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research
The way primary healthcare is being
delivered to the Australian public is
changing. Recent general practitioner
demographic data shows that 41% of
the workforce is aged over 55 years, a
significant increase from 31% in 2002,
and 58.4% of GPs have been working
for 20 years or more. In 2011–12 across
Australia, only 10.7% of GPs worked
in solo practice, and the number of
doctors working in practices with 5–9
individuals, or with more than 10, has
increased significantly since 2002.
1,2
Over the past decade in the Australian Capital
Territory and southeast New South Wales, only
a small number of general practice registrars
have gone on to own, or part own, a practice in
our region. Anecdotally, the situation is similar in
other regions of Australia. In 2011, approximately
12% of GPs worked in a corporate general
practice, compared to 8% in 2008.
2
Although
Australian commentary has been limited,
3
there
has been an international discussion regarding
the benefits and disadvantages of corporatised
healthcare since the late 1990s.
4
The inevitable
conflict between the therapeutic relationship and
the financial profitability of a corporate structure
has been noted.
5
Should there be the complete
disappearance of the doctor-owned model, we
believe this would be to the detriment of general
practice. However, this doesn’t look likely in the
Australian context in the near future.
Due to the low uptake of practice ownership
by recent trainees, it has been assumed that
registrars are not interested in the opportunity
of owning a practice. However, a recent survey
of 63 general practice registrars in the Canberra
region
6
found that 27% were interested
in future practice ownership, with another
38% undecided. Only 21% were definitely not
interested in owning a practice. Over half (54%)
of respondents said they would like to learn more
about how to run a practice during their general
practice training. There was strong interest in
learning via mentoring and face-to-face teaching.
6
This current research further explores acceptable
modes of education delivery for registrars
interested in future practice ownership.
The aim of this research was to explore and
develop models for delivering education on
practice ownership to general practice registrars
and recent general practice fellows.
Methods
This research was undertaken using a qualitative
grounded theory approach with focus groups and
in-depth interviews involving registrars and recent
fellows (completed training within 5 years).
Current registrars and fellows (graduating
2011–12) (total 86) from the CoastCityCountry
General Practice Training Group were invited via
email to participate in either a focus group or
an interview (but not both). Interest in practice
ownership was not a prerequisite for attendance
at a focus group.
Two focus groups were undertaken: the first
involving three senior registrars and one recent
fellow in April, and the second with four junior
registrars and two senior registrars in May
2012. In both groups there was an approximately
equal mix of participants who were interested
in practice ownership and those that were not.
From June to July 2012, a further nine semi-
structured interviews were conducted, seven were
face-to-face and two were via telephone due to
distance. Interviewees were recruited from an
email invitation to registrars and fellows who had
not attended the focus groups, including those
who had expressed interest in attending the focus
Background
Despite low uptake of practice ownership
by recent trainees, research has shown
that registrars are interested in learning
about practice ownership. We aimed to
determine how registrars would prefer to
learn these skills during general practice
training.
Methods
A qualitative study using focus groups
and semi-structured interviews.
Participants were registrars and fellows
from the CoastCityCountry General
Practice training program. Data was
analysed for themes until thematic
saturation was achieved.
Results
Registrars are interested in learning more
about practice ownership in the later
stages of training. They need more than
just information – they are requesting
opportunities to learn from current doctor-
owners. Mentorship from doctor-owners
was seen to be valuable and could be
facilitated through a number of avenues.
Discussion
Registrars are keen to learn more about
practice ownership. Establishing a
mentor relationship with an experienced
doctor-owner is essential for this
education to succeed.
Keywords
general practice; practice management;
medical education; vocational education
To own or not to own
How can we best educate general practice registrars
about practice ownership?
Elizabeth Sturgiss
Katrina Anderson
Martin Liedvogel
Emily Haesler
Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 42, NO. 6, JUNE 2013
503
To own or not to own – how can we best educate general practice registrars about practice ownership?research
groups but were unable to make the specific time.
Recruitment for interviews ceased when no new
themes were emerging in the data. All participants
were asked to complete an anonymous
questionnaire with demographic information.
Focus groups were chosen to provide an
opportunity for new ideas on education delivery
and mentoring to be discussed and developed in
more detail. Within the focus groups, the facilitator
proposed questions for informal discussion among
participants and discussion of ideas between
participants was encouraged. Groups were also
shown two statements about practice ownership
education and were asked to comment on
these. Finally, the groups were shown different
cartoon pictures and asked to comment on which
represented mentorship to them and why.
A thematic analysis was conducted on the
focus group transcripts with the assistance of
software program NVivo9. Reliability of the
themes emerging from the data was ensured
by consensus during regular meetings of the
research team, as well as discussions between
the two facilitators that were present at the
focus groups. Themes that were identified as
being only partially explored formed the basis
for in-depth interviews. The interviews were
conducted using a semi-structured interview
style that provided the opportunity to explore
personal experiences with interest in and
knowledge of practice ownership. Both the
focus groups and interviews were audiotaped
and then transcribed. NVivo9 was used to
collate the de-identified data and the data was
then analysed for themes using the constant
comparative method of grounded theory.
Results
Our complete sample included 10 female
registrars, four male registrars, two female
fellows and three male fellows. Not every
participant chose to answer the demographic
information. Eleven were aged 25–35 years, and
six were aged 36–50 years. None were over
the age of 50 years. Fifteen had completed their
basic medical training in Australia, and 14 were
either on or had completed, the general, general
practice training pathway. Five intended to work
rurally, eight intended to work in metropolitan
or outer metropolitan areas, and five were
undecided about the place they intended to work.
When should practice ownership
education be offered?
A predominant theme was that registrars wanted
to learn about practice ownership toward the end
of their training, with most citing a desire to pass
their clinical exam first.
‘ ... at the moment I’m struggling to do modules
... my focus is to try and pass my exam. If you
ran extra workshops on [practice ownership], I
wouldn’t come at the moment. I guess, maybe
as I got on to a GPT3, it might become more
relevant. So, I guess, the relevance might
change as I’m, sort of, progressing up the
ladder, but at the moment, the first thing I
look at when the release is out is, what meat
is in that that’s going to help me when I go
back to a practice that isn’t particularly good
at education? So, I guess, my ... the small bit
of education I’m getting, I desperately need to
be clinical, but then, I’m a GPT1, so I’m sure
the focus changes.’ [Term 1 registrar, 1]
An alternate theme, that was less dominant, was
that education early in registrar training could
develop better understanding of the practice they
worked in, to assist them in negotiating their
contract and to learn about possible options for
their future.
‘ I felt really on the back foot negotiating my
contract and after 4 months of not seeing a
payslip and finally seeing one, I’ve realised
that, you know, my pay hasn’t been right
once. ... So, maybe earlier would be better,
just in fact to allow us to go out, because
even if we don’t own a practice, we need to
still negotiate our working conditions and
we’re not taught that ... through our training
either. We just go to the hospital and take
whatever contract they’ve got, but when you
go out into the real world, or go out into the
private practice, potentially, I guess, you’ve
got to know how to negotiate a reasonable
contract.’ [Term 2 registrar, 2]
Knowledge around current
education options
Only three registrars were aware of current
educational opportunities in practice management
and ownership. These currently include The
Royal Australian College of General Practitioners
(RACGP), Practice Management Toolkit; General
Practice Registrars Australia (GPET), ‘Future
series’ webinars; RACGP sessions (usually run
in Sydney, New South Wales); sessions offered
by professional indemnity insurers; and private
companies offering workshops to doctors and
other practice owners. The very few registrars
who had participated in these found that the
information provided was overwhelming,
uninspiring and disempowering. A key comment
was that they found that working on these topics
alone without context was not beneficial.
‘ [The RACGP Practice Management Toolkit
was] Not very helpful. I think there’s far more
information that I would like to know and
once again, it’s about practical information.’
[GP fellow, 3]
‘ I think [GPRA webinars] were helpful. It
depends on the actual webinar, you know that
there’s a series of them, so some of them were
more helpful than others, depending on who
was presenting, and the content of the actual
tutorial. And also they said that – this was a
key thing in helping me decide whether or not
I was really interested in practice ownership,
was that he said that most practices don’t
actually have a high profit margin; they just
have a very small profit margin, and then
everyone we refer to, physios, everything else,
have a very high profit margin.’ [Note – this
registrar has now decided not to pursue a
career in practice ownership after participating
in webinars.] [GP fellow, 4]
What methods of education
delivery do registrars prefer?
Registrars and fellows had a low preference for
teleconferences, online group forums and didactic
lectures. They felt these forums would not provide
an opportunity to ask open and honest questions.
‘ If there was web-style learning for the
practice management thing, I think it’s such
a complex area that I’d at least need some
interaction to start with, because it’s just
... you feel like it could ... it could be so far
above my level of understanding, so it would
be too overwhelming to start as a web-based
thing. I feel like it would be hard to, sort of ...’
[GP fellow, 5]
‘ Or it could be, perhaps, initially reading web-
based and then, at some stage, an interaction
where questions can be answered.’
[Term 2 registrar, 6]
504
Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 42, NO. 6, JUNE 2013
researchTo own or not to own – how can we best educate general practice registrars about practice ownership?
‘ That’s right. It seems like something you
should learn from mentors, doesn’t it, like, a
discussion type thing.’ [GP fellow, 5]
An online portal with links to relevant resources in
conjunction with small group tutorials facilitated
by a doctor role model were seen as the best way
to learn about this topic. Again, the participants
highlighted in their discussion that learning alone,
without interaction with a mentor, was not ideal.
Mentorship
Without prompting or probing, registrars and
fellows discussed the concept of mentoring
frequently. Registrars were very keen on the idea
of having a mentor on their practice ownership
journey, especially one that extended after
fellowship.
‘ [Having a mentor] would be useful. Yeah, I
think that would be good to talk to someone
about the, you know, pros and cons and where
to go and … yeah, because I think it all is
quite daunting. We just don’t know much
about … you know, you just don’t know much
about it, what’s involved in the running of it.’
[GP fellow, 5]
Registrars and fellows are already looking to
current practice owners for leadership. Some
reported ambivalent feelings about their current
role models.
‘ The conundrum that I see is the people that I
look up to, as clinicians, are terrible business
people and the people who ... are phenomenal
businessmen I ... certainly wouldn’t admire
them clinically. So, there’s kind of these, you
know, polar opposites ...’ [Term 2 registrar, 6]
‘ My supervisor [is my mentor]. I think he does
a good job, but the hours he puts in, I don’t
think I, or anyone else, would be able to do
it. ... and even talking to the receptionist who
has been with him for years now, says he has
been ignoring his children. He couldn’t spend
any time with them and he’s paid a heavy
price for it.’ [Term 1 registrar, 7]
Interestingly, the registrars who had a stronger
preference for practice ownership had already made
informal links with a current practice owner and
were able to identify strengths of these mentors.
‘ ... I’m impressed by their organisational skills
and impressed by their ability to balance both
seeing patients and doing clinical stuff as
well as keeping the actual business side of
stuff running because that in and of itself can
be a full time job.’ [Term 3 registrar, 8]
‘ [The practice owner] has got a lot of systems
in place so that people with the chronic
diseases are managed very well.
Interviewer: ‘And is that what inspires you
about him?’
‘Yeah and his approach to general practice in
general but particularly… just having… really
well thought out systems in place for your
practice that benefits your patients.’
[Term 3 registrar, 9]
Models of mentorship
Registrars were insistent that they needed to be
able to make initial connections with practice
owners to select their own mentor. A formalised
system that linked registrars and practice
owners arbitrarily was not a popular idea, with
participants wanting a connection with a mentor
to be a personal choice.
‘ You might just have a personality mismatch
that they’re just not the right person for you.’
[Term 2 registrar, 2]
‘ I’m not sure it would have to be a formal
thing, but something that you would
personally approach someone that you felt
would be able to help as well, but then, I
guess you’d then have to know people as
well.’ [Term 2 registrar, 10]
‘ See, this is the thing that worries me with
the idea of mentor based teaching. You
feel strongly about the social aspects of
medicine, but that’s where a difficulty comes
with pairing people with mentors. Well, yes,
because you’ll find people that you are drawn
to, because they have similar ideology to you;
they have ... they may have some things that
you want to learn that you think you’re lacking
in, but that you feel you get on with and
you admire them; that’s fine, but that’s not a
formal thing though, like we’re talking about,
with a mentor based teaching thing.’
[Term 3 registrar, 11]
‘ I imagine it’d end up a disaster, saying “This
person with this person”. I mean, they just
might not gel.’ [Term 2 registrar, 12]
We explored some different educational
opportunities for creating mentoring relationships.
A weekend workshop on practice ownership
and leadership was presented as a learning
option. All but two of the registrars and fellows
who participated in focus groups or interviews
said they would be interested in attending. The
predominant response was that this was an
opportunity they would take up after they had
passed their clinical exams.
‘ If there was ever to be some kind of weekend,
to be able to say the pros and the cons of
everything, because you usually just hear the
pros. If somebody has a practice they say
usually really great things about it, and then
the people who don’t own a practice, these
are the really bad things. But to hear both
sides is really important.’ [Term 2 registrar, 2]
‘ That’s what those getting together releases
are about, networking as well, aren’t they?
Not just the content, but meeting people?’
[Term 3 registrar, 13]
The weekend was seen as a good opportunity
to learn new information, as well as meet other
interested doctors to form mentoring links.
An extended skills term in practice ownership
and leadership during general practice training
(‘practice leadership post’) was acceptable to
registrars. It was seen as a great opportunity
to form a strong mentoring relationship with a
doctor-owner. All participants were keen on the
idea, but couldn’t say whether they would commit
without knowing the finer details of remuneration
and expectations.
‘ I think it would be really, really useful, but
terrifying. ... like your first surgical term, when
you’ve only ever done medical terms. It’d be
terrifying because it’s not a skill set we have.
So I think it would be invaluable. The hardest
terms are usually the ones we learn the most
out of. But it would be terrifying because
we’ve just got no idea.’ [Term 3 registrar, 13]
Discussion
General practice registrars are interested in
learning more about practice ownership. The
educational opportunities currently supported by
the RACGP and GPRA are not widely known by
the registrar community. However, these options
are generally learned ‘solo’, and this study
clearly demonstrates the need for learning to be
interactive. Information about practice ownership
in a vacuum is not acceptable or beneficial to
registrars and fellows.
Our study is unique in including recent fellows
Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 42, NO. 6, JUNE 2013
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To own or not to own – how can we best educate general practice registrars about practice ownership?research
of general practice training. Fellows are more
likely to be in a position to consider practice
ownership seriously for their career. They have
consolidated their training, and our study showed
that registrars would prefer to finish their clinical
exams before embarking on learning about
practice ownership.
The registrars and fellows in our study
perceive that mentorship arrangements in the
final stages of general practice training and during
early fellowship years are the best way to engage
in learning about practice ownership. Having a
learned colleague to bounce ideas off, discuss
new concepts with, and be able to draw on real
life experiences was thought to be very beneficial.
These mentorship arrangements need to be
facilitated to be sustainable.
We propose a ‘practice leadership post’ that
would consist of 1 day a week quarantined for
the registrar or fellow to learn about practice
ownership; that the mentor is paid to spend time
with the registrar or fellow; and that funding is
provided for the registrar/fellow for professional
development. The RACGP Practice Management
Toolkit is a great resource, however, it is much
more effective if used as a tool to facilitate
a learning conversation within a mentorship
relationship. The registrars who chose to be
involved in the research were keen to have this
as an option in their training. The major barrier to
its implementation currently is funding. Informally
supervisors have been filling this role, but often
don’t have the time required to commit to it fully.
Our proposal is to formalise a post so there is
adequate time and remuneration for this essential
part of general practice education.
A weekend workshop was an idea that was
welcomed by registrars and fellows. It was seen
as an opportunity for learning and networking. This
intervention could be easily established within the
current general practice training program, with a
strong suggestion that recent fellows should be
encouraged and funded to attend.
Limitations of this study are that participants
were self-selecting and there may have been
a bias toward registrars interested in practice
ownership. However, these are the registrars
that would be the target of any educational
intervention. Another limitation is that these are
the ideas of registrars and fellows, and have
not been tested. GPET and training providers
need to consider how they facilitate and support
registrars and fellows who are attracted to
practice ownership to develop their existing level
of interest. Recruitment of positive doctor role
models and supporting them with appropriate
mentorship training would be essential to the
success of any program.
Education about general practice ownership
needs to involve interaction between doctor-
mentors and interested registrars and fellows. The
establishment of strong mentorship relationships
will give trainees the skills and confidence to
empower them to consider a career as a practice
owner.
This part of general practice training is
essential in ensuring we have general practice
doctor-owners in the future.
Implications for general
practice
• Registrars and recent fellows are interested in
learning more about practice ownership from
experienced doctor-owners through mentorship
relationships.
• There are a number of options for facilitating
mentorship in general practice training.
Weekend workshops and a ‘practice leadership
post’ are two options that could easily be
accommodated in the current training program.
• These findings are of particular importance to
current doctor-owners who may be considering
succession planning in their own careers.
Authors
Elizabeth Sturgiss FRACGP, BMed, MPH,
MForensMed, is lecturer, Academic Unit of
General Practice, Australian National University
Medical School, Canberra, Australian Capital
Territory. elizabeth.sturgiss@anu.edu.au
Katrina Anderson BMed, FRACGP, MTh, is
Associate Professor and Acting Director of
Academic Unit of General Practice, Australian
National University, Canberra, Australian Capital
Territory
Martin Liedvogel BMed, FRACGP, is a general
practitioner, Canberra, Australian Capital Territory
Emily Haesler BNsg, PGradDipAdvNsg, is Senior
Lecturer, Academic Unit of General Practice,
Australian National University Medical School,
Canberra, Australian Capital Territory.
Competing interests: None.
Ethics approval: Australian National University
Human Research Ethics Committee.
Provenance and peer review: Not commissioned;
externally peer reviewed.
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Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 42, NO. 6, JUNE 2013