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My big idea? Let's replace GP training with something more useful

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To be an excellent GP is challenging and a constant learning process. As a generalist we need to know a reasonable, but not excessive, amount of information about anything. Much of that knowledge comes with time and experience but need it be this way? Shouldn’t GP training be designed to offer experience that covers as many specialities as possible in an environment that is most relevant to the presentations GPs will see?

Most GP training jobs involve 18 months in GP and 18 months in hospital on six-month rotations. This means that the speciality spread in this time is limited to three jobs; there are a handful of schemes that do four-month rotations and so give five or six jobs but these are rare. So what does this mean? If you are lucky you will spend six months on a ward in a hospital doing paediatrics, gynaecology, psychiatry.

We need to scrap GP training in its current form

Are these rotations useful? In part. It is indeed easy to see the newly-qualified GP who hasn’t done paediatrics when bronchiolitis season arrives. So yes, teaching a trainee how to recognise the child that needs to go in is important and useful. And the same applies to all specialities: broad brushstrokes that allow one to differentiate serious from not serious. I loved my gruelling six months on gynaecology. Carrying the gynae on-call bleep and seeing A&E cases was really helpful. I spent much of it in theatre, am adept at subcuticular suturing and can do a caesarean from start to finish. Useful? Hopefully not. 

The most useful part of any one of my three hospital jobs was the clinics. I did general gynae, menopause, general paeds, paeds oncology and psychiatry outreach clinics. This is the GP’s bread and butter. This is where I saw patients at the interface between general practice and speciality. I learned to manage many things and so would not send them in in future, recognised the varying presentations I might see in the speciality concerned and came to understand appropriate and not-so-appropriate referrals. This was what is needed to become an excellent GP. But getting to clinics is hard, especially in paeds and gynae where staff shortages on the wards are high and where the speciality trainees yearn for clinic time too. It's competitive and sometimes soul destroying.

So what is the answer? I think its simple. We need to scrap GP training in its current form. We need to replace it with an absolutely tailored programme of on the job training which will turn out GPs ready to hit the ground running. The structure of this is clear to me.

The entirety of the GP training period, be that three or four years, should be based in a GP surgery. From there, the trainee should be attached to a speciality for six weeks at a time and during this attend only clinics of that speciality. This time should be interspersed with GP clinics, supervision and feedback/discussion and workplace based assessments. At the end of the six weeks in clinic the trainee will be assessed on knowledge critical to GP presentations and referrals. In this way, the GP gets to experience exactly what they need for the job that they are being trained for and have continuity in GP clinics too in order to practice their new skills. This will see the average three year GP training course offering 24 specialities, not three. The GP practice could rotate each year in order to offer a diverse range of patient demographic.

I am convinced that this would have given me the knowledge and skills that I have had to pick up ad hoc along the way as a trainee and now qualified GP. Surely it has to be better. I could have done with orthopaedics, urology, GUM, oncology, gastro, diabetes and so the list goes on.

There is only one thing stopping this scheme being implemented: GP trainees are service provision for hospital staffing, nothing else. 

This is part of our ‘Great GP Debate’ season. If you would like to write a blog on how you see the future of general practice, then please email the Editor at editor@pulsetoday.co.uk.

Dr Renee Hoenderkamp is a GP in north London. You can follow her on Twitter @DrHoenderkamp

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Readers' comments (9)

  • Yes excellent idea. When I was training certain specialties, namely O and G, treated the GP trainee as the poor relative. A cheap pair of hands to be pushed about to wherever there was a gap in service provision, with scant concern as to the skills we would need to acquire to be good GPs.

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  • Scrapping the deaneries and adopting a chambers model like solicitors. Deaneries must surely sock up mssive resources and GPs who perhaps would otherwise have retired but surely some could also do proper GP work?

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  • Nice idea for you maybe, wouldn't we all love to be supernumerary during training.

    But if the GP trainee provides absolutely no service value to the hospital or the consultants, how and indeed why should we bother to teach you?

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  • I agree! Vts is purely service provision, to cover gaps in the rota.. Should be tailor made for each individual. It would be so much better.. I never got to go to OPD clinics in my sho respiratory medicine job.. Could have learnt so much more there.. Rather than just clerking on Mau! Also, I think every GP should do ophthalmology opds, so impt & most of us have no clue about eyes TBH!

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  • Seriously,

    1. How will the training be funded if you don't do any work for the hospital trust. The money will have to come from somewhere as teaching is not free. Clinics need to be reduced, protected teaching time costs money

    2. Why will the consultants want to invest the time and effort in training an unknown succession of GP trainees who drift through their clinics, when they have no other investment in those individuals. Training is hard work

    The apprentice model of learning has lasted this long because it addresses these two issues.

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  • I think that the apprenticeship model whereby the hospital consultants can instill a diligent approach to clinical medicine is the best way to equip a doctor with the necessary pre-requisites for quality practise. In essence this means engendering the thought processes and general approach one needs to pass MRCP. I don't believe that the current duration of training is sufficient to achieve this. By the time a junior doctor leaves hospital medicine to take up a GP registrar position their clinical skills of history and examination are not going to be critically assessed again and without working on this essential foundation the standard of practise will almost always be superficial. From what I have seen repeatedly is the approach of many GPs would lead to ritual humiliation if they were to have a ward-round with a hawkish consultant who would pick them up on the finer details of a case and force them to consider each and every one of these in a fashion that would be required to pass ones finals again.

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  • Hospitals are paid to train doctors but don't. The money isn't ring fenced and instead they spend the money on the electricity bill, protected teaching for their staff to do drs roles etc. For sure a lot of time could be saved training doctors. The US does it. Protected teaching time, consultants trained to a higher standard in a shorter time. The NHS 'training' of doctors is a disgrace.

    This article provides what seems a better way to train GPs rather than the NHS system which lets be honest most of us are brain washed into because it is the only system we know. It sure as hell isnt the best.

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  • Medicine is year on year specialising, yet we still have a system that is woefully out of date where we pretend every student needs to learn a small amount about many different specialities, leading to many wasted years - paediatricians need very little understanding of care of the elderly, and psychiatry and ortho equally have little overlap.

    If specialities branched off earlier, this would in turn enable GP trainees to do more of the simpler activities in many of the specialities.

    But even this would only paper over the cracks of the lack of training GPs undergo in a field which is not only constantly changing, but are required to undertake increasingly complex decisions.

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  • There comes a point where the general experience of medicine helping you learn the scope of the career and importantly decide on a career path becomes less important than teaching you what you actually need to know for your career choice. Thus specialising in year 1 of medical school would be unhelpful, but spending most of you time assisting laparotomies in GPST2 is also less than useful. Throw the need for service provision as junior doctors in to the mix and you have complex decisions to be made about how trainees time should be spent up to CCT. My general thoughts are the quality and appropriateness of training do leave a lot to be desired but for me time spent on acute paeds, O and G clinics and A and E were useful parts of GPST training.

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