Opening the lines of communication

Interns need to receive greater exposure to general practice during their training

 recently saw an interesting discussion on Twitter, which I thought raised valuable points about the interactions between GPs and hospital doctors. Several GPs were commenting on how they were becoming increasingly frustrated by being sent demands from hospital junior doctors on discharge letters for ‘GP to follow’ blood results, scans or outpatient referrals. Many GPs feel these demands have no apparent appreciation for their huge workloads and lack of access to these services in the community, leading many to retort ‘I’m not your intern’!

A lot of it comes down to naivety and poor understanding of the scope of the GP’s role by very junior doctors. I remember being an intern and having no real idea that the local GPs had no way of accessing the results of blood tests done in the hospital until one day, a friend got an extremely irate phone call from a GP which left him quite rattled and upset. This shouting-down to the most inexperienced member of the hospital team obviously isn’t right or fair either.

Not only can it raise a lot of bad feelings on both sides, there are significant safety and medico-legal considerations. For example, who has the responsibility to act on test results that may have been ordered by another person? I know that there are some efforts on the ground to change this. Now, GPs often take part in intern hospital inductions and offer teaching sessions on the importance of informing GPs of changes to medications and management plans on discharge. However, there is still scope for improvement.

At the same time, I was reading a report about how there are increasing concerns that in the future, there will not be enough good-quality intern posts based in large tertiary training hospitals for the ever-increasing numbers of medical graduates. This particularly affects our international graduates who have trained here at great personal financial cost and are subsidising the entire Irish medical school industry with their extremely high fees. These doctors are trained to work in the Irish system but are then lost to us forever.

I have come up with a quite neat solution to both these problems — ensure that each intern has at least one three-month post in general practice during their intern year. This would free-up more intern posts for more graduates and would also increase exposure to general practice early on. Of course, it would require a huge amount of organisation and buy-in from GPs who are under increasing pressure as it is. There would obviously be a demand on a busy GP’s time to provide training and support to these young but enthusiastic doctors.

There are currently very few intern jobs in general practice, usually just one or two per scheme, and they are highly competitive. My colleagues who were lucky enough to get such a post loved them and many went on to join GP training schemes. Being in a practice with a GP is a more of a one-on-one training experience than working for a consultant who you’re not sure knows your name and it can be a far more valuable clinical learning experience to see patients by yourself and come up with your own management plans, rather than just putting in cannulas and rewriting drug kardexes. Of course, not everyone will love the idea of being away the from the buzz of a busy hospital in the relative quiet of GP land; however, most of us are made to do six months of surgical jobs without the slightest intention of ever becoming surgeons.

There is currently huge variation in medical schools on how much exposure students get to general practice, ranging from 18 weeks to as little as two weeks when I was in college. Students are highly influenced by ‘GP bashing’ in medical school — I remember being told in lectures by hospital consultants that half of us would ‘end up’ as GPs, as if it was some personal failing, or the consequences of a once promising career going off the tracks. This continues into working in hospitals, where complaints about ‘bad GP referrals’ are rife.

This may even have the benefit of encouraging more doctors to consider general practice as a specialty at a time when there is an increasing shortage of GPs. Reports predict that 660 GPs are set to retire in the next seven years and we will need at least 2,500 new GPs to meet existing demand.

We need some new thinking about how we train doctors at the start of their career. This is not a perfect solution, but it may improve collegiality and greater understanding of what the role of a GP entails and it may even go in some small way to increase numbers in general practice at a time when we need ever more.