Whether driven by statute or by societal and scientific forces, the NHS is undergoing radical change. How, then, will training adapt so that future GPs have the skills and, importantly, the motivation to meet the challenges ahead? Here, drawing on our experience with the Royal College of General Practitioners’ curriculum and assessments, we comment on the why, the what, and the how.
Given the limited exposure that GP specialty trainees have to the community context, it is remarkable that GP training achieves the standards that it does. The recent acceptance by the Medical Programme Board (of Medical Education England) of the educational case for enhanced and extended training has reinforced the need for the changes we set out here. If enacted as we hope, these changes will equip future trainees to address the significant challenges, some of which are illustrated below, that they will face as independent GPs.
CHALLENGES AHEAD
GPs must be simultaneously proficient in using communication to develop trusting relationships, make decisions in situations of uncertainty, manage time and events, and grasp learning opportunities. They also need to show commitment to values and to people, including themselves. This remarkable conjunction is required for the majority of problems, however small. In the future, GPs will need to engage proactively with their communities and take greater responsibility for leading improvements in population health and reductions in health inequalities.1
On the demographic front, we are moving from an era of mortality from misadventure or ‘straightforward’ causes of death, into an era in which individuals survive to experience prolonged morbidity. Doctors will routinely face the complex clinical challenges of multiple pathology, comorbidity, and polytherapy as described by Tony Kendrick in his George Swift lecture2 along with the interpersonal challenges created by rising expectations and limited resources.
‘Separatism’, both between primary and secondary care and between hospital specialties themselves, can lead to compromises in efficiency, effectiveness, and safety.3 Because the needs of patients and the service do not respect the professional boundaries that are currently drawn, more doctors will need to develop as integrated care practitioners. To this end education, using opportunities such as integrated training posts working across primary and secondary care, should enable bridging of the gaps so that goals and incentives are better aligned and integration is planned into the service.
EDUCATIONAL PRIORITIES
We suggest there are three categories of educational priorities: improving GP clinical skills, generalist skills, and leadership abilities (Figure 1).4
Figure 1 Educational priorities for enhanced GP training (Reproduced with permission from the authors).4
On the broader clinical front, trainees will need to learn to locate and use information and decision-making support routinely5 to guide critical thinking and aid dialogue and shared management with patients. This requires the ability to question critically rather than merely adopt information and the ability to interpret it in the context of risk and probability seen in primary care.
Clinical skills, and therefore the knowledge base, will be enhanced to reflect the growing role as ‘general physician’ in the community, providing a more expert medical assessment and taking referrals from a broadening range of first-contact practitioners.
Arguably, the cardinal expertise of the generalist is to explore situations of uncertainty with patients and colleagues and thereby offer guidance that assists progress. The skills involved are generic and will increasingly be transferred from the consultation to matters concerning the health of the local community and will be used for both clinical and non-clinical problems.6
Leadership is another area of development that requires the breaking down of barriers, for example between doctors and managers. For doctors, leadership involves understanding how the quality of health care depends on the system, not just the individuals that work within it, and that it is a professional duty to contribute to the improvement of that system. This requires competencies ranging from the ability to reflect and gain insight (through effective multiprofessional team working both as leader and follower) to the ability to use information for identifying areas for change and then bring change to fruition.7 The choice is therefore not managerial skills or clinical leadership: each needs the other.
ADAPTING TRAINING
Trainees need more time in GP placements than currently provided, particularly early on in the programme when there is a critical opportunity to lay the foundations of the complex competences that GPs require. Hospital posts in general could be better aligned to the GP curriculum and more specifically, all trainees need specialty-led experience with paediatrics and mental health problems.8
The training workforce is not a monoculture and doctors learning the craft are coming from more diverse backgrounds, including other ethnic and professional cultures, where insight into the special context and requirements of generalism cannot be assumed. For example, communication skills, which include language, are both a diagnostic and therapeutic tool and in general practice need to be sophisticated rather than just competent. Thinking skills also need sophistication, adding intuitive forms of thought to explicit rule-based routines, in order to deal adequately with the ‘messy’ problems encountered in primary care.
Training needs to be prompt and accurate in identifying educational needs and flexible enough to address them through programmes tailored to individuals. Likewise, educators need to tailor their teaching to learning preferences; for example, by using both Socratic and didactic approaches, and by using alternative ways to teach the same learning objective.
Society is also diverse, and it is important that all trainees have equal access to a variety of training environments. A longer period of training will afford opportunities to ensure that they experience general practice in more varied demographic settings. The primary care workplace is the best place to foster generalist expertise and to prepare trainees for the world of work: two changes would accelerate the achievement of this potential.
First, the educational process in the workplace needs to bring meaning to the widespread assessment activity by routinely using judgements (whether based on formal assessment tools or not) to give feedback that promotes learning, rather than just ticks boxes.9
Second, trainees should be nurtured as team members and then trusted and supported to contribute to organisational changes from which they can learn. Without this, future GPs will be impotent observers of change, rather than influential participants in it. Changes to the assessments, which will include quality improvement projects as part of the portfolio of evidence, will catalyse this process.
Without the contribution of educators, these aspirations will remain just that. Building on the exceptional attributes of our GP trainers, we will need greater numbers and variety of educators, appropriately supported and resourced.
EXTENDING THE CURRICULUM
The arguments for extending GP training are strong, but the extension should not be confined to the specialty training period, where it is obviously needed, but should reach both before and after it. The clinical and non-clinical competencies need to be incorporated much more explicitly in the undergraduate curriculum and revisited through a spiral training curriculum that builds expertise both in particular contexts and increasingly across broader contexts. This enhanced undergraduate experience of generalism should encourage more trainees to consider a career in primary care, where more GPs are needed.10
The challenges outlined here are great, but so too are the opportunities. Learning is what makes us adaptable and keeps us valuable to those we serve: our patients. On this basis, GP training cannot be the job of the few — its future is in everyone's hands.
- © British Journal of General Practice 2012
