Teaching in general practice
At present communication skills teaching is undertaken largely by GPs, the belief being that their greater patient contact and long-term follow-up best allows them to do so. However, experience only covers so much. We can all recall a consultant during our undergraduate clinical years who was far from perfect as a mentor — where teaching them the skills to teach may have made a tremendous difference.
A suggestion to tackle this explores the proposal for integrating another relevant subject with the MBChB or respective Royal College qualification. As already discussed, undergraduate teaching in management or even integrating a management qualification can provide food for thought — the same idea can applied to teaching.
The casual acceptance that students who become qualified doctors are also capable of teaching their peers is one that must be addressed as it is evident that this is not always the case. Compare this with school teachers, who have to complete a year of teaching before being employable, many doing so after studying ‘education’ as their primary degree. It is now easy to understand why this may be seen as an example of arrogance in the medical profession.
Being taught the confidence, organisation and skills to teach while at medical school could make a considerable difference to the education of future medical students. Concerning general practice, the gradual shift in emphasis towards patients in the community and the increasing student numbers, means an estimated 1000 further practices will need to be recruited to accommodate these demands.12 When considering over a third of all practices in the UK are already involved in teaching undergraduates, this requirement is significant. With this in mind, today's GPs need to be very competent at teaching to ensure an optimal education for these student doctors. Otherwise, the vicious cycle of students qualifying with little ability to teach going on to train others to have the same level of competence will continue.
One study assessed the effects of teacher training on GPs and their attitudes to teaching students thereafter.13 Set in general practices throughout north London, the results showed an increase in morale and confidence in teaching. One GP said: ‘I felt much more confident — this is the first time that I have had real training in teaching, although I am an experienced [GP] teacher’. The study also recognised that there were many GPs who were insecure about their teaching ability — a point that could be corrected if mandatory tuition in teaching skills were to be implemented at either undergraduate or postgraduate levels.
However, any changes to the delivery of education from general practice will be difficult while receiving only 5% of the NHS teaching budget when delivering, on average, 9% of the medical curriculum.12 Although small increases to funding will be sufficient to engage both the necessary staff and facilities for teaching in community settings, the ramifications for teaching in hospitals may be innumerable.
Conclusions
It would seem that, at a time of increasing specialisation, the GP of today remains the last general physician in medicine. Having the ability to handle business, teach to different knowledge levels and undertake research, in addition to being a diagnostician, makes this even more the case.
However, as medicine moves steadily forward, I believe the training of GPs at both undergraduate and postgraduate levels, has not kept pace. Not every hat the modern GP has to wear is covered in the training and I believe the suggested reforms to training will help the GP become better equipped to thrive in the future.
Compulsory undergraduate education in teaching skills and management will widen the scope for community research and boost the number of juniors entering academic general practice. But it will also help future doctors cope with the demands of contemporary medicine. The more experience undergraduates receive in the different roles of a GP, the greater the number of students that will become interested in primary care.
What the future will bring to medicine is never certain but if these suggestions were implemented, there would be little that the GP could not handle.
Summary of recommendations
Undergraduate
Specific placements in general practices with an interest in research or university departments of academic general practice
Greater encouragement for projects and audits to be primary care-related
Broader range of primary care-related intercalated degrees
Formal tuition in business, financial and personnel management
Formal tuition in confidence, organisation and teaching skills
Greater opportunity for intercalated degrees in management and teaching
Postgraduate
Tuition in management or teaching skills leading to formal assessment by the RCGP and the award of a specialist MBA in healthcare management or recognised teaching qualification
Teacher training programmes for current GPs
Commentary 1
Abul Siddiky identifies key issues crucial for recruitment into academic general practice. We would argue that these do not just apply to academic primary care. Despite the increased focus on community-based undergraduate education, catalysed by the GMC's recommendations, medical students' perceptions of work as a GP are not changing.
Primary care continues to be viewed by many students as ‘low profile’ or ‘a soft option’ where one ‘ends up’! Yet almost all UK medical schools now include attachments in the community setting from the first year of medical school. An ever increasing proportion of the teaching (up to a third in some of the new schools) is delivered in the community. It would be unfair to say that students are lacking in exposure.
The problem lies in the ‘hidden curriculum’. Students arrive with a media-based ER or Casualty impression of medical priorities. These perspectives are reinforced in the teaching hospital environment where, often unintentionally, the changes in delivery of primary care and the opportunities for research are poorly understood. The negative message is covert not overt.
It is up to us to raise the profile and ensure students are stimulated by their experiences of primary care. Unfortunately increased exposure may not be the answer. As student numbers rise, finding practices well prepared to receive them is increasingly difficult. The standards set for postgraduate training are lost. Students are stimulated if their engagement in the practice is interactive and inspiring. The GP as a role model is crucial. Negative experiences are detrimental, quality appears to outweigh quantity.
Siddiky's article is timely. Capacity for training in general practice is now under even more pressure with the imminent introduction of Modernising Medical Careers (MMC). We face a potential crisis unless medical schools and postgraduate deaneries work closely together. How are we going to accommodate training in the foundation years and ensure quality experiences? At a recent planning meeting, it was proposed that PRHOs sit in the waiting room to learn ‘what it is like’. Yet first-term medical students frequently do this. Five years later their expectations are different. The opportunities offered by MMC may be lost unless deaneries embrace the new breed of medical graduate.
Inspiring students to follow academic general practice raises an additional issue: the conflict between research and education. Yes, we do need more innovative ways of engaging students in academic primary care. However, the short-term pressure for high quality five-star research outcomes may marginalise the long-term need to attract others into the same career pathway. Heads of academic departments need to balance this dilemma.
The recruitment of GPs for the new millennium is of paramount importance. Educators in both secondary and primary care need to understand the changing experiences and expectations of undergraduates if enthusiasm for work in primary care is to be nurtured.
Val Wass and Adam Firth
- © British Journal of General Practice, 2004.
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