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Is GP training still fit for purpose?

Two leading GPs debate

Prof Kamila Hawthorne

YES The system creates safe and competent doctors

GP trainees currently have the shortest specialty training but the broadest curriculum of all the medical specialties.

The RCGP has long campaigned for enhanced GP specialty training, to extend the programme for an extra year with more time in a general practice setting.

Our calls to enhance training have not been made because current GPs, and GP trainees, are falling short in any way, but because the amount of work expected of GPs has risen exponentially in quality and depth over recent decades. We feel we can just about fit everything in, but it is becoming increasingly difficult to do so and this can put a strain on GP trainees.

Nevertheless, as it stands, the training programme creates safe doctors who are fit to practise independently. It is approved by a panel of medical educators and educational specialists at the GMC, which evaluates it regularly. We also recently asked the Health Professional Assessment Consultancy to review the MRCGP assessment independently to ensure it is up to date.

The curriculum is regularly updated to reflect changes in general practice

The three-part MRCGP process that determines a GP’s fitness to practise independently, safely and competently in the UK is world renowned as a robust, comprehensive exam, and those who pass it have clearly demonstrated they meet the highest standards to deliver patient care. The training curriculum is regularly updated to reflect the changing environment of modern general practice.

GP trainees’ performance is consistently evaluated by experienced GP trainers throughout their three years of training – at least 18 months of which must be undertaken in general practice.

Through the applied knowledge test (AKT), trainees demonstrate their competence to guarantee safe standards of patient care. The clinical skills assessment (CSA), which evaluates how trainees deal with a range of scenarios within general practice, is rigorously quality assured to ensure it is as typical of an NHS GP clinic as it can be.

GP specialty training needs to be longer, as the workload is becoming increasingly complex; in the meantime our priority is to ensure trainees are adequately supported. More investment is necessary but more also needs to be done to provide pastoral support and encourage peer support to help trainees develop resilience early in their career.

Professor Kamila Hawthorne is vice-chair for professional development at the RCGP

 

Dr Kamal Sidhu

NO Training has failed to keep up with changes

Last year, a House of Lords report declared the GP model was no longer fit for purpose.1 NHS England’s Five Year Forward View advocates alternative models of primary care.2 Indeed, the GP’s working day has undergone a sea change in the recent past. The nature and complexity of our consultations have changed greatly and our gatekeeping role has become much more focused on reducing prescribing costs, referrals and admissions.

Training is now all about maintaining an e-portfolio, and an unhealthy obsession with passing exit exams. Much time is spent on assessment box-ticking. Yet most of us can find DVLA regulations or minute details of guidelines when needed. There really is little value in trainees memorising such things.

The RCGP has declared that 10-minute consultations are unfit for purpose.3 Yet it persists with an artificial assessment based on 10-minute ‘ideal’ consultations, which focus disproportionately on certain competencies, and fails to factor in realities of the job, such as working in challenging and deprived areas.

Many newly qualified GPs are opting for locum and out-of-hours sessions, yet the 2004 contract and resulting changes to training perversely resulted in reduced exposure to out-of-hours work.

There is an unhealthy obsession with passing exit exams

Meanwhile, all the hoops trainees have to jump through, combined with the restrictive nature of the new 2017 contract, leave little time for exposure to practice business and management.

There is immense pressure to pass AKT and CSA tests, which take over trainees’ lives. The prohibitive cost of these examinations only adds to the strain, and hampers efforts to attract doctors to the workforce.

Our relationships with patients are changing. Continuity of care and the ability to absorb uncertainty and risk are being diluted. We are increasingly risk averse and dictated to by guidelines, less reliant on our clinical judgement and ability to make exceptions – qualities and competences we are consequently failing to pass on to our future workforce.

Last year, the RCGP itself decided to review the MRCGP’s fitness for purpose but we have yet to see its conclusions.4

Whatever the outcome, I believe it is high time we took stock and reviewed the needs, demands and wants to ensure that GP training stands the test of time.

Dr Kamal Sidhu is a GP trainer in Blackhall, County Durham

References

1 House of Lords. Select Committee on the long-term sustainability of the NHS. Report of session 2016-17

2 NHS England. Five Year Forward View (2014)

3 RCGP. Press statement November 2017

4 Nash, S. RCGP reviewing whether MRCGP exam is ‘fit for purpose’. Pulse July 2017

 

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Readers' comments (7)

  • GP training is a disgrace. It fails to event mention what the real world is like. It pumps young minds with idealistic cardigan bullshit and sets them up for a massive fall. Shame on you RCGP.

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  • If the purpose is to produce GPs whose depth of knowledge is lacking and who have little concept of a thorough-going diligence then it is fit for purpose.

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  • Another smiley faced Professor from Narnia???

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  • Thanks IDGAF for that charming comment. Hopefully there are some trainees in your practice who you can offer that pep talk to face to face.

    -Salaried GP (qualified last August)

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  • Moniker @8.28pm.

    Its my pleasure; don't mention it.

    As it happens, I do work in a training practise and let me cite to your delicate ear 2 examples from this week and bear in mind today is Wednesday at 5am so today has not started.One relates to a post-MRCGP trainee and the other a relatively newer GP reg.

    1.Patient on the COCP whose BP check was overdue; this was clearly written in the notes. Said patient attends for another issue, seen but no BP was checked. Bear in mind the requirement to check the BP was the last entry in the notes.

    2.Patient who is short of breath and also on lithium; the last serum Li+ level had been done 7 months ago. Blood tests to investigate the dyspnoea were arranged but ,due to no scrutiny of the notes/results/medications, no repeat serum Li+ level was requested.


    The problem as I see it is that the GP trainers do not scrutinise the work (or should we say "service provision") of the trainees to anywhere close to the level it needs to be scrutinised in order to instill these basic but fundamental aspects of approaching a set of case-notes, or a clinical encounter. I have worked in a training practise for over 15 years and these issues are sadly evident year upon year.

    I leave the pep-talks to the trainers but do point these procedural failings out to the trainees, and believe it or not, they are grateful for the pointers I offer.

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  • What training? You spend 80% of your time in garbage hospital posts doing menial donkey work. Consultants can’t be bothered to teach anything. There’s hardly any educational structure to be seen. GP posts are no better. Trainers themselves wouldn’t be able to pass the haphazard and random AKT exam, let alone the CSA. You’ll be lucky to get a trainer who isn’t racist and hellbent on ruining your entire medical career. The ability to pass the CSA seems to be correlated with the colour of your skin and Englishness of your surname. Too much emphasis placed on being a tick-box drone and yes-man to patients. Garbage all around. Get out while you can.

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  • Dr.Sidhu you say as it is

    harry well said - under table politics& statistics of how many should get thro'exams, how many to retain for service provision.'
    pointless..

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