following outcome was achieved (table 4). some 27 percent of aMgs accepted places in the rural training pathway rather than the general training pathway as against 75 percent of the iMg group. Overall, 60 percent of acceptances for 2007 were for the general training program and 40 percent for the rural training program. as noted earlier, the respondents to the gPRa survey were weighted towards the rural program, with slightly more reporting that they were engaged in the rural training program than the general training program. this weighting is detailed in table 5, which shows that 58 percent of the aMg respondents were enrolled in the general training pathway (compared with 73 percent for all aMgs selected in 2007). as expected, most of the iMgs were enrolled in the rural pathway. it is likely that the over-representation of aMg respondents enrolled in the rural pathway reflects their interest in this training option and thus a greater willingness to complete the survey. Nonetheless they are an interesting group, worth close attention. some 27 percent of amgs accepted places in the rural training pathway rather than the general training pathway as against 75 percent of the img group.

Table 3 Intended work schedule by sex male female total male female total

numbers %

Full-time 86 92 178 72 43 53

Part-time 23 98 121 19 46 36

Unsure 4 19 23 3 9 7

Not applicable* 6 6 12 5 3 4

total 119 215 334 100 100 100

* Not applicable - registrars indicating that they did not intend to begin practising as a GP after completing their training.

Table 4 Registrars accepting places in GP training in 2007 by training pathway and entry point Pathway entry point to program

amg amc* total

number % number % number %

general 328 73 43 25 371 60

Rural 119 27 129 75 248 40

total 447 100 172 100 619 100

* AMC stands for Australian Medical Council. The AMC group are International Medical Graduates (IMGs) who must pass an exam and be registered with the AMC before they can enter postgraduate GP training. Source: GPET, 2007.




given that a majority of gP registrars are women, and among our respondents 78 percent were partnered, with over half having children (table 2), it is not surprising that most gP registrars chose the general training program. almost all medical students train in metropolitan areas. thus they (and the men they are partnered with) are likely to have a base in one of australia’s metropolises. Registrars were asked about the occupation of their partners where applicable. in the case of the female registrars, almost all of their partners were employed, with 83 percent in managerial or professional occupations. in the case of male registrars, about 20 percent of their partners were not in the workforce.

thus the majority of these female partners were employed, and like the male partners of the female registrars, their employment was predominantly in managerial and professional occupations.

these results affirm that registrars are young adults, most of whom have family commitments. it is sometimes assumed that because registrars are just beginning their medical careers they are relatively free to select a rural location without adult family constraints. given the family ties just described, this assumption is incorrect for both male and female registrars. Nonetheless, as table 5 shows, 110 of the aMg respondents to the survey did choose the rural pathway. almost all stated that this was their own choice – that is, they were not required to do so. the issue of choice is not relevant to the iMgs, most of

whom had to enrol in the rural pathway because of the ten year rule. table 6 shows the sex of aMgs and iMgs by pathway. as would be expected from the above analysis, the aMg female registrars have a higher propensity to choose the general training pathway than do their male counterparts. some 62 percent of the females chose the general pathway compared with 40 percent of the males.

Notwithstanding this finding, such is the preponderance of female respondents among the aMg group that there were more female registrars (66) enrolled in the rural pathway than male registrars (44). in the case of iMgs, the great majority of both the female and male registrars in this group were enrolled in the rural pathway.

it is sometimes assumed that because registrars are just beginning their medical careers they are relatively free to select a rural location without adult family constraints. given the family ties described, this assumption is incorrect.

What attracted registrars to the rural pathway?We have no conclusive evidence as to why a third of the female aMgs and almost a half of the male aMg respondents chose the rural pathway. they simply declared in the survey that they preferred a rural or regional location over a metropolitan location. When asked whether a rural or regional location suited their lifestyle aspirations and their family needs, the majority indicated that this was the case.

in the case of the iMg group, once they successfully complete their training program, they will have to serve in an area of

need. Because of the recent extension of areas of need to outer metropolitan areas, some will have the option of practising in an outer metropolitan area rather than a regional location. an important issue with these registrars is whether they will wish to remain in such locations once they have completed the ten year requirement.

Table 5 Survey respondents by training pathway and entry point Pathway entry point to

program

amg amc* total

number % number % number %

general 150 58 19 23 169 48

Rural 110 42 62 77 172 48

australian Defence Force - - - - 15 4

total 260 100 81 100 356 100

* AMC stands for Australian Medical Council. The AMC group are International Medical Graduates (IMGs) who must pass an exam and be registered with the AMC before they can enter postgraduate GP training.

of the 72 imgs who indicated that their choice of pathway was determined by the ten year rule, just over half said that they were unlikely to move away when their required period of service was completed.

the survey asked iMgs affected by the ten year rule how they felt about the restrictions involved. Most were not happy about these restrictions. Under these circumstances, it might be expected that they would wish to relocate to a metropolitan practice on completion of their service, especially given that few regional locations possess substantial asian communities. however, of the 72 iMgs who indicated that their choice of pathway was determined by the ten year rule, just over half (38) said that they were unlikely to move away when their required period of service was completed.

Attitudes to the general practice training programit was anticipated that there would be some resentment of the compulsory nature of the general practice training program. as noted, until 1996 medical graduates could enter general practice after completing their internship without any further training. the general practice program they enter also pays much lower rates than they could earn if they went directly into general practice. in 2007 the minimum rate for a basic trainee was $61,346 and for an advanced trainee, $77,336. these rates are paid by participating gP practices – though with a subsidy from the commonwealth

government if the registrar does not achieve billing levels of the amounts listed. Registrars can earn more than the minimum if their billings while on their placements exceed the basic rates.

Registrars are required to do a full year hospital placement and, in addition, an outer suburban and rural placement if on the general pathway. those on the rural pathway have to complete several rural placements. this requirement partly reflects the commonwealth government’s medical manpower concerns. By enforcing this requirement, registrars make a contribution to filling gaps in the medical workforce in areas of need. however, it is up to practising gPs whether they offer their practices for training purposes. in areas where gP shortages are acute this decision may well reflect the government’s concerns, since the practice may need help in coping with the patient load. in addition, there may be some financial benefit for the practice where the registrar is proficient in servicing patients. this might imply some potential for exploitation. however, in the opinion of registrars questioned on the matter, most felt that the manpower factor was not the dominant motive. Rather, participating practices were primarily motivated by an altruistic desire to contribute to the training of their younger peers.

Decisions concerning placements are made on the basis of interviews between doctors willing to act as supervisors and registrars. Registrars list the practices where they would like appointments and the practices in question interview the registrars before making any offer. thus both parties have some choice in the outcome. however, rural pathway registrars tend to have greater bargaining power in the selection process because

Table 6 Training pathway by entry point to GP training by sex training pathway amg amc* other

male female male female male female

numbers

general 37 113 8 11 0 1

Rural 44 66 26 36 0 7

australian Defence Force 11 4 0 0 0 0

%

general 40 62 24 23 0 13

Rural 48 36 77 77 0 88

australian Defence Force 12 2 0 0 0 0

* AMC stands for Australian Medical Council. The AMC group are International Medical Graduates (IMGs) who must pass an exam and be registered with the AMC before they can enter postgraduate GP training.




participating practices are more likely to be in need of support staff than is the case for practices located in inner or middle suburban areas of the major metropolises.

Participating practices were primarily motivated by an altruistic desire to contribute to the training of their younger peers.

Despite the potential for friction in matching registrars to placements, 74 percent of the respondents said they were satisfied with the way placements were arranged. however, just over half of the registrars who responded to the question indicated that they would like their RtP to make available a wider choice of placements (table 7). Perhaps because of the compulsory nature of the program, there was an element of resignation among respondents to the survey. Less than half indicated that that they had high expectations of the general practice training program when they began it.

Nevertheless, when asked to evaluate the specific aspects of their training program, as the results listed show, the great majority indicated that they were satisfied. this attitude was mirrored in the interviews conducted with gP Registrar Liaison Officers (RLOs) and other informants. RLOs are employed by Regional training Providers (RtPs) to represent the registrars within their training program.

the main explanation for this satisfaction (despite the compulsory nature of the training program and the modest expectations registrars had of the program when they began) is that most registrars believe that it is appropriate that they participate in postgraduate gP training. there is a gap between university training and gP practice. this is partly because university medical school courses are less “hands on” these days than was the case in the past. thus the gulf between the knowledge base imparted during medical school and what is needed to function successfully in practice has widened. informants indicated that registrars recognise the need for an extended induction into the profession which involves both supervised practice and further academic instruction. in the past, gPs learned “on the job”.

when asked to evaluate the specific aspects of their training program, as the results listed show, the great majority indicated that they were satisfied. executives within the Royal australian college of general Practitioners (RacgP) responsible for shaping the training program acknowledge that the gap between completion of undergraduate training and independent general practice is far longer than in the past. however, it is their judgement that when

Table 7 Would you like greater choice in your placement than your RTP has/is providing? Persons % valid %

Yes 185 50.7 58.7

No 130 35.6 41.3

Not stated/inadequately described 50 13.7 -

total 365 100.0 -

Table 8 What were your expectations of the GP training program when you began? Persons % valid %

high quality program 151 41.4 47.8

Moderate quality program 90 24.7 28.5

No strong expectations 75 20.5 23.7

Not stated 49 13.4 -

total 365 100.0 -

registrars begin such practice, their professional skills are at a much more advanced level that was the case for gPs early in their careers before the advent of the compulsory training program.

there is also an awareness among registrars that if the status of general practice is to be enhanced relative to the other medical specialties, the gP training program should be of high quality, and as well, should be seem to be of high quality. in this context, the finding that less than half of the respondents expected the gP training program to be of high quality (table 8) is a matter for concern. there was a hint in some of the responses that the program could be more demanding. this point is developed further in the later discussion of the fellowship examination. Experience with the GP training programas previously stated, the majority of respondents said that they were satisfied with the gP training program. When asked to rate their overall satisfaction with the training program they responded as shown in table 9. some 78.5 percent of those who stated an opinion thought the program was very good or good. there was a similar response to questions concerning their remuneration during the program, the hours they worked and the accommodation provided with their placements. the gPet survey recorded similar levels of satisfaction. as table 10 indicates, a few thought that they received too much income!

the findings of the gPet survey of registrars are not reassuring. it reported that 67 percent of registrars attended rtP workshops, but that “a large proportion” (33 percent) had not. On the educational release program (the time spent in study programs organised by their RtP), again, most respondents were satisfied with the support they received from their RtP. Registrars interviewed said that the seminars organised for the release program, in which they explored the latest information on diseases and their treatments as well as public health and related matters, were crucial to their training. it was this training that helped justify the claim that postgraduate gP training constituted a specialist area of medicine. in this context, the findings of the gPet survey of registrars are not reassuring. it reported that 67 percent of registrars attended RtP workshops, but that “a large proportion” (33 percent) had not.

xii

The RACGP examinationthe final phase of the training program involves preparation for the fellowship examinations conducted by the RacgP. the satisfactory completion of this exam is not as severe a hurdle as is the case with some of the fellowship exams conducted in surgery and other specialities. For the years 1999 to 2004, over 90 percent

Table 9 How would you rate your satisfaction with your GP training so far? Persons % valid %

very good 99 27.1 31.3

good 149 40.8 47.2

Just OK 55 15.1 17.4

Not very good 10 2.7 3.2

some serious deficiencies 3 0.8 0.9


total 365 100.0 -

Table 10 How do you feel about the income earned in your placement? Persons % valid %

Far too little 14 3.8 4.4

too little 83 22.7 26.3

adequate 212 58.1 67.1

too much 7 1.9 2.2


total 365 100.0 -




of australian-trained registrars passed and around 70 percent of iMgs.

xiii No further results have been published, but according to

the RacgP, examination outcomes since 2004 have been similar to the earlier pattern.

this examination involves an applied knowledge test, a key feature problems test (which assesses clinical decision-making) and a clinical test. Before taking the exam the registrar must achieve an overall satisfactory assessment from placement supervisors and their RtP (the lack of which can occasionally delay the taking of the examination). however, the registrar’s record of practice does not count in the final assessment for the fellowship.

since registrars would be aware that the vast majority pass the fellowship test at their first attempt, it is unlikely that they would be too critical of the test. Nonetheless, there are some contentious issues. One is whether it may be too easy to pass, given concerns that gP training should be perceived as being as demanding as that of other medical specialties. another issue concerns whether the fellowship examination should include a component reflecting the registrar’s record of practice while in their placements. Registrars were asked about this matter. as table 11 indicates, of those that had an opinion, most thought that this performance should be taken into account.

the RacgP is currently examining the merits of adding a competency measure to its assessment, though it has no immediate intention to move in this direction. From a workforce point of view there could be advantages in adopting a competency component to the assessment, or even to make it the basis of the fellowship. if so, the evaluation of the clinical performance of registrars would become central to the assessment. the workforce advantage would flow from the possibility that some registrars attain clinical performance levels adequate for independent practice well inside the three years required for the gP training program.

another issue concerns whether the fellowship examination should include a component reflecting the registrar’s record of practice while in their placements.

it should be noted that in the future there will be an alternative fellowship process leading to vocational registration through the australian college of Rural and Remote Medicine (acRRM). acRRM will have its own curriculum and will conduct its own examinations. the details of this are not yet available.

Table 11 Final assessments should take into account performance during work placements Persons % valid %

Yes 189 51.8 60.2

somewhat 71 19.5 22.6

No 16 4.4 5.1

Unsure 38 10.4 12.1

Not stated/inadequately described 51 14.0 -

total 365 100.0 -

Conclusionthe survey results support those of earlier gPet soundings of registrar opinion on the functioning of the postgraduate general practice training program. Most registrars acknowledge the need for the program and are satisfied with the working conditions and the benefits they receive in skills and experience.

Because they cannot gain full registration to practise as independent gPs without completing the program, there is some tension between registrars’ desire to complete the requirements expeditiously and the aspiration (which many registrars appear to share) of ensuring that the program is of the highest quality.Pursuit of the latter goal might require greater emphasis on cutting-edge research and analysis of medical issues (which all

registrars would be required to participate in during their training) and high fellowship examination standards.

most registrars acknowledge the need for the program and are satisfied with the working conditions and the benefits they receive in skills and experience. any reorientation in this direction may be seen as impeding the workplace training and patient service function of the program. however, if the general practice training program is to attract an increasing share of medical graduates, a refocusing in this direction is likely to contribute to this goal.


i Bob Birrell and Lesleyanne Hawthorne, Immigrants and the Professions in Australia, Centre for Population and Urban Research, Monash University, 1997, p. 27ii Australian Medical Workforce Benchmarks, Australian Medical Workforce Advisory Committee, January 1996, p. 23iii Unpublished 2006 Census data held by the Centre for Population and Urban Research, Monash Universityiv Bob Birrell and Andrew Schwartz, “Assessment of overseas-trained doctors – the latest chapter”, People and Place, vol. 15, no. 3, 2007, p. 67v Catherine Joyce, Johannes Stoelwinder, John McNeil and Leon Piterman, “Riding the wave: current and emerging trends in graduates from Australian university medical schools”, MJA vol. 186, no. 6, March 2007, p. 310vi Brett Lennon, “Medical Workforce Expansion in Australia – Commitment and Capacity”, 9th International Medical Workforce Collaborative Conference, 2005, Melbourne vii Biennial Review of the Medicare Provider Number Legislation, December 2005viii Australian General Practice Training, General Practice Education and Training, 2007 Selection Outcomes Report, February 2007ix GPET, Annual Report 2005-06, p. 8x G. Winyard, “Medical immigration: the elephant in the room”, British Medical Journal (BMJ), vol. 335, Sept. 2007, p. 697xi The Registrar Guide, GPRA, 2007, p. 9xii GP Registrar Survey Report, p. 9

xiii Bob Birrell and Andrew Schwartz, “Accreditation of overseas trained doctors: the continuing crisis”, People and Place, vol. 14, no. 3, 2006, p. 42

glossary of terms aPPendix

ACRRM - Australian College of Rural and Remote MedicineacRRM has an alternative curriculum of educational objectives for rural gPs and a separate fellowship process to the RacgP.

AMC - Australian Medical Councilinternational Medical graduates (iMgs) must complete accreditation examinations with the aMc before they can undertake gP postgraduate training.

AMG - Australian-trained medical graduateaustralian-trained medical graduates can undertake gP postgraduate training after completing their intern year.

AMWAC - Australian Medical Workforce Advisory CouncilaMWac (disbanded in 2006) provided advice to the australian health Ministers’ advisory council (ahWac) on a range of medical workforce matters.

GP - general practitionergPs are australia’s primary health care doctors. there is currently a shortage of gPs in australia, particularly in rural, remote and outer metropolitan areas.

GPET - General Practice Education and TraininggPet is a national body funded by the commonwealth Department of health and ageing which administers the postgraduate general practice training program and tenders out training to RtPs.

GPRA - General Practice Registrars AustraliagPRa is the peak body representing the interests of registrars in australia. it has a board of eight directors and an advisory council made up of RLOs from every RtP.

IMG - International Medical Graduatein the last intake (2007) into gP postgraduate training, 28 percent were iMgs. iMgs are required to train in the rural pathway and work for ten years in rural, remote or outer metropolitan areas of need in a government strategy to address geographically-based gP shortages.

RACGP - Royal Australian College of General Practitionersthe RacgP sets training standards, curriculum and an exam, and accredits practices for gP training. the college awards fellowship of the RacgP on successful completion of training and their exam, which entitles a person to work independently as a vocationally registered gP.

RLO - Registrar Liaison OfficerRLOs are employed by RtPs to represent and advocate for gP Registrars.

RTP - Regional Training ProviderRtPs tender for contracts from gPet to provide regional gP training.


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postgraduate training in general practice: the registrar perspective

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