Intended for healthcare professionals

Editorials

The future of the primary medical workforce

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5006 (Published 22 August 2011) Cite this as: BMJ 2011;343:d5006
  1. Stephen Trumble, chair, clinical education and training development 1,
  2. Lucio Naccarella, National Health and Medical Research Council postdoctoral training fellow 2,
  3. Peter Brooks, director 2
  1. 1Melbourne Medical School, University of Melbourne, Melbourne, Vic, Australia
  2. 2Australian Health Workforce Institute, University of Melbourne, VIC, 3010, Australia
  1. brooksp{at}unimelb.edu.au

Is in jeopardy unless GPs have a more central role in healthcare and develop special skills in areas of unmet need

Yet another study has reported increasing difficulty in recruiting medical students to careers in general internal medicine. This study from the United States showed that although 24% of 1177 students who graduated in 2007 planned careers in internal medicine, they perceived this specialty to be associated with a higher workload and more stress than other specialties and were less interested in a career in general internal medicine than students in a similar study in 1990.1 The trends in these data are not dissimilar to those reported in relation to general practice and family medicine in Australia,2 New Zealand and Canada,3 and the United Kingdom.4

Recruitment to general practice has improved a little in Australia in recent years since the creation of rural clinical schools that provide undergraduates with at least half of their clinical training in rural environments. But the fact remains that around the world primary medical care is not a favoured career choice for specialty training and practice.

Medical students make their career choices for a variety of reasons, including other people’s perceptions of the job, opportunities for patient contact, a preference for shorter and more flexible working hours, ideas about a better work-life balance, and exposure to the discipline as undergraduates or postgraduates.5 Some of these factors should draw students towards general practice, but other sociocultural and systemic factors are repelling them.

Cohorts of new doctors leaving medical schools now include more older graduates and women than was the case 20 years ago, which, along with increasing generational determination to have a balanced life, ought to favour recruitment to general practice, given that part time work with standard hours and little on call is easier to organise in general practice than in the hospital or private specialist practice setting, yet the numbers deciding on a general practice career have not altered substantially.

The ability to pay back debt is another important determinant of career choice,6 and salaries in primary medical care are lower than those of other specialists (except in the UK), with substantial differences occurring in countries such as Australia and the US that have fee for service reimbursement systems, where each item of service is billed and fees are significantly higher for procedures. Increases in undergraduate fees now occurring in some countries may slightly plump up the education sector only to starve the health sector by driving increasingly debt burdened students towards the more remunerative expensive specialties.

The challenge of recruiting to general practice is occurring in an environment where the health system is already under financial stress, with predictions of it consuming up to 20% of gross domestic product in most developed countries by 2020.7 This pressure is further driven by increased demands of an ageing and chronically ill population, and a society that in many high income countries seems to have unrealistic expectations of what the health system should provide and at what cost.8 Many countries have reimbursement systems that reward doctors for doing something rather than thinking about it, and exciting—but usually expensive—medical advances only fuel this. Recruitment and retention of health workers is a major challenge to all nations, with a worldwide shortage of health workers of at least 4.5 million in this decade (2006-16) alone.

Many think that the viability of health systems in high and low income countries depends on major reform from a hospital and specialist focus to one that recognises the importance of primary care and preventing hospital admission.9 10 11 The future of a sustainable health system would seem to rest in primary care as never before, yet few want to work there. So what is the answer?

We have health systems that preserve the separate roles of health professionals rather than allowing patient participation in healthcare decision making to achieve best patient outcomes. We can continue to tinker around the edges with small changes to our health and education systems. Or we could truly accept that a primary medical care solution is what is needed, and place general practice firmly at the centre of the health system rather than continuing to focus on hospitals, specialism, and ill health. This will require a substantial redirection of funding from hospitals to home based primary care, an increase in health literacy in the community, and a recognition that general practitioners have an equal place in the health hierarchy as valued, broadly skilled “cognitive specialists” (who rely on their diagnostic and medical management skills rather than primarily performing procedures).

To prevent a crisis in the primary care workforce, medical schools must increase student training in primary care and support primary care departments (and their affiliated clinical teachers), as they do their teaching hospital departments.12 The primary medical care career path should be promoted throughout all stages of clinical education. All specialist groups (colleges in particular) need to consider their interfaces with primary care and work with primary care teams—general practitioners, nurses, allied health professionals, and other primary care workers—to align their services and achieve the best patient outcomes. General practitioners need to seize a more central role in healthcare by developing special skills sets in areas of unmet need, so that they can maintain their interest and enthusiasm. Long portrayed as the hapless foot soldiers at the front line of healthcare, it is time for general practitioners to take on leadership roles as the generals at the very centre of the health system.

Notes

Cite this as: BMJ 2011;343:d5006

Footnotes

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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