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WHY NOT BASE CLINICAL EDUCATION IN GENERAL PRACTICE?
148
Medical Education
SOME GMC OBJECTIVES FOR WHICH TEACHING IN GENERAL PRACTICE PROVIDES AN IMPORTANT SETTING
WHY NOT BASE CLINICAL EDUCATION IN GENERAL PRACTICE? NIGEL OSWALD
University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ IN the 1940s it was barely possible to envisage general practitioners as teachers of medical students in the United Kingdom. With a very few exceptions GPs made no contribution to clinical courses, and Lord Cohen, in his report for the British Medical Association Curriculum Committee of 1948, argued that the idea was impracticable and undesirable.1 However, shortly after that, the climate of opinion began to change. The College of General Practitioners, founded in 1952, argued for the teaching of general practice by GPS.2 The Todd Report3 emphasised
the place of general practice as a specialty, and the result was growing support for university departments of general practice and for statutory vocational training. The contribution of general practice in medical schools and in postgraduate training is now established. Has the time come to consider whether GPs could take a leading role in clinical medical education? A Lancet editorial4 on this topic said "it seems premature to transfer a major proportion of undergraduate teaching... out of hospitals and into the community". The arguments supporting this view include the patchy quality of general practice, its deficient academic base, and the very small size of some departments. But the fact that the question has been considered at all entitles one to ask whether the present pattern of hospital training is as secure and effective as some like to think. The teaching hospitals are already facing major difficulties in fulfilling their educational role, and these seem likely to worsen. Existing difficulties lie in three main areas: the gap between educational objectives and the skills of teachers; the availability of patients; and the availability of teachers. After
publication of the Todd Report and its own reorganisation after Merrison, the General Medical Council
broke with tradition, and wrote its 1980 recommendations5 for basic medical education in terms of the acquisition of knowledge, skills, and attitudes instead of prescribing minimum periods of study in particular specialties. The old system fitted well with a medical curriculum compartmentalised by specialty, in which a teacher’s duty was to impart such aspects of his or her special subject as seemed appropriate. The new recommendations, with their broad educational and behavioural emphasis, sit awkwardly in a system whose teachers are specialists with increasingly narrow areas of expertise. By contrast, GP teachers take
ZY, Liu CB, Francis DP, et al. Prevention of perinatal acquisition of hepatitis B virus carriage using vaccine: preliminary report of a randomized, double-blind placebo-controlled and comparative trial. Pediatrics 1985; 76: 713-18. 12 Wahl M, Iwarson S, Snoy P, Gerety RJ Failure of hepatitis B immune globulin to protect against experimental hepatitis B infection in chimpanzees. J Hepatol (in 11 Xu
press) CE, Taylor PE, Tong MJ, et al. Yeast recombinant hepatitis B vaccine. Efficacy with hepatitis B immune globulin in prevention of perinatal hepatitis B virus transmission. JAMA 1987; 257; 2612-16
13. Stevens
pride in their ability to remain generalists,
and teaching of in of the GMC’s recommendations general practice many would be appropriate.6 Some cannot be effectively learnt if a hospital perspective alone is taught (see table). Aside from this fundamental difficulty is the question of patients or, in teaching lingo, "clinical material". Patients in teaching hospitals represent only a tiny, selected fragment of the illnesses that affect people, mainly with rare disorders or serious manifestations of common disorders. Even these patients are being admitted, investigated, and discharged with an ever-increasing intensity that is good news for hospital activity analysis but disastrous for medical students. The time available to clerk and get to know a patient is often greatly reduced by the patient’s absence because of surgery, special investigations, or early discharge, not to mention the pressures of the patient’s mealtimes, need for sleep, and visitors, and the student’s other commitments in the lecture room and library. Clinical experience is whittled away and even those patients clerked may, for the same reasons, not be taught on. Under the White Paper proposals there will be strong pressure for these trends to continue. What of the teachers in teaching hospitals, who are also under increasing pressure? Although many provide teaching of the very highest standard, they are not selected for teaching ability nor trained to teach. For some, especially those still in training, teaching is an unwelcome chore and the effects of Achieving a Balance will not lighten their service commitment. At the same time the need to publish research findings, and the emphasis in academic departments on generating research income means that of the trio of service, research, and teaching, teaching is bound to suffer. Can general practice help? We need to look at what general practice has to offer and make a conceptual jump to see how the idea could be turned into reality. On offer are three important ingredients-patients, teachers, and time. Most hospital admissions, even acute ones, represent episodes in continuing processes; general practitioners spend a large part of their time dealing with the same illnesses in the same patients as do hospital doctors. Almost all patients spend nearly all their lives outside hospital. A patient does not need to be in diabetic ketoacidosis for a student to learn about the effects of glucose intolerance and its complications. Although it is essential that a medical student be involved in the management of such an emergency there is an equally strong argument that he or she should experience the out-of hospital care necessary for diabetic patients who are blind or have lost a leg. Many GPs are now both trained and approved as trainers for the purposes of vocational training. This means that they
149
accept standards, have met them, and have been seen to meet them. General practice is ahead of hospital medicine in the training it gives its teachers and what it knows of their capability. The small size of many departments of general practice is one of the arguments against increasing their role in clinical training. This argument neglects the fact that most of the teaching is done not by departments themselves but in local and regional practices. In the Cambridge Clinical School at least 150 general practitioners are involved, most of them experienced teachers of students
and/or trainees. Whereas teachers in hospitals may feel that they are already over-committed to the teaching part of their duties, there is an obvious opportunity in training practices to contribute more to clinical teaching. GP trainers do their work in, effectively, the last year of a 10-year training. At modest cost, GPs could relieve the hospital of a substantial teaching load, and the opportunity to exploit the continuum between undergraduate and postgraduate training could be realised. THE CONCEPT
It is traditional to look at the medical curriculum as a pie divided according to the contribution of specialties in terms of time. However, this represents the curriculum, not illnesses or patients. In particular, it does not represent the teaching potential of general practice nor the relation between general practice and the hospital. Although it is still an imperfect image, this concept is much better represented by a cartwheel with general practice at the rim and the hospital at the hub, connected together by the "spokes" of the specialties. This image serves as a reminder of several salient points. Firstly, the great reservoir of patients and their teaching potential is in general practice. Secondly, general practice retains an interest in all specialties and is therefore in touch with a very wide range of specialists and services inside the hospital as well as outside. Conversely, the expertise of hospital specialists is necessarily narrower, and their interest in general practice is confined to the segment defined by the limit of their "spoke". Thirdly, it is the same patients who
being treated, the connection between the hospital and general practice being an open one. Fourthly, although all hospital patients have a GP, the GP is also dealing with a range of disorders that are never seen in hospital, not because they are minor (although many are) but because are
their solution does
not
involve the skills contained in
a
teaching hospital. With the concept of the cartwheel in mind, it becomes possible to visualise the expanded contribution which general practice, as the unifying theme of the whole of clinical medicine, could make to clinical teaching. It would be wrong to expect that all teaching could be done in this setting. What I envisage is a coordinated programme between hospital and general practice, with far more interchange between them, founded on the idea of students following patients from general practice into the hospital (as outpatients or inpatients) and back again. In this way the GMC educational objectives would be much more effectively achieved. To make this idea work we should need a clear idea of what we want students to learn and which of those things can be provided only in the hospital and which in general practice. We therefore need a detailed curriculum, eschewing the chance element that leaves one student
attached to a medical firm with a dominant interest in renal disease while another learns largely about the gastrointestinal tract. Such a curriculum does not presently exist, although McManus and Wakeford8 also suggest the need for a "core" curriculum. From the curriculum we would derive a comprehensive list of experiences and teaching that would be completed during the course, ensuring that no large gaps had been left. A key difference from the present system would be that these experiences would not be acquired in any particular order. Next we would need to organise a large part of the teaching on patients whom the students saw from presentation to resolution of the illness. The raw material for this teaching would be the patients of a well-organised teaching practice. In such a scheme patients needing referral to hospital would be accompanied by the student whatever the specialty-to ophthalmology outpatients for a patient with a cataract or to the surgical on-call firm for a patient with appendicitis. In contact with the specialist team, and following the progress of the illness to its resolution or otherwise, the student would acquire a feel for the outcome of illness and the strengths and weaknesses of scientific medicine, as well as learning in the context of a particular patient the specialised information otherwise learnt in specialist "blocks". By following patients in this way, students would experience those aspects of medical training that only hospitals can provide-for example, knowledge about imaging and other specialised investigation techniques-and gain relevant experience as a student in the operating theatre, admission unit, and the post-mortem room.
A defined and agreed lecture course would also be needed, covering topics that are most effectively and economically taught in this way. Some would be given by specialists, some by general practitioners, and some by, for example, staff in community medicine departments. Finally, the student, preferably working as part of a small group of about four, would need continuing contact and teaching from a GP in whose professional life such education formed an important part. Have these proposals got anything to offer? I think they the answer to how to educate students rather than train them, how to break down the divisions in medicine, and how to instil appropriate knowledge, attitudes, and skills while giving greater practical experience. Such a solution could help to ease the burden on hospital teachers as well as aid progress towards the continuum of medical education that has been discussed for decades but has proved elusive in practice. Finally, I believe that such an education would be appropriate both for those whose future lies within specialist hospital medicine, and for future GPs. Primary and secondary care are, after all, part of the same process. are
REFERENCES 1. British Medical Association. Report of the Medical Curriculum Committee. The training of a doctor. London: British Medical Association, 1948. 2. Undergraduate Education Committee of the College of General Practitioners The teaching of general practice by general practitioners. Br Med J 1953; ii: 36-38. 3. Royal Commission on Medical Education (Cmnd 3569). London: HM Stationery
Office, 1968. 4. Editorial. Undergraduate general practice. Lancet 1989; i: 702-03. 5. General Medical Council Education Committee. Recommendations on basic medical education. London: General Medical Council, 1980. 6 Royal College of General Practitioners. Undergraduate medical education in general practice. Occasional paper, 28 1984. 7. UK Health Departments, the Joint Consultants Committee, and Chairmen of Regional Health Authorities. Hospital Medical Staffing—achieving a balance. London: HM Stationery Office, 1987. 8. McManus IC, Wakeford RE. A core medical curriculum. Br Med J 1989; 298: 1051.
Medical Education
SOME GMC OBJECTIVES FOR WHICH TEACHING IN GENERAL PRACTICE PROVIDES AN IMPORTANT SETTING
WHY NOT BASE CLINICAL EDUCATION IN GENERAL PRACTICE? NIGEL OSWALD
University of Cambridge School of Clinical Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ IN the 1940s it was barely possible to envisage general practitioners as teachers of medical students in the United Kingdom. With a very few exceptions GPs made no contribution to clinical courses, and Lord Cohen, in his report for the British Medical Association Curriculum Committee of 1948, argued that the idea was impracticable and undesirable.1 However, shortly after that, the climate of opinion began to change. The College of General Practitioners, founded in 1952, argued for the teaching of general practice by GPS.2 The Todd Report3 emphasised
the place of general practice as a specialty, and the result was growing support for university departments of general practice and for statutory vocational training. The contribution of general practice in medical schools and in postgraduate training is now established. Has the time come to consider whether GPs could take a leading role in clinical medical education? A Lancet editorial4 on this topic said "it seems premature to transfer a major proportion of undergraduate teaching... out of hospitals and into the community". The arguments supporting this view include the patchy quality of general practice, its deficient academic base, and the very small size of some departments. But the fact that the question has been considered at all entitles one to ask whether the present pattern of hospital training is as secure and effective as some like to think. The teaching hospitals are already facing major difficulties in fulfilling their educational role, and these seem likely to worsen. Existing difficulties lie in three main areas: the gap between educational objectives and the skills of teachers; the availability of patients; and the availability of teachers. After
publication of the Todd Report and its own reorganisation after Merrison, the General Medical Council
broke with tradition, and wrote its 1980 recommendations5 for basic medical education in terms of the acquisition of knowledge, skills, and attitudes instead of prescribing minimum periods of study in particular specialties. The old system fitted well with a medical curriculum compartmentalised by specialty, in which a teacher’s duty was to impart such aspects of his or her special subject as seemed appropriate. The new recommendations, with their broad educational and behavioural emphasis, sit awkwardly in a system whose teachers are specialists with increasingly narrow areas of expertise. By contrast, GP teachers take
ZY, Liu CB, Francis DP, et al. Prevention of perinatal acquisition of hepatitis B virus carriage using vaccine: preliminary report of a randomized, double-blind placebo-controlled and comparative trial. Pediatrics 1985; 76: 713-18. 12 Wahl M, Iwarson S, Snoy P, Gerety RJ Failure of hepatitis B immune globulin to protect against experimental hepatitis B infection in chimpanzees. J Hepatol (in 11 Xu
press) CE, Taylor PE, Tong MJ, et al. Yeast recombinant hepatitis B vaccine. Efficacy with hepatitis B immune globulin in prevention of perinatal hepatitis B virus transmission. JAMA 1987; 257; 2612-16
13. Stevens
pride in their ability to remain generalists,
and teaching of in of the GMC’s recommendations general practice many would be appropriate.6 Some cannot be effectively learnt if a hospital perspective alone is taught (see table). Aside from this fundamental difficulty is the question of patients or, in teaching lingo, "clinical material". Patients in teaching hospitals represent only a tiny, selected fragment of the illnesses that affect people, mainly with rare disorders or serious manifestations of common disorders. Even these patients are being admitted, investigated, and discharged with an ever-increasing intensity that is good news for hospital activity analysis but disastrous for medical students. The time available to clerk and get to know a patient is often greatly reduced by the patient’s absence because of surgery, special investigations, or early discharge, not to mention the pressures of the patient’s mealtimes, need for sleep, and visitors, and the student’s other commitments in the lecture room and library. Clinical experience is whittled away and even those patients clerked may, for the same reasons, not be taught on. Under the White Paper proposals there will be strong pressure for these trends to continue. What of the teachers in teaching hospitals, who are also under increasing pressure? Although many provide teaching of the very highest standard, they are not selected for teaching ability nor trained to teach. For some, especially those still in training, teaching is an unwelcome chore and the effects of Achieving a Balance will not lighten their service commitment. At the same time the need to publish research findings, and the emphasis in academic departments on generating research income means that of the trio of service, research, and teaching, teaching is bound to suffer. Can general practice help? We need to look at what general practice has to offer and make a conceptual jump to see how the idea could be turned into reality. On offer are three important ingredients-patients, teachers, and time. Most hospital admissions, even acute ones, represent episodes in continuing processes; general practitioners spend a large part of their time dealing with the same illnesses in the same patients as do hospital doctors. Almost all patients spend nearly all their lives outside hospital. A patient does not need to be in diabetic ketoacidosis for a student to learn about the effects of glucose intolerance and its complications. Although it is essential that a medical student be involved in the management of such an emergency there is an equally strong argument that he or she should experience the out-of hospital care necessary for diabetic patients who are blind or have lost a leg. Many GPs are now both trained and approved as trainers for the purposes of vocational training. This means that they
149
accept standards, have met them, and have been seen to meet them. General practice is ahead of hospital medicine in the training it gives its teachers and what it knows of their capability. The small size of many departments of general practice is one of the arguments against increasing their role in clinical training. This argument neglects the fact that most of the teaching is done not by departments themselves but in local and regional practices. In the Cambridge Clinical School at least 150 general practitioners are involved, most of them experienced teachers of students
and/or trainees. Whereas teachers in hospitals may feel that they are already over-committed to the teaching part of their duties, there is an obvious opportunity in training practices to contribute more to clinical teaching. GP trainers do their work in, effectively, the last year of a 10-year training. At modest cost, GPs could relieve the hospital of a substantial teaching load, and the opportunity to exploit the continuum between undergraduate and postgraduate training could be realised. THE CONCEPT
It is traditional to look at the medical curriculum as a pie divided according to the contribution of specialties in terms of time. However, this represents the curriculum, not illnesses or patients. In particular, it does not represent the teaching potential of general practice nor the relation between general practice and the hospital. Although it is still an imperfect image, this concept is much better represented by a cartwheel with general practice at the rim and the hospital at the hub, connected together by the "spokes" of the specialties. This image serves as a reminder of several salient points. Firstly, the great reservoir of patients and their teaching potential is in general practice. Secondly, general practice retains an interest in all specialties and is therefore in touch with a very wide range of specialists and services inside the hospital as well as outside. Conversely, the expertise of hospital specialists is necessarily narrower, and their interest in general practice is confined to the segment defined by the limit of their "spoke". Thirdly, it is the same patients who
being treated, the connection between the hospital and general practice being an open one. Fourthly, although all hospital patients have a GP, the GP is also dealing with a range of disorders that are never seen in hospital, not because they are minor (although many are) but because are
their solution does
not
involve the skills contained in
a
teaching hospital. With the concept of the cartwheel in mind, it becomes possible to visualise the expanded contribution which general practice, as the unifying theme of the whole of clinical medicine, could make to clinical teaching. It would be wrong to expect that all teaching could be done in this setting. What I envisage is a coordinated programme between hospital and general practice, with far more interchange between them, founded on the idea of students following patients from general practice into the hospital (as outpatients or inpatients) and back again. In this way the GMC educational objectives would be much more effectively achieved. To make this idea work we should need a clear idea of what we want students to learn and which of those things can be provided only in the hospital and which in general practice. We therefore need a detailed curriculum, eschewing the chance element that leaves one student
attached to a medical firm with a dominant interest in renal disease while another learns largely about the gastrointestinal tract. Such a curriculum does not presently exist, although McManus and Wakeford8 also suggest the need for a "core" curriculum. From the curriculum we would derive a comprehensive list of experiences and teaching that would be completed during the course, ensuring that no large gaps had been left. A key difference from the present system would be that these experiences would not be acquired in any particular order. Next we would need to organise a large part of the teaching on patients whom the students saw from presentation to resolution of the illness. The raw material for this teaching would be the patients of a well-organised teaching practice. In such a scheme patients needing referral to hospital would be accompanied by the student whatever the specialty-to ophthalmology outpatients for a patient with a cataract or to the surgical on-call firm for a patient with appendicitis. In contact with the specialist team, and following the progress of the illness to its resolution or otherwise, the student would acquire a feel for the outcome of illness and the strengths and weaknesses of scientific medicine, as well as learning in the context of a particular patient the specialised information otherwise learnt in specialist "blocks". By following patients in this way, students would experience those aspects of medical training that only hospitals can provide-for example, knowledge about imaging and other specialised investigation techniques-and gain relevant experience as a student in the operating theatre, admission unit, and the post-mortem room.
A defined and agreed lecture course would also be needed, covering topics that are most effectively and economically taught in this way. Some would be given by specialists, some by general practitioners, and some by, for example, staff in community medicine departments. Finally, the student, preferably working as part of a small group of about four, would need continuing contact and teaching from a GP in whose professional life such education formed an important part. Have these proposals got anything to offer? I think they the answer to how to educate students rather than train them, how to break down the divisions in medicine, and how to instil appropriate knowledge, attitudes, and skills while giving greater practical experience. Such a solution could help to ease the burden on hospital teachers as well as aid progress towards the continuum of medical education that has been discussed for decades but has proved elusive in practice. Finally, I believe that such an education would be appropriate both for those whose future lies within specialist hospital medicine, and for future GPs. Primary and secondary care are, after all, part of the same process. are
REFERENCES 1. British Medical Association. Report of the Medical Curriculum Committee. The training of a doctor. London: British Medical Association, 1948. 2. Undergraduate Education Committee of the College of General Practitioners The teaching of general practice by general practitioners. Br Med J 1953; ii: 36-38. 3. Royal Commission on Medical Education (Cmnd 3569). London: HM Stationery
Office, 1968. 4. Editorial. Undergraduate general practice. Lancet 1989; i: 702-03. 5. General Medical Council Education Committee. Recommendations on basic medical education. London: General Medical Council, 1980. 6 Royal College of General Practitioners. Undergraduate medical education in general practice. Occasional paper, 28 1984. 7. UK Health Departments, the Joint Consultants Committee, and Chairmen of Regional Health Authorities. Hospital Medical Staffing—achieving a balance. London: HM Stationery Office, 1987. 8. McManus IC, Wakeford RE. A core medical curriculum. Br Med J 1989; 298: 1051.