The discipline of general practice: recognition and teaching

UNEQUAL FUNDING AND RESPECT FOR GENERAL PRACTICE

When the NHS was established in 1948 many arrangements were made with the medical schools at a time when general practice was not a discipline and there was no professor of general practice in the world. The medical schools were initially entirely specialist led, linked to tertiary specialist hospitals with many special privileges.

Training specialists was the priority and leading specialists, like Lord Moran, a Dean of St Mary’s Medical School, saw GPs as: ‘… having fallen off the ladder’.⁶

Professors of general practice came late to the party, first in Scotland in 1963, and in England in 1972. They were vigorously resisted by the Bristol, Cambridge, and Oxford medical schools, which appointed late in the 1990s.

General practice/primary care struggled to gain entry to medical schools and even in 2017 has only a toehold, with just 6% of academic staff and 6% of medical school deans. The national medical education system systematically discriminates against general practice. The funding system is secretive, with about a billion pounds of public money not properly audited. Public money should be publicly reported. Millions of educational pounds go to hospital managements. Health Education England pays hospitals more than general practices to teach the same medical students (personal communication, SAPC, 2017).

Postgraduate medical training allows only 18 months in general practice itself when some hospital specialties have five times longer, a huge educational advantage.

Some of the largest UK medical schools now do not have even one professor of general practice and so have no professorial voice or senior GP academic role model. These medical schools do not respect general practice as a discipline. This visible priority feeds the hidden curriculum, and some of these institutions have under 10% of their medical students choosing GP postgraduate training.

I learned in the Academy of Medical Royal Colleges about a common, deep-seated misunderstanding among many leading specialists, including some deans of medical schools, who visualise general practice as: ‘hospital medicine outside hospital, practised at a more superficial level’(my conclusion in 2000 from numerous discussions with other presidents and medical school deans).

This ignores the fact that general practice has a unique, research-based body of knowledge, which forms a coherent discipline of its own, providing a distinct approach to medical care. General practice is not better or worse than hospital practice. The two are equally important and complementary.

GENERAL PRACTICE AS A DISCIPLINE

Medical schools still do not teach the theory and principles of general practice, and British medical students usually have no badged, research-based course on it, despite RCGP and parliamentary directions from 2016.⁷ Nor are research-based general practice principles examined in the MB final examinations. There are two continuing confusions: first, between general practice as a place where students can learn and general practice as a discipline all medical students need to learn. Second, confusion exists between the diseases seen in general practice, which are usually well taught, and the principles of general practice, which are often not taught at all. The non-verbal signal to medical students is that general practice principles are of little or perhaps no importance.⁸

CORE GP PRINCIPLES

What are the core principles and what research underpins them? First, general practice is essentially a personal, patient-centred medical service based on the longest and deepest patient–doctor relationships in British medicine. In my former practice, in 2016, the median duration of registration was 7.3 years and the upper quartile of patients have been registered for 20 years. Patient-centred medicine is effective.⁹

Of 20 core GP principles,¹⁰ continuity of care is a great efficiency factor. It is associated with better patient satisfaction, greater adherence to advice, significantly greater take-up of personal preventive care, significantly less use of hospital services, both accident and emergency and inpatient admissions, and even lower mortality rates.

‘Family physician’ is the commonest term for generalist doctors worldwide and the focus on the family/household is a longstanding feature. Research in genetics/genomics¹¹ and human behaviour¹² are now coming together to reinforce the logic of a family/household perspective in understanding the health of individual patients.

SOCIAL DETERMINANTS OF DISEASE

Social and health inequalities are among the biggest problems worldwide, so all medical students need to learn that general practice is the most effective branch of medicine in ameliorating these.⁵ Students need to learn how this can be done,¹³ usually by work outside hospitals.

GPs are the doctors who most often see first-hand many social determinants of disease and health inequalities,¹⁴ and can alter some. Similarly, the life-course theory¹⁵ shows that both GP consultation rates and hospital admissions in adult life are significantly related to life experiences earlier in life. These two theories alone make longitudinal care in general practice fascinating.

Current GP teaching is challenged by today’s medical students who are more highly selected on intellectual criteria than ever before. These students need to know the ‘hows and whys’ of medicine, which means learning the underlying GP-oriented research. Undergraduates reading English, for example, are shown and analyse the leading thinkers and writings in English literature. However, students studying general practice are often not introduced to the writings of leading GP researchers and writers. General practice research requires specific teaching. These able minds are not stretched enough, so 84% choose specialist practice, which usually demonstrates its underlying research well.

WHAT TO TEACH MEDICAL STUDENTS?

GP placements, especially longitudinal ones, should be encouraged, as there is a modest correlation with career choice.¹⁶ However, medical schools muddle what GPs should teach: clinical skills or demonstrating certain aspects of care? Teaching general practice research and principles gets lost.

Of the 20 core features of general practice, 25% are invisible to medical students in GP placements (Pereira Gray D. GP syllabus: 20 components of the theory and core principles of general practice. April 2017, Exeter). No GP can demonstrate a man who has not had a heart attack or a woman saved from cervical cancer. The invisibility of great GP clinical achievements, such as the 4.7 deaths prevented a year for each GP,¹⁷ needs to be better known and valued, especially by GPs themselves.

About 20 half-days, plus 20 half-days in the teaching practices digesting each principle in turn, is a good start — less than 1% of the 5-year medical undergraduate programme. The GP sessions on the principles should be badged in the medical course, taught enthusiastically within the medical school separate from disease-based teaching, and systematically assessed in the knowledge tests and MB finals.

Although pressures in service practices will inevitably influence students, the major reform needed is to stop 29% of new British doctors agreeing that medical schools had not put them in a position to ‘assess general practice as a career option’.³

Half of all medical students will choose general practice as a career only when they see it is intellectually respected, as a research-based discipline. Then they will understand its fascination and potential.