Competent but Not Confident?

Daniel Edgcumbe

doi:10.3399/bjgp10X544168

Newly qualified GPs are not as well prepared as they used to be. They are ‘competent but not confident’. ‘General practice is different these days’, ‘it is more complicated now’. These were some of the arguments trotted out by some senior members of the College at the 2010 annual RCGP conference in Harrogate, who support the extension of GP training from 3 years to 5.

In recent years there has been a huge investment by the College in the education of its trainees. We now have a formal curriculum. There are workplace-based assessments. Patient satisfaction questionnaires mean direct patient feedback is a feature of modern training. These tools are combined with a rigorous and structured process of educational oversight, involving frequent formal reviews and reports from clinical supervisors.

Despite this educational tour de force, newly qualified GPs are considered by the College to be inadequately equipped to deal with life outside of the VTS.

Some might consider this an indictment of the curriculum and assessment system; but for the real answer, we must look away from the soaring educational rhetoric to the more humdrum actuality of everyday training.

Current GP training schemes are formulated to meet the needs of the service and not those of trainees. Some are excellent, with innovative training posts offering trainees customised learning, truly designed to meet their needs. However, standards of training are patchy. Programmes are all too often rigidly inflexible and many have significant omissions.

In my own deanery, an emergency department that has lost accreditation for the training of emergency physicians retains its approval as a suitable place for training GPs. The message this sends to trainees (and incidentally, other medical Colleges) is that GP trainees can be slotted in to the jobs that no- one else wants to do, or that offer such a poor training experience no other College will endorse.

New entrants to general practice training, perhaps more than in any other specialty come from a diverse range of backgrounds. Making reference to the Kennedy review,1 Steve Field, at the RCGP 2010 conference branded it a ‘disgrace’ that only 40% of trainees have a paediatrics attachment. However former paediatric registrars with many years of experience looking after children are required to undertake placements in paediatrics as part of their training schemes, while their colleagues who may have barely set eyes on a child before are not afforded such opportunities. This is simply demented.

There is a gap between theory and practice. It would be easy to lose focus and to forget the intentions of training. We must not allow that division to widen. The College recently announced that the curriculum is to be revised to include sustainability.2 This is voguishness of the worst kind, subjugating the crucial function of education to the caprices of the day.

There are practical reasons for not extending GP training: it would be unaffordable; it would almost certainly have an adverse effect on recruitment — applications to training have already dropped from 9000 in 2008 to 5500 in 2010, barely exceeding the number of places on offer.

It is also debatable whether the confidence desired of trainees could ever be attained by further supervised practice. The best place to learn about independent clinical practice is in independent clinical practice. If one is always having one’s hand held, it may be harder to finally let go.

However, all these are overshadowed by one fundamental truth: before we extend training to 5 years, we need to take a long hard look at what is happening in 3. GP training can be like a sausage factory, and merely slowing down the conveyor belt will not make for better bangers.