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Getting the Most out of Primary Care in the Prevocational Years

Getting the Most out of Primary Care in the Prevocational Years. Simon Willcock November 2011 simon.willcock@sydney.edu.au. Getting the Most out of Primary Care in the Prevocational Years. A Tale of Two RMO terms The History of Primary and Community Care JMO Placements

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Getting the Most out of Primary Care in the Prevocational Years

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  1. Getting the Most out of Primary Care in the Prevocational Years Simon Willcock November 2011 simon.willcock@sydney.edu.au

  2. Getting the Most out of Primary Care in the Prevocational Years • A Tale of Two RMO terms • The History of Primary and Community Care JMO Placements • The Current Environment • Evaluation of PGPPP • Where to from here?

  3. A Tale of Two RMO terms

  4. A Tale of Two RMO terms

  5. What does this tell us? Not all “criteria” are equal We need to acknowledge both tangible (structure, content, feedback etc.) and intangible (passion, mentorship) criteria in terms The value of the experience will to a large degree be determined by the characteristics and expectations of the learner!

  6. What is Primary Care? General practice is whole person care, characterised by the provision of person centred, continuing and comprehensive medical care to individuals and families in their communities. As a relationship based discipline, general practice seeks to build health, wellbeing and resilience through a continuing patient‐doctor relationshipof trust, clinical acumen, the application of best available evidencein the unique context of each consultation, and planned coordination of clinical teamwork, resources and services. The patient’s needs, values and desired health outcomes always remain central to the general practitioner’s evaluation and management processes.

  7. The Scope of General Practice in Australia Australian general practitioners require skills in: • Diagnosis of acute medical disorders e.g. IHD • Skills in chronic disease management e.g. Diabetes, COPD • Skills in managing patients with complex co-morbidities e.g. Elderly patients with multiple organ system pathology • Skills in managing common psychological health disorders e.g. Anxiety and Depression • Skills in preventive health implementation e.g.Immunisation, Healthy Lifestyle • Procedural skills (depending on the work situation)

  8. Evidence Supporting Primary Care • Better health outcomes for same resource expenditure (WHO 2008) • More primary care physicians the better the health outcomes (Starfield et al 2008) • Higher the number of consultant specialists, higher cost of health care and poorer outcomes (Starfield et al) • Decline in number of GP’s in Australia from 192/100,000 in 2000 to 179/100,000 in 2005 (AIHW 2006)

  9. The History of Primary and Community Care JMO Placements 1974 – Hornsby General Practice Unit 1976 – 1980s – RACGP Family Medicine Program 1990s – Rural and Remote Area Placement Program (RRAPP)

  10. Community and Rural Terms for Junior Doctors in Australia - 2002 • no consistent model around the country. The exception to this is the RRAPP, which allows terms that meet core criteria to be developed in rural/remote regions, at the same time allowing these terms to be appropriate to the needs of the local community. • ... not currently realistic to expect 100% of JMOs to do a community and rural placement in their first 2 postgraduate years

  11. Prevocational General Practice Placements Program(PGPPP) The PGPPP provides junior doctors with professional, well supervised and educational general practice rotations as part of their hospital / prevocational training

  12. PGPPP Aims (for Junior Doctors): • Build confidence, exposure and interest in general practice through supervised placements of 10-12 weeks • Increase understanding of the integration between primary and secondary health care • Gain a better understanding of general practice – whether looking at a career in GP or any other specialty

  13. PGPPP Supervision Model 4 Stages of Supervision: • Observed • WAVE Model

  14. Observed and “Wave” consultations

  15. PGPPP Supervision Model 4 Stages of Supervision: • Observed • WAVE Model • Reviewed (PGY2 only) • Independent (PGY2 only)

  16. Prevocational General Practice Placements Program “In hospital a lot of people portray quite a negative image of GPs and then you actually see them at work and they are the most knowledgeable and highly expertised doctors I have come across” Dr Faith Dyer PGPPP 2011 – Evans Street Surgery, Inverell, NSW

  17. The Value of Mentoring

  18. Prevocational General Practice Placements Program PGPPP Placement Overview • Variety – migrant, aged care, to aboriginal health etc - acute, chronic, preventive care • Personal mentoring by respected GPs • Direct patient contact in community based practice • Urban, regional, rural and remote settings • Increased confidence and independence

  19. Attracting more Students and Prevocational Doctors...

  20. Prevocational General Practice Placements Program “ On arriving at Oenpelli I was welcomed wholeheartedly by everyone at the clinic, which was in full swing, and on my first afternoon I was accompanying two patients out to the airstrip to be evacuated by air to Darwin” “I enjoyed the autonomy of seeing my own patients in the GP setting, working them up from the start, and trying to make a difference” Dr Michael Ryan, PGY1, PGPPP 2011, Oenpelli, West Arnhem Land NT

  21. Prevocational General Practice Placements Program “I felt that each day and every consult taught me something that will be useful in the future” “ In no other term will you have the consultant there to answer your clinical and non-clinical questions 100% of the time” Dr Michelle Nguyen, PGY2, PGPPP 2011, General practice for Children and Young Families, Campbelltown, NSW

  22. Prevocational General Practice Placements Program Figure 3: Allocation and participation by program year (2007 - 2010)

  23. Prevocational General Practice Placements Program Figure 11: Distribution of FTE Weeks by RA and Program Year

  24. Prevocational General Practice Placements Program Figure 11: Distribution of FTE Weeks by State/Territory and Program Year Territory and program year

  25. Prevocational General Practice Placements Program • 910 placements allocated in 2011 – expect at least 700 to be filled • 975 placements in 2012 – expect all to be filled • Distribution of places – based on medical workforce and community needs – minimum 50% in RA2+

  26. PGPPP EvaluationCETI – NSW Preliminary data • Term 5 2010, and Term 1 2011 • N = 17/22 • Comprehensive orientation processes • Good exposure to clinical, procedural and communications skills • Supervisors available and approachable • Good “in practice” teaching • Workload reasonable, occasionally too light

  27. PGPPP EvaluationCETI – NSW Preliminary data • 100% would recommend the term to a colleague • 65% reported that their knowledge, skills and confidence as a doctor were “significantly improved” • 100% (knowledge and skills) and 94% (confidence) were “improved or significantly improved”

  28. GP’s of the Future - Does a PGPPP term make a difference? Dr Liz Marles, Dr Jennie Kendrick, Dr Penny Browne and Dr Alyssa McNaughtHornsby-Brooklyn GP Unit November 2010

  29. Unit set up by Hornsby Hospital to provide prevocational GP training in 1973. PGPPP commenced in 2005 – 56 JMO’s completed terms Practice is over 2 sites 25 km apart 2 FTE Senior GP Educators 1FT GP Registrar 2 FTE PGPPP + / - medical students Practice nurse, practice manager and reception The Hornsby-Brooklyn GP Unit

  30. Most Valuable Aspects of the Term Candidates ranked the 10 options 1-5 and each option was allocated 5 votes for 1st choice, 4 for 2nd, 3 for 3rd etc.

  31. Value of the Community Attachments %

  32. Understanding of the Information Required by the GP in a Discharge Summary %

  33. Community Term Placements – Where to from Here ? • Changing perceptions

  34. Just see coughs and colds Don’t get to do any procedures Refer all the interesting stuff to specialists Lot’s of boring paperwork No influence No impact “…or are you just a GP”

  35. AGPT Applicants

  36. Proportion of Australian Graduates entering GP training

  37. Community Term Placements – Where to from Here ? • Changing perceptions • Maintaining quality placements • Growing the teaching and supervision resource

  38. Incentives....?

  39. Getting the Most out of Primary Care in the Prevocational Years If our goal is to provide a comprehensive and balanced training experience for our new medical graduates... ... the expansion of prevocational training into primary care sites is both inevitable and essential

  40. Thank You

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