Dr Bob Vickers

These GPs may be managing a 10-year-old boy with a distal radius fracture one minute and a 60-year-old palliative care patient with symptomatic ascites the next.

Then, just as the shift’ s about to end, a 30-year-old woman who is 36 weeks pregnant presents in labour with an obstetric emergency requiring urgent delivery.

In an ideal world, the GP treating the child with the wrist fracture would be able to perform a closed reduction and a plaster cast under regional anaesthesia, Bier block or procedural sedation.

The palliative patient would be able to undergo paracentesis close to home and the pregnant patient would be managed safely with mother and baby having a good outcome.

It’ s obvious these GPs need broad training to ensure they can effectively manage every patient who walks through the ED doors.

This means making sure there are enough training positions and opportunities for registrars to undertake, and enough practice procedures during their fellowship programs.

However, currently, this doesn’ t appear to be the case.

An arm of the Registrar Clinical Encounters in Training study, published in June, shows registrars are not performing up to one-third of the

112 procedures considered core skills for independent rural and regional practice. 1

According to the survey of 1299 GP registrars, the procedures they do perform include venepuncture, wound swabs and suturing of superficial skin lacerations.

Procedures they are not performing include lumbar puncture, insertion of chest tubes, gastric lavage and female urethral catheterisation.

“ These findings are particularly concerning as some registrars will be practising in rural centres where a lack

of competency in procedural skills could significantly limit their practice and, in the case of some skills, may have implications for patient safety,” the authors conclude.

The study did not look at the reasons for this skills shortage but, at a time when Australia has a medical workforce distribution problem and needs more GPs to work in rural areas, it exposes a serious issue.

And with more and more doctors coming through the training pipeline, the opportunities for hands-on experience are diminishing.

PROCEDURES REGISTRARS ARE NOT PERFORMING INCLUDE LUMBAR PUNCTURE, INSERTION OF CHEST TUBES, GASTRIC LAVAGE AND FEMALE URETHRAL CATHETERISATION.

There are currently more than 5000 GP registrars in training, with 1500 to be added to make up the 2018 cohort.

If one-third of the 2018 cohort decide to work rurally, 500 towns could potentially have the medical workforce to manage the above-mentioned patients safely.

But we need to ensure these registrars are able to access the training they need to build the necessary core procedural skills to take on these roles.

So what’ s the solution? Training a doctor is not cheap and so collaborative

planning is needed at local, state and federal levels.

The idea of a national rural-generalist training program has been repeatedly suggested over the years, which the RACGP and ACRRM have supported. This concept has also been backed by the Federal Government.

I believe such a program is a vital tool for a sustainable rural health workforce.

There are already state-based rural generalist training pathways— most notably in Queensland— with some procedural training positions in a

mix of metropolitan and regional / rural hospitals that could be used as templates. However, these programs shouldn’ t allow us to ignore potential training gaps for those who wish to work as rural GPs.

Other solutions include replacing the extended skills term in the RACGP’ s fellowship program with a mandatory six-month emergency medicine term for rural pathways registrars. As a GP registrar who has worked in a rural area, I would support such a move.

GP registrars undertaking the ACR- RM’ s fellowship program already complete a procedural logbook that covers most of the 112 core skills, which, I believe, are an essential part of training for rural work.

Critical illness has no respect for geography, which is why one of the core themes of maintaining an appropriately skilled and sustainable medical workforce is“ the right doctor, with the right skills, for the right location” as then Assistant Minister for Health Senator Fiona Nash said. 2

Australia is failing to fully deliver on this at present and unless action is taken to address the lack of procedural skills among GP registrars, the future looks even bleaker for rural patients. Dr Vickers is a GP registrar and ED medical officer in Singleton, NSW.

1. Australian Family Physician 2017; online.

2. Senator Fiona Nash press release. 31 October 2014.