Where Do All The Good GPs Go?

I have had a running discussion (well, running may not be the word... let's say a slow-paced stroll) with an Anonymous commenter about my previous post Ann Bolch Meets Doogie Howser.

One of my criticisms of Ann Bolch's executive summary of the GP workforce was that describes (emphasis added):

At present this occupation has a high vacancy level, with 71 per cent of the vacant positions stemming from staff turnover within the industry

I think that this is an inaccurate portrayal of an industry where firstly, GPs are generally self-employed. Therefore while there is a shortage of GPs, not many of these are as employees - so how can you have vacant positions when such positions are rarely as an employee, and as such are not advertised?

Secondly, once a GP has completed training, they do not generally move from practice to practice in the same way that, for example, an accountant might. I would consider "turnover within the industry" to mean that a GP is poached from one practice to another. Someone please correct me if I am wrong, but I don't think this is commonplace.

Lastly, Anonymous states that:

There is significant turnover of General Practitioners. Many go off into other careers. These are the people that go onto specialize, namely in fields such as psychiatry and O & G.
1:10 AM, September 15, 2007

My response was, and remains:

I stand by my statement that it is unusual and uncommon for a GP to do anything other than work until they retire from medicine. Perhaps a small number of GPs give up medicine because it is too frustrating and decide to run hobby farms, play the stock market, or start up non-medical businesses instead - but you can hardly call that staff turnover.

Perhaps we are disagreeing over the semantics of the term "turnover". I see turnover as when someone gets fired, or leaves to go to another job (as Ann Bolch says, "within the industry"). Generally I don't think you can have staff turnover when GPs are not usually "staff" anyway - but clearly if we are to make any sense of her description we must try to read between the lines rather than taking Ann Bolch's words literally.

As for Anon's concept that a large and significant proportion of GPs go into other careers or specialise... I can't find anything to back this up. Instead, there is a plethora of workforce studies citing the impact of age-related retirement on attrition in the GP workforce.

• Schofield, Fletcher. Medical Retention and Retirement in Australia, 2000 to 2025 - Presented to International Medical Workforce Conference, Vancouver, Canada, March 2007 (PDF)
  • NB Schofield and Fletcher again use the terms "General Physicians" to describe General Practitioners. This adds to the degree of confusion but I understand they may have done this for the benefit of the North American audience.
• Schofield. Submission to Health Workforce Study, Productivity Commission, 2005 (PDF)
  
• Schofield, Beard. Baby boomer doctors and nurses: demographic change and transitions to retirement. MJA 2005; 183 (2): 80-83
  
• Schattner, Coman. The stress of metropolitan general practice. MJA 1998; 169: 133-137
  

While Schattner & Coman did find that "Fifty per cent of respondents had considered leaving their current workplace and 53% had considered abandoning general practice because of occupational stress" this does not translate to GPs actually leaving practice. Rittenhouse et alia (No Exit: An Evaluation of Measures of Physician Attrition. Health Services Research 39 (5), 1571–1588) writes:

The strongest predictor of both intention to leave clinical practice and actual departure from practice was older age. Physician dissatisfaction had a strong association (OR=5.6) with intention to leave clinical practice, but was not associated with actual departure from practice.

The closest that I could find to support Anonymous' point of view was this section of the Health Workforce Study Report (PDF, Dec 2005):

And in the area of general practice, the Australian College of non-VR General Practitioners said that because of the differential treatment of their members (that account for 10 per cent of the total GP workforce) who receive less than 70 per cent of the Medicare rebate available to vocationally registered GPs:

Non VR GPs have been leaving general practice ... and moving into other sub-specialities such as women’s health, cosmetic surgery, skin clinics, insurance companies and workcover clinics where the rate of pay is more attractive.
(sub. 128, p. 1)

To Anon - I don't disagree that GP work can be financially and personally frustrating, and that GPs may choose to expedite their retirement as a result of this. Many other specialties share your frustration. I also agree that GPs may choose to subspecialise into areas of interest such as Sexual Health, Mental Health, Obstetrics, GP Anaesthesia, Rural GP practice, Chronic Pain, Acupuncture, Erectile Function, Cardiac Screening, or Skin Cancer treatment. But these GPs are not undertaking recognised Specialist Training (especially as far as the Federal Government is concerned) and they continue to provide services within the realm of General Practice.

I think there is little to be gained in you or I escalating this tiff over the definition of the word "turnover", but I suspect you will respond anyway.