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Asia Pacific Journal of Family Medicine Volume 5 Issue 2
Primary care is the answer: The role of general practice in Australia
Michael Richard KIDD1,2 and Ian WATTS1
1The Royal Australian College of General Practitioners, Melbourne, Victoria, and 2Department of General Practice, The University of Sydney, Sydney, New South Wales, AustraliaCorrespondence: Michael Kidd, President, The Royal Australian College of General Practitioners,Palmerston Crescent, South Melbourne, Victoria, Australia, 3205.
Accepted for publication 23 May 2006.
Primary care is capable of providing the answer to many of the world’s major health problems. Strong primary care requires a strong system of primary medical care, and in many nations of the Asia-Pacific region this includes strong family medicine and general practice. In this paper, based on a keynote presentation at the Asia Pacific Regional Conference of the World Organization of Family Doctors (Wonca) held in Kyoto, Japan in 2005, the authors examine the role of general practice and family medicine in Australia in supporting primary care. The paper outlines six principles to ensure safe and sustainable high-quality general practice. These are: attracting the brightest and the best of medical school graduates to a career in general practice; supporting lifelong learning; providing and supporting excellent practices; ensuring ready access to the best available evidence; valuing the generalist tradition; and maintaining morale and a yearning for excellence among the members of our general practice workforce.
Key words: family medicine, general practice, medical education. quality care, primary care, standards
The world is facing many healthcare challenges. And the answer to the world’s great health care challenges lies in primary care. Primary care is the only way we will be able to effectively fight the epidemics of major communicable diseases affecting our region – dreaded diseases like HIV, tuberculosis and malaria, and new and emerging diseases like SARS and avian flu.
Primary care is the only way we will be able to effectively fight the epidemics of non-communicable diseases starting to ravage our region – especially cardiovascular diseases, respiratory diseases and cancers. We are seeing rising numbers of early deaths among middle-aged adults in the nations of our region and this will only get worse as rates of smoking and obesity and poor nutrition and lack of physical activity continue to rise. We need to seek out those at risk, and assist them to reduce their risk.
Primary care is the only way we will be able to effectively fight the rise in mental health problems affecting the people of our region. We know that the burden of morbidity caused by depression is rising rapidly.
Primary care is the only way we will be able to effectively manage the health care needs of the increasing proportion of elderly people in many of our nations.
And primary care is the only way we will be able to effectively contain rising health care costs in our nations, through support for preventive care, health promotion and improvements in chronic disease management and the management of comorbidities.
If we are going to have strong primary care in our nations, then we need a strong system of primary medical care, and this includes strong family medicine and general practice. If we are going to effectively tackle these major health care challenges, then our academies and colleges need to join together and share our knowledge and resources. And Wonca, our World Organization of Family Doctors, has a key role to play in ensuring that this working together and sharing happens.
General practice is a strong clinical discipline in Australia. Australia has over 20 000 general practitioners serving our population of 20 000 000. The majority of Australia’s medical practitioners are general practitioners (GPs) or family doctors.
Each year, there are 100 million consultations between Australians and their GPs. Each year over 85% of all Australians visit a GP at least once. And the majority of Australians have their own GP.1
We also provide a huge amount of aged care. Last year there were 25 million consultations between Australians aged over 65 years and their GPs and that included nearly 1 000 000 home visits by GPs to those aged over 75.
The Royal Australian College of General Practitioners (RACGP) has a 50-year tradition of ensuring that the people of Australia have access to high-quality general practice care, delivered by well-trained and highly skilled GPs. The RACGP is responsible for setting and maintaining standards for quality clinical practice, education and training, and research for Australian general practice. Our College defines the nature of our clinical discipline of general practice in our country. Our College also has a role in advocating to our governments on any issue which affects our abilities as family doctors to deliver high-quality service to our patients and our communities. And responsibility to our patients and to our communities is the paramount responsibility of our professional College.
The RACGP is Australia’s largest medical college with nearly 14 500 members. The majority of Australia’s GPs are members of our college. The RACGP also has over 4500 rural members and this is by far the largest rural membership of any medical college in Australia. And nearly 100% of our doctors training to become GPs are members of the RACGP. This is important because our College has a special focus on supporting our young members who are the true future of Australian general practice.
Principles to ensure safe and sustainable high quality general practice
The RACGP has a number of principles to ensure that safe and sustainable high-quality general practice is available to all people in our country.
The first important principle is attracting the ‘brightest and the best’ of our medical school graduates to a career in general practice. General practice is an attractive profession. As doctors we are valued by our patients, by our community and by our peers. As professionals we need to be stretched and challenged in our daily work, but that does not mean being unnecessarily stressed in our daily work. With the knowledge that we have, we will perform as best as we can. However, we also need recognition and reward for the quality of the work that we do.
We need to ensure that our medical students and our recent medical graduates receive exposure to high-quality general practice and excellent role models, as this will help to inspire them to consider general practice as their own future career.
Those doctors who do choose general practice need to receive high-quality education and training. The RACGP is responsible for setting and maintaining the standards for the education of our young doctors. Many of our members are involved in providing this education to our young doctors in their own practices.
The RACGP is responsible for Australia’s largest medical college Fellowship examinations. Each year up to 1000 candidates sit our Fellowship examinations across Australia, and over 1000 of our Fellows take part as examiners. Those who pass the College Fellowship examination are competent for unsupervised general practice anywhere in Australia, rural or urban. We also run our Fellowship examination in a conjoint arrangement with the colleges for family physicians in Malaysia and Hong Kong.
For those who wish to undertake further training in various procedural aspects of general practice, for example in obstetrics or anesthetics, our College offers a highly popular Graduate Diploma in Rural General Practice. In addition to our Fellowship, 100 registrars enrol each year in training for our Graduate Diploma in Rural General Practice.
This year the RACGP has commenced an extensive review of our curriculum for Australian general practice. The new RACGP curriculum will be expanded to cover the needs of medical students, recent graduates, doctors in training and established GPs. Our curriculum for general practice forms a key component of ensuring the standards of our academic discipline.2 It addresses the five key domains of general practice:
1 Communication skills and the patient-doctor relationship
2 Applied professional knowledge and skills
3 Population health and the context of general practice
4 Professional and Ethical Roles
5 Organizational and legal dimensions
The second principle is support for lifelong learning
We need to cultivate a yearning for lifelong learning among all family doctors. This needs to be part of vocational training and part of our continuing professional development.
Lifelong continuing professional development is critical for all medical practitioners and our RACGP Continuing Professional Development Program provides support to over 22 000 medical practitioners, including over 4000 rural doctors. It is the largest professional development program of any specialist medical college in Australia.
The general practice workforce in Australia includes many wonderful doctors who trained in other countries and who have migrated to our country. Our College has a strong program of support and education for international medical graduates, providing support to the thousands of doctors who enter our country from overseas each year.
The RACGP also provides online continuing professional education to our members through our education resource, gp learning, which is available to all College members free of charge, and is very popular.
The next principle is providing excellent practices
Our colleges need to ensure the standards for the locations where we work in general practice and for the processes, structures and outcomes of our work as GPs. These standards should also apply to other primary medical care services.
The RACGP sets the standards for our general practice locations, our physical places of work. Our standards have been adapted for use in several other nations. We have just completed a comprehensive review of our Standards for General Practices and the standards are realistic, affordable and achievable for general practices across Australia and include standards for the use of information technology in general practice.3
The fourth principle is ready access to the best available evidence
Family doctors need access to the best available evidence to support our clinical decision-making. We need to ensure access to excellent international resources such as the Cochrane Library of evidence-based medicine, and to national resources.
It is important that the findings of research in general practice reach our GPs. Australian Family Physician is our College’s internationally respected, peer-reviewed, Medline-listed medical journal. It has a proud 50-year tradition and each month is sent free of charge to over 34 000 medical practitioners in Australia, including all GPs and all specialist physicians.
The RACGP produces excellent guidelines to support high-quality preventive care in general practice, guidelines to support chronic disease management, and guidelines to support healthy decision-making by all our patients.
Our Preventive Care Guidelines4 (our ‘Red Book’) focus on the preventive care interventions recommended for men and women at each stage of our lives. It is available free of charge through our website at www.racgp.org.au
Our SNAP guide supports preventive care and health promotion work through general practice. SNAP stands for Smoking Cessation, Healthy Nutrition, Safe use of Alcohol, and Physical Activity – all factors which make an impact on health and longevity. The RACGP SNAP Guidelines provide support to our nation’s GPs to support our patients to adopt more healthy lifestyles.5
The RACGP also has guidelines on the care of elderly Australians. This is our ‘Silver Book’.6 We need to ensure that we assist in maximizing the health of the aged members of our community. Preventive health care and health promotion still can have an impact when you are 90 years young. Falls prevention, regular health assessments, influenza and pneumococcal vaccination and the safe use of medications are just some of the key areas of attention for the aged.
The health of indigenous Australians is our national shame. Indigenous Australians have a life expectancy up to 20 years less than that of non-indigenous Australians. Our College takes our responsibilities in this area very seriously and we work with key indigenous health organizations to develop guidelines and to support improvements in primary health care services to all indigenous Australians.
Research is a critical component of general practice and is the foundation for the evidence base for our clinical discipline. This year the RACGP Research Foundation will distribute over $350 000 through scholarships and grants to young general practice researchers.
The RACGP library and resource center, named in honour of Australia’s most famous GP, author and educator, Professor John Murtagh, provides free access to journal articles, books, training videos and other resources to all our members and has a very healthy online collection. Our library and resource center contains the largest primary health care collection in the southern hemisphere
The next key principle is that we value generalist tradition
As family doctors we are specialists in primary medical care. We specialize in the generalist tradition of medical practice. We specialize in preventive care and health promotion. We specialize in early diagnosis and management. We specialize in the management of undifferentiated illness. We specialize in the management of acute conditions and medical emergencies. We specialize in the management of complex chronic diseases and comorbidities. We specialize in mental health and the impact of social and environmental issues on our patients’ health. We specialize in palliative care and have the ability to support our patients to die with dignity. And each of us is a specialist in the unique health care needs and concerns of our own unique patient population. This is all part of our generalist tradition.
In order to specialize in our generalist tradition we need strong standards of education and training and strong government and community support.
Sadly, the governments of some of our nations fail to recognize the importance of supporting strong systems of family medicine and general practice. Our governments need to value our generalist traditions, and funding structures and workforce arrangements need to support the generalist approach to high-quality primary medical care.
The final principle is to maintain morale and a yearning for excellence
We need to keep our doctors if we want to maintain high quality. There is strong evidence that happy doctors are better doctors. Our communities cannot afford to lose doctors who would otherwise continue working in general practice, providing high-quality care to their local community.
I believe it is the context of general practice, rather than its content, that is the key issue in reduced morale among some family doctors. One of the RACGP’s key activities this year is leading the development of a structured program of peer support for all medical practitioners across Australia, in response to the high levels of emotional health concerns among medical practitioners in our country, and the alarming high rate of suicide, among women doctors in particular.
The RACGP is committed to ensuring that general practice remains the center of high-quality health care in Australia and that general practice remains a satisfying and rewarding vocation for all GPs.
There are many exciting advances in health care just around the corner. The impact of genomics will have a major impact on primary care in ways none of us can predict. Information technology will also have a major impact in supporting improvements in the safety and quality of the care we provide. And evidence-based health care will continue to develop and guide our clinical decision-making. All these initiatives will depend on strong primary care if the benefits are to be shared by all the people of each of our nations. While implementing these innovations, we must ensure that equity of access remains a core principle of strong primary care.
We are privileged to be family doctors and general practitioners. We each strive to the best of our abilities to provide a high-quality service to the people who trust us for their medical care and advice. We may feel undervalued at times but we receive warm acknowledgment of our contribution from our patients and their families every day.
Each of us makes a positive difference to the lives of our patients.
I wish you all well in your continuing important work meeting the health care needs of the people who trust you for their medical care and advice.
1 Britt H, Miller G, Knox S et al. General practice activity in Australia 2002–2003. AIHW Cat No GEP 14. Canberra: Australian Institute of Health and Welfare, 2003.
2 The Royal Australian College of General Practitioners. Training Program Curriculum, 2nd edn. Melbourne: RACGP, 1999.
3 The Royal Australian College of General Practitioners. Standards for General Practices, 3rd edn. Melbourne: RACGP, 2005.
4 The Royal Australian College of General Practitioners. Guidelines for Preventive Activities in General Practice, 6th edn. Melbourne, RACGP, 2005.
5 The Royal Australian College of General Practitioners. Smoking, Nutrition, Alcohol, Physical activity (SNAP): a population health guide to behavioural risk factors in general practice. Melbourne: RACGP, 2004.
6 The Royal Australian College of General Practitioners. Medical Care of Older Persons in Residential Aged Care Facilities, 4th edn. Melbourne: RACGP, 2006.