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GPs are already primary care consultants

Letter from Dr Cathy Welch, Isle of Arran, Scotland

With recent discussions about giving GPs recognition on the specialist register, in line with hospital consultants, there has been a lot of chatter about equivelency of consultant physicians vs GPs, MRCP vs MRCGP. I think all of this has missed the point. General practice has changed beyond recognition over the past 20 years, with more complexity, more diagnostic and treatment responsibility and tougher clinical governance than ever before. And, according to Professor Bruce Keogh, there is more to come over the next 20 years.

When you look at ‘time served’, like an apprenticeship, then yes, GP training of three years does not appear on a par with three years CMT plus three or more ST training. But MRCP and MRCGP cannot be compared fairly - they are testing different skills for different scenarios in different environments. They are equivalents, tested at much the same time.

Should we then consider ‘First 5’ as an equivalent to speciality training, the time to develop and hone the specialist diagnostic, patient management, professional behaviours and service management skills needed at consultant level?

The only difference I see between GP training and development compared with hospital physician training is the personalised, self-directed approach as a ‘First 5’ GP vs the proscriptive, directed, portfolio-flogged approach of hospital speciality training. Politicians, planners, lawyers and registration bodies are so reliant on reproducible, measurable data to prove competency that a free-flow, non-examined, experience-based form of training is hard to stomach. But is it any less valid for the function it performs?

And ultimately, the message we hear from Professor Keogh and others is that medical care is likely to move more into the community arena, the realm of primary care. The clinicians that will be taking more overall responsibility for that care need to be appropriately recognised and afforded equal parity to hospital clinicians in the eyes of the medical world, legal system, politicians and the public.

So I say that experienced GPs are consultants in all but name and formal recognition - primary care consultants.

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Readers' comments (14)

  • Training and achieving Consultant status and becoming a GP, they are just not equivalents and that's that. It's not even close!

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  • Please elaborate Dr Kumar. This is about the debate and we all need to see alternative view points, not just pat ourselves on the back for an opinion well expressed and then move on to the next rant.
    Have you done MRCP and specialist training?
    Personally I was just about to sit MRCPath Pt2 when left Pathology, 6months from CCT. I got much more resource and uncertainty management education, and clinical confidence as a 1st 5 GP than ever did as a senior trainee round the corner from consultancy. OK, maybe I would not have passed MRCPath Pt2, but I saw plenty others who did but felt completely unprepared for consultancy because everything was clinical clinical clinical, and that does not prepare for being a departmental or practice senior.
    An interesting experiment would be to put a group of successful MRCP candidates through the MRCGP CSA- some would certainly pass without additional training, but I would be surprised if it was a high percentage. On the flip side, proper discussion and evaluation may uncover some of the hidden holes in the MRCGP system. Amazing, though, how MRCGP is so easily accepted in other countries now looking to acknowledge GPs on their specialist registers including Australia and Canada.

    I look forward to reading alternative arguments- 2 sentences or more please, trolls are just boring

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  • Here are several sentences to keep the writer engaged and I earnestly wish, not bored.

    I believe I am not mistaken in having seen this 'article' before which originally came into existence as a reply in another thread.I find this kind of re-hashing tiresome.I did provide a reply to it in the original thread.

    The interesting experiment cited above is utterly meaningless because the MRCP candidate is trained to identify and interpret clinical signs, something which the actors in CSA typically do not have.

    The point remains that on achieving MRCGP which is now mandatory the holder is a fully-fledged GP even if their knowledge begins to erode from the day they pass;conversely MRCP is the pre-requisite which simply allows one to undertake specialist training for a medical discipline.

    I also reiterate that I hold MRCP(UK) and am grateful for the confidence, knowledge and appreciation for the art of medicine it has bestowed upon me.

    Lastly I am not surprised that seeing patients gave the writer more clinical confidence than dissecting bodies and viewing slides.

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  • the crisis in GP numbers has somewhat altered, hopefully temporarily, the balance, but having completed a MINIMUM of 3 years, but in most cases rather more, of a specialist SHO GP VTS training scheme, (to broaden my training, I did almost 3 years extra after MRCGP), and gained the exit exam, plus extras (many GPs do MRCP or others as well), a new GP, six years after finishing F2 jobs, can start as a Junior Partner in a Practice (or/and do 'First 5' training.
    The final outcome to Senior Partner can take longer than many specialty training membership programmes.
    And I have had several cases referred back to me as I 'have had more experience' of some presentations than the incumbent Specialty Team at our local hospitals.
    I certainly seem to be referred all the difficult prescribing interaction checks by our local hospital services, and that cannot be only because I have a computer with interaction warnings, as it is not foolproof.
    I am, incidentally, already on the GMC's specialist GP register, as most of my colleagues should be also.

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  • My apologies, IDGAF, you are indeed correct that this is word-for-word (other than a correction) my reply to Carolyn Wickware's article 'GPs will be 'consultant physicians' in 20 years, says NHS England medical lead' 16th Feb, and indeed I did reply to your reply (and round and round we go). However, after posting that (which cannot be deleted) I decided I would go for the wider audience to stimulate more discussion.
    The discussion is about professional respect and equivelency in the eyes of the public, judiciary and (unfortunately as it should not be needed) medical colleagues. The term 'Consultant' still seems to have a higher position in the societal mindset, yet is a term denied the largest section of the Medical Profession through a variety of reasons, mostly historical. The example of my own history just illustrates the comparison of GP training and ultimately Seniority/partnership (often 8years post FY) with that of a Pathology Consultant, (4.5 years post FY). Bias, ignorance of other specialities' needs and priorities still rears its ugly head as descrimination, derogation and institutional bullying of General Practice (and other specialities) in medical school and the wards. This may be news to you, IDGAF, but you have provided perfect examples of the reason why these underlying erosive beliefs persist, not just in this thread, but in others. You are your own worst enemy if you think your attitudes and outright abusiveness towards your medical colleagues, be it GP or Pathology, will in any way help you get your patients appropriately assessed and treated by hospital colleagues.
    Also, as you see, IDGAF, I am using my own name here- I will only say here what I would say to your face, I will not hide behind a pseudonym. Agree with me or not, that's what debate is all about, but there is no place for overt abusiveness or trolling

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  • In reply to anonymouse3, absolutely it is the reality that many GPs have done far more than today's 'minimum' of 3years post FY. The 3 year 'run-through' training schemes were a product of the MMC revolution of 2005, and we have seen how successful that has been with other specialities and training applications over the years! Prior to that there was a minimum 24 months training SHO posts in various specialties before qualifying for the final year as a GP Registrar in a practice. As you say most did more than that, and many migrated (and still do) into General Practice from other specialities.
    I can't find when the GMC's GP Register began and became compulsory to practice as a GP in the U.K., but not all that long ago. However , unfortunate, the GP register is still not afforded the accolade of 'Specialist' and remains a separate register from the GMC 'Specialist Register'. It may seem a small technicality, but just see the difference in people's reactions when you introduce yourself as a GP or as a Primary Care Physician at a dinner party!

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  • I have to take a different view from Dr Kumar, I have spent more years in training posts than most consultants, including ITU, ENT, Orthopaedics, Paediatrics, General surgery, Accident and emergency and done diplomas in Dermatology, Obs and Gynae,I have MRCS as well as MRCGP, and can do minor ops dermoscopy, joint injections, implanon etc It takes a long time to build up a broad skills base. Our breadth is comparable to depth in one speciality. Our 'area' of knowledge if one was to measure it in terms of depth x width to give a total 'area' of knowledge is comparable to most specialities, and indeed for many GPs would exceed it. Dermatology is a four year training programme. Most of us have done more than that whilst working out what do do with our lives. Dr Kumar are you saying you feel inferior to a consultant psychiatrist? Perhaps you are comparing yourself by pay esp if factoring the private practice of a consultants income, but price is simply what you pay, value is what you get. It doesn't mean an orthopaedic surgeon knows more than GP they just happen to have been trained in using mechano sets. Just because we are underpaid, doesn't mean we are any less skillful. We have a different skills set. I continue to work in our local emergency dept, am up to date with ATLS, APLS and ALS and there is very little a consultant can do that I cannot, esp given I had a year of intensive care training. I do think however that General practice training needs to up its game to reflect our skills, and incorporate more practical skills into our training such as dermoscopy given 10% of ur patients have skin presentations. I don't see why doppler exclusion of DVT, micro suctioning of ears, assessment of endometrial thickness, endoscopy etc cannot all be done by general practice, after all these skills are already done by nurse practitioners. GPs can be dual skilled as in the Australian system to perform Obs, Anaesthetics, etc and a GPwSI is much more a flexible and utilisable resource than a narrowist, oops I meant a specialist. In rural and remote areas there is no-one to touch us. I spent many years at sea and would do everything from family planning, X-ray my patients, intubate and ventilate patients we had resuscitated from cardia arrest, treat inpatients with cellulitits and chest infection, public health, suture minor wounds, infectious diseases, etc. You find me a specialist who can do that and I'll..... well I'll just wait to see who you can find. We are undervalued, and underpaid compared to our status colleagues. That does not mean we are inferior in any way. I guess its your attitude towards your own career. Have you invested in your own skills? I choose a different pathway from other specialities but ours is a speciality of its own and deserves to be recognised as one and equal. I sat down with a pen and paper and reckon it would take 6-7 years to train a GP to maximise their potential with time in most specialities served with practical teaching in skills all GPs should have, including time in radiology. General practice is the future of medicine, specialists just drive up the cost and the complication rate for many issues, but we are on the defensive when we should be on the offensive showing what we can really do and how we could do half of what consultants do, but at a fraction of the cost.

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  • PS - Dr Kumar, if you feel we are so.. 'inferior'...... why are you a GP and not retraining to become a 'proper' doctor? Many GPs go on to retrain in hospital specialities showing yet again that we can do anything we choose to do, and we have the potential (Though thanks to the current system it remains largely untapped due to lack of innovation and investment from those at the top, and those wanting to keep us dumbed down to protect their private who seriously thinks a knee injection from an ortho consultant at a private clinic is better than one we can give??????) and the consultants i've met who were once GPs are the better for it, they do take a more holistic approach, know when to ease off and have better interpersonal skills..... Im off to Australia next to do a Masters in skin cancer...because... I can.... not because I can't......

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  • Last PS - quick one for Dr IDGAF- true story - true patient - Dr ( myself - not a consultant) - called at 02:00am in the early hours of the morning - called to medical bay on a ship (Somewhere north of Libya) to see a patient, 25yrs of age, nepalese female, foaming at the mouth (literally) fixed dilated pupils, GCS 3, pulse 42 BP 60 systolic, possibly, difficult to record, PMHx - nil of note - found by colleagues on floor of cabin...... you have 2 nurses..... no other medical support, too far out for helicopter recovery...... whats the diagnosis? What do you do? You can't call an ambulance - you are more than 12 hrs away from the nearest evacuation point. This is a case handled by 'just a GP' - PS- the patient made a full recovery. I highlight this case to show what 'just a GP' (with a small amount of the right training )can do solo without a full resuscitation team. Rural and remote doctors are often GPs and save critically ill patients in the most difficult of circumstances with limited equipment with often unbelievable results.... I only say unbelievable because often consultants often don't believe it...... but I believe, and I know what great GPs can do..... and its usually unrecognised..... theres no private practice sticking in west drains on the roadside, or treating status in a 2 yr old on a snowbound island...... thats because private practice consultants find reward in the money..... there are many great GPs who do wonderful things for nothing and indeed it costs them their time because they are not remunerated for it... like a lot of great Prehospital doctors. And I do attend prehospital cases for the ambulance service if needed and I am available.
    These are the broad 'specialist' skills that save lives and should be acknowledge with the title consultant..... perhaps am I a consultant in pre-hospital care?

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  • Sorry can't resist, perhaps the RCGP should just disengage from the GMC and regulatory bodies - stating loss of confidence and that the fees are too high, tell all the GPs to stop paying their subscription and pay for a new one instead with regulation by ourselves, not the GMC, and start up our own register of Primary Care Physicians, and award them consultant status, with recognition of sub specialist skills. e.g. Consultant in Primary Care and Family Planning, Consultant in Primary Care and Dermatology. We could have our own training courses, and I would largely ignore other specialities that say we can't and just do it. The training is available internationally. I can't practice radiology in this country but yet my ability to do so is recognised elsewhere. The RCGP could choose to recognise its own training. And if we stand firm how can they stop us? Insurance? Stuff it ,we should start out own, after all, look how much the chiefs of our indemnity firms get paid.... 7 figures for what? Not seeing patients? We could train our own team up in medico-legals and use the savings to lower our premiums in a co-operative rather than giving away our hard earned cash to a for-profit insurance firm. Its time to stop being dictated to by other colleges and other bodies with their own agenda as to what we can and cannot do.... I believe "Yes we can". We can tell the government that we are going private as an alternative to their crumbly old system and if they want to purchase GP services from us in the future, they can, but as we'll also be billing patients directly, their offers better be reasonable, we aren't going to do it for their peanuts and put up with their b******t. What can they do if we en-masse hand in our resignations and just do it????

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