The right upper quadrant

July 2013

Research

To own or not to own

How can we best educate general practice registrars about practice ownership?

Volume 42, No.7, July 2013 Pages 503-506

Elizabeth Sturgiss

Katrina Anderson

Martin Liedvogel

Emily Haesler

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.

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 region6 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 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]
‘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 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.

Competing interests: None.
Ethics approval: Australian National University Human Research Ethics Committee.
Provenance and peer review: Not commissioned; externally peer reviewed.

References

  1. Britt H, Miller GC, Charles J, et al. A decade of Australian general practice activity 2002–03 to 2011–12. General practice series no. 32. Sydney: Sydney University Press, 2012.
  2. Carne A, Howard S, Bywood P. Summary Data Report of the 2010–2011 Annual Survey of Divisions of General Practice. Adelaide: Primary Health Care Research & Information Service, Discipline of General Practice, Flinders University, and Australian Government Department of Health and Ageing, 2012.
  3. Lipscombe MV. Practice management. Med J Aust 2003;179:51.
  4. Mars S. The corporate practice of medicine: a call for action. Health Matrix Clevel 1997;7:241–300.
  5. Poduval M, Poduval J. Medicine as a corporate enterprise: a welcome step? Mens Sana Monogr 2008;6:157–74.
  6. Liedvogel M, Haesler E, Anderson K. Who will be running your practice in 10 years? Supporting GP registrars’ awareness and knowledge of practice ownership. Aust Fam Physician 2013;42:333–6.

Correspondence afp@racgp.org.au

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