Dr Michael Tam is a General Practitioner, currently a Staff Specialist in General Practice, General Practice Unit (Fairfield Hospital) and a Conjoint Senior Lecturer, UNSW Australia.
Thanks for joining us for this discussion, Michael. How did you get started in General Practice?
General Practice / Family Medicine in Australia is a “broad church”, and encompasses many settings and scopes of practice. Thus, rather than framing where my career in general practice started, it is better to describe the evolution of my career.
I was a JMO in the Illawarra, and by my PGY2 term, I recognised that my talents and interests lay with “generalist” rather than “partialist” medicine. In 2004, I applied to enter the general practice training program, and was accepted by the then regional training provider in central Sydney.
My clinical rotations in the training program included six-month hospital terms in rehabilitation medicine (Coledale Hospital), and paediatrics (Sydney Children’s Hospital). I trained over a number of different general practice clinics: an inner Sydney practice with a focus on sexual health and HIV medicine; a small rural practice in Western NSW, where I covered the local ED (1 in 3 on-call) and had VMO admitting rights; a practice in a leafy and wealthy suburb of the lower North Shore; and finally, a practice in the Sydney Inner West (Glebe) that had a wonderfully diverse population across the socioeconomic spectrum. I attained my Fellowship with the Royal Australian College of General Practitioners (RACGP) at the end of 2007.
I stayed on in the practice in Glebe for seven years, and developed a special interest in adult mental health, and also in medical education. These were initially small steps – starting a postgraduate degree in mental health, and supervising medical students on their primary care rotations.
In 2011, I went a little mad and took up a one-year contract for joint academic position between the University of New South Wales, and GP Synergy (the Sydney GP vocational training provider). Despite reducing my clinical work to a single (long) day, I was still effectively working three jobs! However, this exposed me to both the undergraduate and vocational medical education academic spaces, allowing me to develop invaluable skills and knowledge in student learning and teaching, assessment, and curriculum design. My salaried position at UNSW also allowed me to conduct my study, write my thesis, and complete my master degree in mental health.
For the subsequent three years, I worked part-time for UNSW as a staff academic in the School of Public Health and Community Medicine (medical education, research, service and administration), and part-time in clinical general practice. From the perspective of medical education, my key interests have been in the development of technologically enhanced learning and supervision methods, and the better integration of family medicine and public health into medical training. The goal of my ongoing research program is to identify and develop acceptable methods of implementing risky drinking detection in primary care. Service wise, I have been the GP representative on a number of governmental and other health system committees to ensure that primary care perspectives are considered, especially in the field of mental health.
In 2014, I was fortunate enough to be the successful candidate for the full-time Staff Specialist position at the General Practice Unit in Fairfield Hospital. This is an academic family medicine clinic that is funded by South Western Sydney Local Health District, but is also a teaching and research facility of UNSW. This is an unusual model, with only two academic GP units in NSW (Hornsby and Fairfield Hospitals). This position has finally allowed me to integrate in a single workplace clinical medicine, medical education, and research. Exciting for me, the nature of the Unit and its role within the LHD allows us to influence and lead health system redesign, especially as it relates to integrating care between the LHD and community general practice.
Why did you choose General Practice?
As a junior doctor I did not find any single hospital related specialty interesting enough for me to devote my career to. I could not define my interest to a body system, disease cluster, or restricted scope of practice. Rather, my interest lay centred in people, their experiences, and then outward from that, to systems and structures.
General Practice is about expert generalism, integrating data, making individualised decisions with patients, all the while holding onto and respecting uncertainty. More so that in any other specialty, GPs are not only witnesses, but are part of people’s lives. This is an enormous privilege and incredibly rewarding.
What would be your one-line ‘sales pitch’ to prospective GP trainees?
General Practice is hard medicine – however, it remains endlessly variable and interesting throughout your career.
Had you had a favourite or least favourite position?
My favourite position is what I have now! I do not have a least favourite.
What would you do differently if you had the chance to start your career from scratch?
As a GP registrar, I did not consider doing an academic term. Typically, academic registrars would spend a year conducting research under the supervision of an experienced GP researcher, and their salaries are funded through the Federal Department of Health. It was much more difficult being a research student after fellowship as it necessitated making important sacrifices in time and salary.
What job/specialty would you do if you weren’t a GP?
Possibly general medicine or liaison psychiatry.
How has the job changed over time?
Recently, General Practice has come under a number of structural assaults from the Abbott Government. Medicare Benefits Schedule rebates remain frozen, and the unhelpful threats of mandatory patient co-payments came and went. The GP vocational training system (GPET) is undergoing transition – its functions absorbed into the Department of Health, and the vocational training providers all having to retender for their contracts.
The pragmatic effect on the ground is that there is less funding for primary care, and this affects the poorest patients the most.
Where do you see General Practice heading?
Long-term structural reform of the health system is inevitable. The growth in health expenditure is almost entirely in the hospital sector, and little of it is in primary care. When politicians talk about the health cost growth being “unsustainable”, this actually refers to the cost of providing secondary and tertiary care. Workforce projections demonstrate saturation or an excess of most hospital specialists by 2025. As such, health sector investment will increasingly be out of hospitals, and into integrated care strategies that aim to keep people well and health in the community.
The concept of the “medical home” is well established, and the RACGP recently released their “vision for general practice and a sustainable healthcare system” (http://www.racgp.org.au/support/advocacy/vision/). It is probable that general practice will transition towards this model of care.
What are some lessons learnt (from the clinical practice perspective) that you would pass on to a GP trainee?
It is important to remember that from the ecology of health care perspective, for every 250 adults who seek primary care services, less than 1 is admitted to a tertiary hospital. General Practice / Family Medicine is very different to the medicine you may have practiced in terms of context, content, and clinical reasoning. Most trainees find the transition difficult, and this is okay!
The core of general practice training is the apprenticeship model, with registrars developing close and in-depth relationship with their supervisors. Foster this relationship, seek help, and seek guidance.
Tips for training/exams?
Try to work in training practices that are in a number of different contexts, or service very different populations. No single clinic will cover the breadth of general practice.
Many registrars focus just on the content, which is substantial in general practice. This is a strategic error – the clinical reasoning is just as important. You need to discuss your cases with supervisors to develop mastery.
Develop a study group with your peers early.
For the OSCE, practice!
Additional education/training/courses to consider?
I suggest only do additional courses because you have an interest, and they add meaningfully to your clinical work. Common courses:
https://beathealth.com.au/wp-content/uploads/2015/10/DSC46831.jpg21472651Shaun Hughstonhttp://devsite.beathealth.com.au/wp-content/uploads/2016/07/Beat-Health-Logo-PNG-copy-2-300x72.pngShaun Hughston2015-10-08 16:57:572016-04-15 05:00:30Specialty Spotlight - General Practice - Dr Michael Tam