How to produce competent general practitioners…faster

Aug 20, 2022
Doctor patient
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Father and daughter general practitioners, Dr William Howson and Dr Anna Howson, work in the same group practice in Wonthaggi, Victoria. They’re acutely aware of the GP workforce crisis and have thought about ways to address this. Katrina Watson caught up with the family in their natural habitat.

Wonthaggi is a relaxed seaside town 136 km from Melbourne, on the lands of the Boonwurrung people, and is known for the coal once mined there. A State Coal Mine was established in 1910 and was quickly surrounded by a town of tents. The mine gradually expanded until it produced 60% of the State’s railway coal in 1930.

Nowadays the coal mine is closed, and the tent town has become a town of shops and businesses which service the surrounding farms, Victoria’s desalination plant, wind farms and the many tourists attracted by the beautiful Bass Coast and Wilson’s Promontory.

Dr Sleeman established the town’s first hospital in 1910, and Wonthaggi now has 16 doctors in 2 practices, who look after a district population of approximately 16,000.

Dr Bill Howson is one of them. He was always preparing for country practice. “Being a country lad, I wanted to return to the bush to practise medicine and raise a family,” he says. His childhood was spent in Maffra, 168 km north-east of Wonthaggi. He attended secondary school in nearby Sale, and then did his medical degree at the University of Melbourne, graduating in 1976. He worked at Box Hill Hospital as an Intern/Resident for 2 years and followed that up with a year in the U.K., at Ashington in Northumberland, during which time he did a Diploma of Anaesthetics.

On return, Bill joined an 8-person rural practice. “I felt confident because of my hospital training, particularly the Emergency Department component. At that time, in Wonthaggi, we were seeing 8 patients/hour. Yes, this will sound excessive, but we were short staffed. Just not enough doctors. But we never turned a patient away.”

As a result of this baptism of fire, Bill knows what is needed to make doctors who are fit-for-purpose for general practice. “The number one way to make new doctors feel comfortable in general practice is to make sure they are good and confident diagnosticians.” He says medical students need to spend extensive hours during their undergraduate course seeing patients in ward and Emergency Department (ED) settings. He’s not so sure of the value of long hours of exposure to general practice in the early medical student years. “Any general practice teaching should be designed to enhance students’ diagnostic skills,” says Bill. “At the moment, the usual teaching format is to schedule 30-minute consultations with follow-up patients. Yes, it’s good for learning how to communicate with patients, but it does nothing for the diagnostic skills of the student.”

“The first two years postgraduate should also be spent in large city or regional hospitals,” he says. “The ED experience is vital. They have to learn to make a quick diagnosis.” He believes that GP registrars should then spend their third- and fourth postgraduate years working in larger group practices, with at least 3 other GPs. “Your best sources of information are usually your colleagues,” says Bill. “Patients should be booked at 15-minute intervals initially, until the registrar feels confident, and then frequency can be increased to 10-minute consultations. Obviously, some patients will take 20 minutes or longer, but most will be less than 10 minutes (the majority being reviews or acute simple cases). If you can’t see patients quickly you just can’t make a living, not even a modest living, it’s as simple as that.”

Bill has enjoyed his long career immensely. “It has been very rewarding. Although I’m 71 years old, I would feel very reluctant to retire. Part-time work is an excellent choice as GPs age.”

The practice has steadily grown, and now has branch clinics in Inverloch, Grantville and Newhaven. Dr Sleeman’s hospital is about to be replaced by a shiny new one, and this is attracting city specialists, a very welcome development in the country.

Bill says his greatest success in the marketing of general practice has been to encourage daughter Anna to the group practice in Wonthaggi. Anna and her partner are each involved in their respective, very busy careers, and together they have three young children. Anna grew up in Wonthaggi and has been interested in medicine since she was “knee high to a grasshopper,” says Anna’s mother. Like her father, Anna did her medical degree at the University of Melbourne. She says she didn’t need much persuading to come home. “The clean air, the bush, the beach – and the way I can work – what more could I ask for? Plus, I’ve got Mum to help,” she laughs.

Anna and Bill have similar thoughts when it comes to preparing medical graduates efficiently for general practice. They believe the current average training program is protracted and inefficient. “Registrars are allowed to sit the FRACGP exam after four years of experience, but often don’t take the exam until after six years, or even more,” Anna says. “Sometimes this is due to inadequate skills, or because they are still deciding on additional qualifications, such as whether to do a Diploma of Obstetrics for example. The whole process takes way too long.”

They also say the College of General Practitioners exam lacks relevance. “It needs to be realistic and pertinent to general practice,” says Bill. When the FRACGP Vocational Registration (VR) scheme was introduced, experienced GPs were “grandfathered” – meaning they were accorded VR status without being required to sit the exam. But Bill recalls that some of his experienced colleagues “who are excellent GPs” took the exam voluntarily and failed. “The exam’s got to be appropriate,” he says.

And when it comes to the status of general practice, Anna has some pet hates: “Being referred to as just a GP – this phrase makes me so angry. It makes GPs sound like they aren’t contributing much, and just acting as referrers to specialists. In fact, GPs have to be abreast of everything.” Anna is equally scathing about the pay difference between GPs and specialists. “The pay discrepancy between GPs and specialists is simply ridiculous.”

But she instantly brightens when she is asked for some positives. It took about a nanosecond for her to come up with quite a list. “The really positive parts are the work hours, the flexibility, the collegiate team environment, the ability to do locum work all across the country, the ability to be as procedural as you desire, the ability to do diplomas and specialise, the ability to be able to look after multiple generations and help people through the good and the bad times.” She pauses for a moment. “It’s pretty special.”

Anna, Bill and the family are just back from Broome, where Anna and Bill have shared a job as locums for 2-5 weeks over winter for numerous years. Everyone in the Howson family goes along. “Locums provide a change of scenery and a different work perspective, and also offer relief for remote GPs, who would otherwise have difficulty taking holidays,” Anna said.

Anna and Bill are enthusiastic ambassadors for general practice, but they see the looming workforce crisis. “We’ve got some thoughts about training of GPs,” says Bill, “and how training can produce effective, competent GPs … faster.”

 

Article written by Dr Katrina Watson MBBS MPH FRACP OAM (Retired gastroenterologist, Melbourne, Vic.)

The coalface:

Dr William Howson, MBBS Dip Anaesth FRACGP(General Practitioner, Wonthaggi, Vic.), and

Dr Anna Howson, MBBS FRACGP (General Practitioner, Wonthaggi, Vic.) and Ms Jocelyn Howson.

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