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TRAINING FOR GENERAL PRACTICE
1008 to strains which he is able to assess. He gives the first-aid treatment in all emergencies, and sends full information with any patient when he refers to a conTRAINING FOR GENERAL PRACTICE sultant. He has many legal and administrative duties to do with the National Health Service, death certificates, REPORT BY A B.M.A. COMMITTEE dangerous drugs, and the giving of medical evidence; IN The Training of a Doctora committee of the a and these demand from him much clerical work. In British Medical Association gave their views on the a addition he may hold one or more part-time appointments medical curriculum. Now another B.M.A. committee, -in public health, industrial work, maternity and childsitting under the same chairman, Sir HENRY COHEN, welfare work, or school inspection. And finally he is F.R.C.P., have considered the postgraduate training of the always being asked for advice on subjects which are often general practitioner, and have reported.2 The members are: aa far cry from straight medicine. Sir LIONEL WHITBY, F.R.C.P., Dr. C. W. C. BAIN, F.R.C.P., Since, to meet these many calls, the general practitioner Dr. E. A. GREGG, Dr. J. A. BROWN, Mr. A. M. A. MooRE,must ] have a wide range of knowledge based on the F.R.C.S., Mr. A. LAWRENCE ABEL, F.R.C.S., Dr. JANET K.jfundamental principles of medicine, and a synoptic AITKEN, F.R.C.P., Dr. J. T. BALDWIN, Dr. G. W. BAMBER, of of the the grasp scope specialties, the committee F.R.C.P., Dr. G. 0. BARBER, Sir ALEXANDER BIGGAM, F.R.C.P., deprecate the traditional distinction in status between Mr. NORMAN CAPENER, F.R.C.S., Mr. V. ZACHARY COPE, general practice and the specialties. Every doctor should F.R.C.S., Dr. H. GUY DAIN, F.R.C.S., Dr. HUGH DAVIES, be free to follow the branch of medicine which appeals D.M.R.E., Dr. R. G. GORDON, F.R.C.P., Dr. K. H. C. HESTER, to him, and should be properly trained after registration F.R.C.S., Dr. R. P. St. L. LISTON, Prof. HILDA N. LLOYD, P.R.C.O.G., Mr. J. D. McLAGGAN, F.R.C.S., Miss IDA MANN, for his chosen branch ; and all branches should offer F.R.C.S. (resigned, July, 1949), Dr. J. I. MILNE, Dr. CHARLES reasonable prospects of material reward. Opportunities NEWMAN, F.R.C.P., Sir PHILIP PANTON, Sir LEONARD PARSONS, should be made for general practitioner and specialist F.R.C.P., F.R.S., Dr. I. C. B. PEARCE, Dr. C. M. SEWARD, to cooperate fully. Doctors in a group practice should W. TUDOR F.R.C.P., Dr. DONALD STEWART, F.R.C.P., Mr. J. each be encouraged to develop some special interest ; THOMAS, F.R.C.S., Dr. C. W. WALKER, Prof. B. W. WINDEYER, but this should be within the scope of general practice, and Prof. G. M. F.R.F.P.S. F.R.C.S., WISHART, and should not include services ordinarily given by a The committee regard general practice as a special fully trained specialist. branch of medical practice requiring an adequate period The committee see the general practitioner as humane, of training under supervision, and continuous ’education with all company, ready for work which demands throughout the doctor’s life ; and they believe that the easy the sacrifice of much of his home life, healthy and robust, conditions of his life should be adjusted to give him cultural with interests that develop the whole man in him. leisure enough to interest himself in such education.
exposed
Special Articles
g
_
-
-
.
THE WELL-RUN PRACTICE
General Practice
In order to do his work and still have time to keep The change chiefly affecting general practitioners in abreast of medical advances, the doctor needs to organise the past century has been the growing bulk of medical his work well, acquiring some understanding of business knowledge. In the early 19th century doctors could be method, and the ability to delegate non-medical duties conversant with almost the whole range of medical to competent ancillary staft. An account is given of a knowledge ; but in our own century it has become well-organised firm in a small country town : a full-time impossible for one man to practise or comprehend in secretary and qualified dispenser are employed who " do detail the whole field of medicine, or to possess or use all all possible work that can be done by an unqualified the necessary equipment. A review of a typical day’s i.e., telephones, correspondence, appointments, person, work in different types of practice confirms the usual admission to hospital, all forms, visiting lists, all disbelief that minor ailments, and acute and chronic illness, urine testing, &c." The surgery is well designed, provide most of the general practitioner’s work-the pensing, with dispensary, large waiting-room, and two consultingconditions most often seen being respiratory, digestive, rooms, all communicating by means of small talkingand circulatory disorders, rheumatic and skin diseases, hatches as well as doors. children’s diseases, and minor psychological disturbances. Yet even a well-organised practice cannot run itself Doctors who attend current postgraduate courses comwhile the doctor is attending a refresher course. The plain that their lecturers do not give sufficient attention suggestion that a central pool of permanent locums should to these types of illness. be provided did not commend itself to the committee, DUTIES OF THE FAMILY DOCTOR since doctors who are willing to spend their lives in this The degree of responsibility taken by doctors for pursuit are not usually of the highest quality. Locums various types of case differs ; thus one reported that he can best be found, the committee believe, among young treated most ear, nose, throat, eye, and skin cases, doctors returning from abroad or waiting for appointwhile referring only the most difficult to a ments, or newly discharged from their term of National another wrote that he referred nearly all eye cases and Service with the Forces. Young doctors training f9r skin cases to the clinics. In the estimation of the comgeneral practice should be allowed, they consider, to take mittee the responsibilities undertaken by the general short locums in their third postgraduate year. practitioner include continuous care of patients, health General practice today gives greater opportunities education and preventive medicine, treatment of the than it did for health education of the family, and patient as an individual, diagnosis, treatment (including carries a greater responsibility for prompt and accurate emergency treatment, aftercare, and reablement), infordiagnosis. The doctor must have time to do his work mation to specialists, administrative and legal responsimake thorough examinations, to see his properly—to bilities, and other miscellaneous duties. As family doctor patients, and to consult specialists as often as he deems he sees the. beginnings of disease and the interrelation necessary-as well as time for postgraduate study. He of illness, environment, and occupation. He is able to must not be isolated from other medical services, or give continuous advice on the maintenance of health, from his colleagues. and undertakes such active ’preventive measures as The First Three Years vaccination and diphtheria immunisation. He sees the The committee recommend that before the newly
specialist,
.
1. The Training of a Doctor. London, 1948. See Lancet, 1948, i, 839. London : British 2. The Training of the General Practitioner. Medical Association, 1950. Pp. 88. 7s. 6d.
registered
doctor begins independent general practice he should spend three years in specially designed training. For the first’of these,years he should act ag trainee and
1009
assistant to an established general practitioner. The second year is to be spent in specially designed and preferably residential hospital appointments, and the third should provide supplementary training at the choice
The whole course would be organised by postgraduate committee and dean appointed by a university or medical school. During his three-year period the doctor would receive an adequate salary, and take an amount of responsibility appropriate to his experience. After .consulting with the heads of the l’orces’ medical
of the trainee. a
services, the committee decided to recommend that the
spent in National Service should count as 12 months of the three years’ training for general practice. 18 months
The general practitioner to whom the assistant trainee is to be attached in his first year must be experienced ; but the committee is not in favour of compiling an approved list " of principals. Every practitioner who has been in independent practice for not less than five years should be allowed, if he can provide the right opportunities, to train entrants for general practice. The committee believe that a few years’ experience would show which principals were the best teachers, and trainees would gravitate to them. The teacher’s aim would be to show the trainee how the general practitioner lives and works, how he and handles patients and relatives, and how he runs his practice. Information administrative side of general practice might, it on. be given in a series of lectures during the is. intern year, and a syllabus is outlined, covering setting up in practice, common ailments, equipment, recordkeeping and paper-work, preventive medicine in general practice, and medical ethics. The hospital appointments during the second year of training should be resident posts in the larger nonteaching hospitals under the regional hospital boards, and should give the trainee experience of the kind of case met in general practice and enable him to recognise when to seek specialist help. Though arrangements should be flexible, to cater for varying tastes, each trainee should be encouraged to get experience of infectious diseases, obstetrics, paediatrics, ear, nose, and throat conditions, eye and skin diseases, psychological medicine, and casualties. He should also acquire those techniques in treatment and pathological investigations which he will need in practice. In the third year the trainee could either take further hospital appointments, or simultaneous clinical assistantships in different subjects, and should do a short period of whole-time work in a laboratory. He should also have some further instruction in "
approaches
the suggested,
psychiatry.
should be made of cases in the chronic and casualty departments of nonteaching hospitals. The course should refresh the doctor’s basic knowledge of procedures, including clinical methods; inform him on new methods of diagnosis and treatment ; relate new knowledge to his own approach to medicine and to his patients ; and restate the contribution of other sciences to medicine. Methods of teaching should include tutorial classes, conferences, demonstrations, and discussions. use
outpatients,
’.
ALL THE
YEAR ROUND
Local
arrangements should also be made, for continuous postgraduate training. The local medical society, which can
do
much, should become
a
medical club, the
centre of all professional life. The committee recommend that in each area the profession should develop an active
medical society, in the conduct of which general practitioners and specialists should participate. Programmes should include lectures and demonstrations, courses at local hospitals, discussion groups and conferences, and clinicopathological and clinicotherapeutic conferences, medical films, brains trusts, and meetings with members of other professions. It is suggested that edited reports of clinical conferences of interest to general practitioners should often be published in a general medical journal. The committee believe that the divorce of the general practitioner from the hospital i8 bad for the efficiency’ of the whole medical service. Arrangements should be made for doctors to attend outpatient sessions and ward rounds, and to hold clinical assistantships which would enable them to develop their knowledge of a particular ’aspect of general practice, and to move more easily from general practice to specialties if they wished. Some doctors, it is thought, would prefer a fortnight’s resident hospital appointment as an alternative to a refresher course ; and this might be arranged. The committee also’strongly support, from an educational standpoint, the growing demand among family doctors for hospitals or wards where they can treat those of their own patients who cannot conveniently be nursed at home. Self-education during practice must depend on contact between the doctor and the hospital medical staff. -The doctor should accompany his patient to hospital. for consultation, when possible, and should be free to visit him in the wards at any time. The hospital medical staff should keep the family doctor informed of the patient’s progress while he is in hospital. Doctors in general practice should have opportunities to contribute to field researches in medicine and social science planned by university departments. They should also have leisure for " systematic, unhurried and uninterrupted professional reading;" and should. make full use of medical libraries, including the facilities now offered for purchasing ’Photostat’ copies of any given article at a small price. The committee conclude that the better the -general practitioner the more insistent will be his demand for adequate and appropriate postgraduate medical education. He must be given time for it, however, and on a long-term view this should be possible if general practice gains in interest and status, so that more newly qualified men are willing to enter it. The committee believe that. if their recommendations are fulfilled, a larger supply. of such doctors will be forthcoming. ,
Continuous Education education for those in general
practice is process continuing throughout active life, intended to preserve and increase technical competence and keep the -doctor in touch with hospital practice and medical advances. The need for postgraduate education of general practitioners was agreed to be great, both by consultants and the general practitioners themselves. insufficient in extent Current courses are said to be and inadequate in content." The postgraduate committee and dean appointed by the university should be responsible, it is suggested, for coordinating arrangements for postgraduate education of general practitioners in the area, and should collaborate with hospitals, specialists, and medical committees and societies for the purpose. Courses of varying lengths should be available, but educational work in the hospitals -clinical and clinicopathological discussions and conferences, and ward rounds-should be just as important as set courses, and should supplement the activities of local medical societies. as
tioners. Full
wards,
’
Postgraduate
seen
night ; and the committee consider the last, held in an appropriate teaching or regional hospital, to be- the most useful. They oppose the idea of compulsory attendance, or the offer of special inducements, believing that a well-run course with good and useful teaching and social amenities-including entertainment for the doctors’ wives while their husbands are attending lecturesshould be its own attraction. Teachers of high standing should be selected for their interest and competence in teaching, and should include suitable general practi-
a
"
THE WELL-PLANNED COURSE
Postgraduate
courses
to -leave his practice for
will a
usually require the doctor a week, or a fort-
weekend,
exposed
Special Articles
g
_
-
-
.
THE WELL-RUN PRACTICE
General Practice
In order to do his work and still have time to keep The change chiefly affecting general practitioners in abreast of medical advances, the doctor needs to organise the past century has been the growing bulk of medical his work well, acquiring some understanding of business knowledge. In the early 19th century doctors could be method, and the ability to delegate non-medical duties conversant with almost the whole range of medical to competent ancillary staft. An account is given of a knowledge ; but in our own century it has become well-organised firm in a small country town : a full-time impossible for one man to practise or comprehend in secretary and qualified dispenser are employed who " do detail the whole field of medicine, or to possess or use all all possible work that can be done by an unqualified the necessary equipment. A review of a typical day’s i.e., telephones, correspondence, appointments, person, work in different types of practice confirms the usual admission to hospital, all forms, visiting lists, all disbelief that minor ailments, and acute and chronic illness, urine testing, &c." The surgery is well designed, provide most of the general practitioner’s work-the pensing, with dispensary, large waiting-room, and two consultingconditions most often seen being respiratory, digestive, rooms, all communicating by means of small talkingand circulatory disorders, rheumatic and skin diseases, hatches as well as doors. children’s diseases, and minor psychological disturbances. Yet even a well-organised practice cannot run itself Doctors who attend current postgraduate courses comwhile the doctor is attending a refresher course. The plain that their lecturers do not give sufficient attention suggestion that a central pool of permanent locums should to these types of illness. be provided did not commend itself to the committee, DUTIES OF THE FAMILY DOCTOR since doctors who are willing to spend their lives in this The degree of responsibility taken by doctors for pursuit are not usually of the highest quality. Locums various types of case differs ; thus one reported that he can best be found, the committee believe, among young treated most ear, nose, throat, eye, and skin cases, doctors returning from abroad or waiting for appointwhile referring only the most difficult to a ments, or newly discharged from their term of National another wrote that he referred nearly all eye cases and Service with the Forces. Young doctors training f9r skin cases to the clinics. In the estimation of the comgeneral practice should be allowed, they consider, to take mittee the responsibilities undertaken by the general short locums in their third postgraduate year. practitioner include continuous care of patients, health General practice today gives greater opportunities education and preventive medicine, treatment of the than it did for health education of the family, and patient as an individual, diagnosis, treatment (including carries a greater responsibility for prompt and accurate emergency treatment, aftercare, and reablement), infordiagnosis. The doctor must have time to do his work mation to specialists, administrative and legal responsimake thorough examinations, to see his properly—to bilities, and other miscellaneous duties. As family doctor patients, and to consult specialists as often as he deems he sees the. beginnings of disease and the interrelation necessary-as well as time for postgraduate study. He of illness, environment, and occupation. He is able to must not be isolated from other medical services, or give continuous advice on the maintenance of health, from his colleagues. and undertakes such active ’preventive measures as The First Three Years vaccination and diphtheria immunisation. He sees the The committee recommend that before the newly
specialist,
.
1. The Training of a Doctor. London, 1948. See Lancet, 1948, i, 839. London : British 2. The Training of the General Practitioner. Medical Association, 1950. Pp. 88. 7s. 6d.
registered
doctor begins independent general practice he should spend three years in specially designed training. For the first’of these,years he should act ag trainee and
1009
assistant to an established general practitioner. The second year is to be spent in specially designed and preferably residential hospital appointments, and the third should provide supplementary training at the choice
The whole course would be organised by postgraduate committee and dean appointed by a university or medical school. During his three-year period the doctor would receive an adequate salary, and take an amount of responsibility appropriate to his experience. After .consulting with the heads of the l’orces’ medical
of the trainee. a
services, the committee decided to recommend that the
spent in National Service should count as 12 months of the three years’ training for general practice. 18 months
The general practitioner to whom the assistant trainee is to be attached in his first year must be experienced ; but the committee is not in favour of compiling an approved list " of principals. Every practitioner who has been in independent practice for not less than five years should be allowed, if he can provide the right opportunities, to train entrants for general practice. The committee believe that a few years’ experience would show which principals were the best teachers, and trainees would gravitate to them. The teacher’s aim would be to show the trainee how the general practitioner lives and works, how he and handles patients and relatives, and how he runs his practice. Information administrative side of general practice might, it on. be given in a series of lectures during the is. intern year, and a syllabus is outlined, covering setting up in practice, common ailments, equipment, recordkeeping and paper-work, preventive medicine in general practice, and medical ethics. The hospital appointments during the second year of training should be resident posts in the larger nonteaching hospitals under the regional hospital boards, and should give the trainee experience of the kind of case met in general practice and enable him to recognise when to seek specialist help. Though arrangements should be flexible, to cater for varying tastes, each trainee should be encouraged to get experience of infectious diseases, obstetrics, paediatrics, ear, nose, and throat conditions, eye and skin diseases, psychological medicine, and casualties. He should also acquire those techniques in treatment and pathological investigations which he will need in practice. In the third year the trainee could either take further hospital appointments, or simultaneous clinical assistantships in different subjects, and should do a short period of whole-time work in a laboratory. He should also have some further instruction in "
approaches
the suggested,
psychiatry.
should be made of cases in the chronic and casualty departments of nonteaching hospitals. The course should refresh the doctor’s basic knowledge of procedures, including clinical methods; inform him on new methods of diagnosis and treatment ; relate new knowledge to his own approach to medicine and to his patients ; and restate the contribution of other sciences to medicine. Methods of teaching should include tutorial classes, conferences, demonstrations, and discussions. use
outpatients,
’.
ALL THE
YEAR ROUND
Local
arrangements should also be made, for continuous postgraduate training. The local medical society, which can
do
much, should become
a
medical club, the
centre of all professional life. The committee recommend that in each area the profession should develop an active
medical society, in the conduct of which general practitioners and specialists should participate. Programmes should include lectures and demonstrations, courses at local hospitals, discussion groups and conferences, and clinicopathological and clinicotherapeutic conferences, medical films, brains trusts, and meetings with members of other professions. It is suggested that edited reports of clinical conferences of interest to general practitioners should often be published in a general medical journal. The committee believe that the divorce of the general practitioner from the hospital i8 bad for the efficiency’ of the whole medical service. Arrangements should be made for doctors to attend outpatient sessions and ward rounds, and to hold clinical assistantships which would enable them to develop their knowledge of a particular ’aspect of general practice, and to move more easily from general practice to specialties if they wished. Some doctors, it is thought, would prefer a fortnight’s resident hospital appointment as an alternative to a refresher course ; and this might be arranged. The committee also’strongly support, from an educational standpoint, the growing demand among family doctors for hospitals or wards where they can treat those of their own patients who cannot conveniently be nursed at home. Self-education during practice must depend on contact between the doctor and the hospital medical staff. -The doctor should accompany his patient to hospital. for consultation, when possible, and should be free to visit him in the wards at any time. The hospital medical staff should keep the family doctor informed of the patient’s progress while he is in hospital. Doctors in general practice should have opportunities to contribute to field researches in medicine and social science planned by university departments. They should also have leisure for " systematic, unhurried and uninterrupted professional reading;" and should. make full use of medical libraries, including the facilities now offered for purchasing ’Photostat’ copies of any given article at a small price. The committee conclude that the better the -general practitioner the more insistent will be his demand for adequate and appropriate postgraduate medical education. He must be given time for it, however, and on a long-term view this should be possible if general practice gains in interest and status, so that more newly qualified men are willing to enter it. The committee believe that. if their recommendations are fulfilled, a larger supply. of such doctors will be forthcoming. ,
Continuous Education education for those in general
practice is process continuing throughout active life, intended to preserve and increase technical competence and keep the -doctor in touch with hospital practice and medical advances. The need for postgraduate education of general practitioners was agreed to be great, both by consultants and the general practitioners themselves. insufficient in extent Current courses are said to be and inadequate in content." The postgraduate committee and dean appointed by the university should be responsible, it is suggested, for coordinating arrangements for postgraduate education of general practitioners in the area, and should collaborate with hospitals, specialists, and medical committees and societies for the purpose. Courses of varying lengths should be available, but educational work in the hospitals -clinical and clinicopathological discussions and conferences, and ward rounds-should be just as important as set courses, and should supplement the activities of local medical societies. as
tioners. Full
wards,
’
Postgraduate
seen
night ; and the committee consider the last, held in an appropriate teaching or regional hospital, to be- the most useful. They oppose the idea of compulsory attendance, or the offer of special inducements, believing that a well-run course with good and useful teaching and social amenities-including entertainment for the doctors’ wives while their husbands are attending lecturesshould be its own attraction. Teachers of high standing should be selected for their interest and competence in teaching, and should include suitable general practi-
a
"
THE WELL-PLANNED COURSE
Postgraduate
courses
to -leave his practice for
will a
usually require the doctor a week, or a fort-
weekend,