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At the heart of general practice since 1960

Three-year GP training is long enough already

Dr Sarah Merrifield

The RCGP Council once again discussed this week the prospect of extending GP training to at least four years. Reasons put forward included that a longer training programme could improve reputation and enhance the training received. I would, however, argue that this would not necessarily be the case.

Currently training to be a GP or indeed any specialty doctor is a bit like going on the seemingly never ending moving walkways at the airport. Young, naïve 18-year-old you decides they want to go on flight, pays their fees and boards the travelator complete with baggage. During this time you may glance wistfully at those shopping in duty free or chilling in the business lounge. However, once you’re on the travelator, unfortunately there’s no way of getting off. Children can distract you and the baggage may become harder to carry but still, on you go, moving forward no matter what.

What would this extension really add? 

There is, of course, the odd occasion between travelators where you can pop off (FY3 year anyone?), change destinations or even decide to take the emergency exit. For most, however, the next travelator is an inevitable step having already come so far.

There are several issues with this structure. Firstly, when passengers reach the end of the travelator they may struggle to find direction and walk independently, having been passively carried and protected for so long. Secondly, it does not allow lateral movement, keeping the passenger on a fixed path. I would hence argue the shorter the travelator the better; no one wants to spend longer on the travelators than they need to, they are just a means of getting to where you want to be.

The question is, what would this extension really add? The very nature, and indeed beauty of general practice is its unpredictability. Even GPs close to retirement will see new concepts and presentations. The rapidly evolving evidence base and technology means practice is changing all the time. So shouldn’t training have more focus on equipping trainees with the skills and ability to problem solve and continuously develop throughout their career? There obviously needs to be a basic safe level of clinical knowledge but I would argue that the three years already achieves this; unless of course there’s been a huge rise in First 5 lawsuits that I’m unaware of. GP is not the same as a specialty like surgery where the aim is to become competent in performing operations by practising hundreds of times. There is much more of an art to what we do, that to an extent, no amount of added years of training could prepare us for.

I would suggest that instead of extending training further it would be prudent to look at ways to improve what we already have. Some hospital posts use GP trainees for service provision which adds little value to their future work; from a personal perspective I had a cracking time in O&G doing C-sections, I’ll obviously be doing hundreds of these as a GP? Given the differing speciality posts undertaken by trainees there is also a lack of consistency so is this really what we should spend 50% of our training time doing?

A short training programme is a big attraction to the speciality with the scope to be free and finally be able to take control of one’s career after three years. Whilst I appreciate general practice is currently by no means the holiday sought at the airport (holiday to hell some might say?) it does allow movement, flexibility and a much welcome end to the travelator. Extending this process seems an unnecessary and in many cases, an unwanted change. In a recruitment crisis focus should be on quality and relevance of training, not quantity.

Dr Sarah Merrifield is a GP leadership fellow in Yorkshire

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Readers' comments (20)

  • There's nothing as dangerous as those who don't know what they don't know.

    the gulf in basic clinical knowledge with trainees and newly qualified is apparent in all specialties.
    I work closely with renal and rheum spr's and the gaps in clinical ability for these post MRCP trainees is quite scary. Much of the limitation is not raw book knowledge but issues around judgement and experience.

    I cannot believe this is not happening to GP trainees or the new qualified GPs.

    Its not actually even the trainees' fault but those who have designed the training systems - HEE.
    Surely trainees in all specialties need to signed of when they have gained adequate experience and with limited hours that should be longer for most of the specialties.

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  • Jmd

    This debate has been raging for years. Would the public accept a consultant with 3 year training, I don't think so.
    With primary care taking on more 2ndry care responsibilities it is time that the curriculum is revisited. Personally a registrar needs the following, paeds,AED,Ent,dermatology,mental health ,muskyloskeletal,general medicine as the minimum exposure.
    Yes, if GPS want equal status as specialist they will need to demonstrate the improved and wider Gp training.

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  • The MRCGP exam is a well planned exam that determines whether a trainee has the knowledge , attitudes and consultation skills to be able to practice safely as a newly appointed (salaried or locum) GP and I agree entirely with Dr Merrifield. What it does not do is prepare or inspire GPs for partnership- and perhaps that is one of the reasons why newly trained GPs are not considering this option, and it does not prepare GPs for the wide range of scenaria and portfolio career options which are available. The question is whether this is best done as part of basic training or as continuing medical education and it makes some sense -both practical and financial that it is the latter.Early appraisal therefore should have a strong focus on career development. Either way this variety of career pathways and skills requires a modular approach so that trainees/ junior GPs can access relevant training which they are interested in and will enhance their personal career choices.

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  • AlanAlmond

    You don't learn to be a GP in hospital - it happens when you work as one. If extending training means more hospital rotations I don't see the point. It was severals years after I qualified before I lost a generalized feeling of anxiety that I wouldn't know how to deal with the next punter through the door. General practice is basically the art of dealing with uncertainty often with limited information and no immediate back up. You don't lean these skills in a hospital stuffed with scanners, pathology departments and a crash team 60 seconds away. It happens when you spend hour on hour alone seeing folk one after the other who come in with anything and everything there is. Some pretends to be illness and is nothing of the sort, some is a sign of impending death...most is somewhere in between. Life and most illness doesn't happen in hospital..most of it actually happens out in the world, that's where you need to be to learn to be a GP.

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  • I think that there is little point in extending training from 3 years of poorly focussed learning to 4 years of the same. Nevertheless, it is clear to me that something does need to change and I am not qualified to propose the answer. I have grave reservations that MRCGP is sufficient, particularly as the trend seems to be towards more secondary care-type stuff landing in the lap of the GP, and I will cite a few examples of what I believe to be illustrative of this. Simple things like a patient on thyroxine who is seen for an acute and unrelated to the thyroid issue whose attending doctor fails to inspect the results which if he/she had done so would have noted that the last TSH was elevated and was from 2 years ago and the Hb back then was 80 and neither had been repeated.A hospital discharge asks for repeat renal function in a week; the GP arranges this but fails to discern that the patient is also diabetic whose last HbA1C was on a rising trajectory and was last checked some 9 months ago.A quick look at the notes/results would have allowed a GP with a proper approach to have opportunistically got the full diabetes bloods done with the renal profile. I won't bore the readers with more examples of sub-optimal practise (as I see it) and would suggest that the information which JimmyRiddle in the preceding post describes as limited is not being used to fully extract the cogent data.Speaking for myself I found MRCP(UK) and working for a good number of hawkish consultants makes me guilty of such acts of suboptimal practise relatively infrequently and has allowed me to adopt an approach which goes back to first principles- something we were all able to do at the point we got our medical degrees.

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  • I have to disagree.... the travelator if well designed will make sure we all cover the same ground to give a sound basis on which to practice...... medicine is an increasingly complex and bottomless pit, to be able to cope moving forward we need to up our game and skills base.... simple example- can you scan to exclude a DVT or are you still doing D-Dimers and referring? Which one is more cost effective? A GP with ultrasound skills or one without? Can you use a dermoscope? If not how can you safely assess a pigmented lesion or are you over referring? I have to agree with Jo Smit on this one....I am sure you would find it lovely to wander all over in your career, away from the travelator, but what about the risk of loosing focus? The risk of veering off into obscurity and perhaps avoiding the topics one doesn't like but one still needs knowledge and experience of? I know you want to take control of your career, perhaps you want to veer off and do Botox for a living but that is not what a GP is trained for in this country.....GPs are meant to be sound all rounders who can pick up the ball when consultants drop it.....for me this week it was re-referring a malignant skin lesion misdiagnosed by a consultant- referred elsewhere- pt now listed for full thickness skin graft, last week it was a consultant endocrinologist (Professor to be precise) prescribing an inappropriate and actually harmful dose of thyroxine.... as GPs we actually need to know more than our consultant colleagues because our remit is wider, we should take that responsibility seriously. And as for C-sections- have you looked at rural practice in Australia? Oh look, its the GPs doing them......the travelator is there for safety, its a minimum, you're supposed to make the journey to ensure that you've covered the minimum ground. I would redesign the travelator, but experience at the coal face is essential, seeing the patients as we learn, in clinics alongside the experts is how we truly learn, not from books and pictures. Yes we need experience in the community, but our random encounters there might not cover all the topics we need to know. Speak to the defence unions about missed diagnoses by GPs..... are they still paying out? Whats happening GP premiums? This tells us that we have an issue..... yes we have an issue with the legal profession, but if we do our jobs properly as expected, then litigation shouldn't be an issue. There remains a mismatch. The danger is assuming 'I know enough' but we don't know what we don't know..... a varied and extended training will help open our eyes to our blind spots.

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  • AlanAlmond

    I suspect at least some of the poor practice alluded to in comments above results from a lack of continuity of care coupled with excessive volumes of work, rather than poorly trained GPs. In my experience when abnormal results are over looked and/or one issue is focused on whilst other important issues are neglected, multiple clinicians have typically been involved, some possibly only on one occasion, all adding superficially to a trail of care but with little invested in the "bigger picture" - continuity of care isn't there and important issues are missed. When you come across such errors it's tempting to take the view in hind sight 'this should have been dealt with already'..'why didn't Dr X do what I am now forced to?' etc. etc. but for every issue caused by someone else's omission you find sufficient time to invest to fix, I suspect there may be others you yourself have failed to spot as you scan through the test results of 60 patients, read the hospital letters of 70 individuals and reflect on the fact that you have only met 10 of these individuals yourself. This is not the description of a well resourced and well run service but general practice is not well resourced and I suspect these kind of issues more are wide spread than they should be. I wouldn't be too quick to blame the bulk of the woes of general practice on poor training of GPs. We aren't being adequately funded, continuity increasingly isn't there and is being eroded by a fragmenting service. Increasing numbers of errors will be the unfortunate result. How can we improve training to ensure we can handle the transfer of more and more from secondary care? I don't know. Maybe we're going to need more GPwSIs?

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  • Dear Jimmy
    Two points.... if you felt a state of generalised anxiety when you started working, does that not imply that GP training left you in some way ill prepared for the job? Psychologically if nothing else? I agree with your observation about volume of work, and that this is an issue and that we are underfunded, but missed diagnosis for a patient standing in front of you? A couple of years ago I did a locum on the west coast of Scotland... in one of those practices struggling along on a series of locums... one lady, who worked in a pharmacy came in for er hypertension.... she had seen a whole series of fresh out of training, bright eyed, intelligent, stylish young locums from the circuit......the first question I asked this lady was 'how long have you seen on the steroids for?' she wasn't, and hadn't- her skin gave the clue, paper thin.... a steroid suppression test n the community and her diagnosis of Cushings was made.... this was NOT a rushed off your feet practice.... this was 15 minute consultation territory. There is an issue when we feel we are fantastic and don't need anymore training. This lady was undiagnosed for years and had seen countless young locums.
    My second point is I continue to do shifts in the emergency dept- I still see significant numbers of referrals from colleagues in General Practice where the patients have been referred in my estimation inappropriately - in that, as a GP Ive been able to send them away without any special hospital based tests...that IS a training issue.... the ?Cauda Equina syndrome being one of my favourites....
    I am not blaming the bulk of the woes in General Practice, we would all agree this is a tax issue.... mostly in our handling of the multinationals.... but that doesn't excuse us from not aiming to be the best trained GPs we can be, we do have control over our training, its about the only thing we have some say over. There is no substitute for experience, and I would tighten up the MRCGP, and have more assessment of our diagnostic and practical skills.
    I am concerned about complacency about 'knowing enough' - none of us ever can.... but spending more time in the clinics seeing and dealing with the common and weird and wonderful does increase the chances we will recognise the conditions in the future. I think the RCGP should offer an additional period of training in diagnostics and practical skills such as Ultrasound, dermoscopy, etcfor those who want it, and let them be distinguished with alternate lettering and let those who think they are better with shorter periods of training continue on their own path..... an analysis of complaints and litigation between the two groups would help put the argument to rest.....

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  • Quick question for anyone out there.... if experience on the job makes us better, then why does the rate of litigation increase the further away from our training we get? i.e. Middle aged GPs are more likely to get sued than Young doctors just out of training... how does this demonstrate that on the job training makes us better? Why do litigation rates not decrease as we get better?

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  • Doctor McDoctor Face

    I did my GP training in the late 1980s when you could mix and match jobs yourself. I purposely extended my own training to 4 years by doing extra SHO jobs(ENT, Dermatology & Rheumatology) to get more experience and I am glad I did.

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