Preparing for general practice

Introduction

It is Monday morning. You are getting towards the end of your morning surgery. So far today you have seen 12 cases, including a child with an ear infection, a woman with high blood pressure, a man with depression, a painter and decorator with backache, two people with chest infections and a man with a possible stomach cancer. You have injected a painful shoulder joint and arranged an urgent hospital admission.

The door opens and 12-year-old Andrew comes in. When he first joined your list his asthma was badly out of control. If he tried to run anywhere he would cough and wheeze almost straight away. You and your team have spent the past few months teaching him about asthma, and gradually adjusting his medication. He seems much better and today he was full of smiles. After all, he has just been selected for the school football team – something he thought he could never achieve in a million years. As he leaves your consulting room he turns to you, ‘Thank you doctor’, he says, ‘You really have changed my life.’

Haslam 2007

“By learning you will teach; by teaching you will learn.”

Latin proverb

General practice education must be of high quality; not only does GP training generally supply 50% of the hospital trainee workforce, good general practice reduces healthcare inequalities and morbidity in the population (Howard et al 2011). General practice is an important specialty, and nothing quite captures the specialty of general practice more than this statement and the quote above from Professor David Haslam, a leading general practitioner (GP) and past President of the Royal College of General Practitioners, UK. General practice composes a specialty which is a complex mixture of holistic medical management in a primary healthcare setting, enhanced by evidence-based preventative care, teamwork and managerial administration, all facilitated by excellent communication and up-to-date clinical skills.

Within such a complex arena it is hardly surprising that the ‘medical education’ surrounding general practice has taken many significant and different courses over the last few years; some of its innovations have formed the basis of standard educational practice, and GP educators have played a significant part in healthcare educational reform.

This chapter will bring to the readers’ notice some of the new changes that have occurred in teaching, learning and assessment in general practice. Cognisance is given to the fact that there are many variations of its definition; most of what appears in this chapter will apply to the UK model. However, readers should be aware that preparing for general practice is specific to the country within which the practice occurs, refined by that country’s definition and the impact of specific cultural, religious and healthcare needs.

“Never continue in a job you don’t enjoy. If you are happy in what you’re doing, you’ll like yourself, you’ll have inner peace. And if you have that, along with physical health, you will have had more success than you could possibly have managed.”

Johnny Carson (1925–2005), U.S. comedian

Background

It is not possible to outline the whole history of general practice and how it developed in this chapter; readers are referred to the further reading list at the end. However, it is important to look at some of the milestones in the development of general practice which have inextricably bound together the specialty with teaching and learning.

In the UK, as early as 1776, it was Professor Andrew Duncan who proposed the building of a Peoples Dispensary in Edinburgh (UK) for the ‘unfortunates of the city’ who could not afford medical care. This building, finally built in 1783, was probably the first example of something akin to a general practice surgery. In its early description of purpose there was a significant paragraph in which Professor Duncan highlighted the importance and need for teaching and community-based research within the building, in order to give the doctors of the future an insight into the realities of caring for all: a truly life-altering statement in the early days of institution-dominated education.

Somewhat later, in 1878, and again in Edinburgh, graduated Sir James Mackenzie, one of the future doyens of general practice teaching and international research. He subsequently inspired Dr Richard Scott, who developed and built the first unit of general practice, specifically built for teaching, and in the same year that the National Health Service was formed (1948). Scott also opened the first academic Department of General Practice in 1956 and eventually took up the world’s first post of Professor of General Practice in 1963.

The Royal College of General Practitioners (RCGP) was founded in 1952; it was the first officially recognized College specific to the specialty of general practice. The College became the main academic body for the subject and a key player in the educational development of all GPs through its key objective:

… to encourage, foster and maintain the highest possible standards in general medical practice … through effective teaching and ongoing professional development.

Involving its local faculties, its devolved councils in Scotland, Ireland and Wales and its internal organization, the RCGP in 2005 was one of the first in the UK to be given an unconditional approval of its training programme by the Postgraduate Medical Education and Training Board (PMETB), the body responsible for validating all postgraduate medical education training in the UK. The RCGP is now the parent organization through which the postgraduate programmes for general practice are governed.

Recent years have seen the expansion of general practice: greater variation in activities providing a varied approach to healthcare and the daily activities of its practitioners. These years have seen the emergence of different models of employment (salaried, sessional and portfolio practitioners) and contracts (Personal Medical Services); different patterns of teamwork (group practice, health centres); geographical variation (rural and inner city practice); an arena for a combination of skills and interests (police surgeon, occupational health, media doctor) and the development and accreditation of special interests which enhance patient care (GPs with special interests, e.g. gastroenterology, gynaecology, ophthalmology).

These recent changes not only have brought a new perspective into general practice and potentially an enhanced service, but also have made it one of the most potentially varied specialties in healthcare. This variation also creates a greater opportunity to look at the teaching, learning and assessment procedures within the specialty, creating opportunity for exciting educational innovations and educational research.

From an international perspective, many countries have ‘adopted’ the specialty of general practice. Frequently known as family practice, this branch of healthcare now follows many different patterns, each carrying its own training programmes, assessment and accreditation models and place within the hierarchical world of medicine and healthcare provision. Not all of these models provide diversity of healthcare. Not all provide equally comprehensive services, or the recognition of general practice as a specialty. Many countries follow the ‘inverse-care law of general practice’: those countries that would benefit from the advantages of effective general practice are often those that have a poorly developed or absent system of general practice.

What remains at the heart of general practice (be it the established and proven effective models found in the UK, United States and Australasia; the more refined models in Europe, sub-Saharan Africa and India; or the evolving models in the Far East, Eastern Europe and Middle East), apart from its diversity, is its reliance upon effective teaching and learning. It remains at the heart of the unique patient consultation and in the development of the specialty.

“An understanding heart is everything in a teacher, and cannot be esteemed highly enough. One looks back with appreciation to the brilliant teachers, but with gratitude to those that touched the human feeling. The curriculum is so much necessary raw material, but warmth is the vital element for the growing plant and for the soul of the child.”

Carl Jung (1875–1961)

Undergraduate education and general practice

The seminal document Tomorrow’s Doctors (GMC 1993) placed great emphasis upon the need both for undergraduate medical curricula to teach within a community setting (community-based education) and for programmes to encompass a community orientation towards healthcare (community-orientated education).

“Clinical teaching should adapt to changing patterns in health care and should provide experience of primary care and of community medical services as well as of hospital-based services.”

GMC 1993

When the General Medical Council (GMC) revised this document in 2003 and 2009, their statement regarding the use of general practice by universities expanded to include the wider variety of community placements, to be able to capture the demographic diversity of the community and for all students to contextualize their learning through the use of these community placements for early clinical exposure.

“Clinical education must reflect the changing patterns of healthcare and provide experience in a variety of environments including hospitals, general practices and community medical services … From the start, students must have opportunities to interact with people from a range of social, cultural and ethnic backgrounds and with a range of disability, illness and conditions.”

GMC 2009

As a result of these directives, the majority of medical schools in the UK use general practice to greatly facilitate student learning, and comparative models exist in undergraduate education throughout the world.

Although the percentage of time that students are placed within the community and at what stage in the programme varies greatly among medical schools and countries, it is important to realise that general practice and the community can be used for two types of learning: