Johnny Lyon-Maris

GP workload: time for a rethink of the generalist model of care to promote retention

Much has been written in recent months about the ‘crisis’ in general practice; a crisis that has been linked to difficulties in recruiting to and retaining the workforce, changing working patterns, increasing care demands, and bureaucracy in the system of care. The debate has rippled through the press,1,2 been the subject of discussion at conferences and in the pages of journals,3 as well as prompting a number of reviews.4–6 While rarely out of the headlines or journals, it would seem that there is more ‘heat than light’ in identifying a way forward. This lack of clarity prompted us to seek the experiences of GPs and their views of working in general practice today, and to ask them to look ahead to the future. This article is based on an analysis of data gathered in Wessex by a survey of GPs ( n = 1445) and interview of a purposive ‘key informant’ sample of seven,7 reflecting different ages, career stages, and role types. The latter were recruited by invitation through local GP and practice networks, and those participating consented to undertake semi-structured telephone interviews. Both datasets were thematically analysed, and a fuller description of this work can be found elsewhere.8 A recent article in BJGP by Abbt and Alderson3 argues ‘It’s not workload’ , however the views expressed by our informants would challenge this. They described today’s general practice working environment as being very different to that of some 20 or 30 years ago. The lack of a well-defined career structure, alongside other influences, was seen as being a significant factor in GPs no longer seeking to be partners, especially those in the early stages of a career. This seems to have arisen as a result of the extended responsibilities that come …

Procedures and processes of accreditation for GP trainers: similarities and differences

A survey of all UK deaneries was carried out to identify the processes and procedures associated with the approval of GP clinical and educational supervisors and to document the current similarities and difference between deaneries. The results of the survey were placed in the context of recent literature. Results showed notable variation in some areas as well as relatively recent developments becoming established practice, such as the requirement for a certificate of medical education. Overall, results indicate a time of transition and the potential for practice to be aligned across deaneries and local education and training boards (LETBs).

High fidelity trainee simulation to improve trainer performance

Background:  Using trained actors to simulate trainee doctors in difficulty is a cost‐effective communication skills teaching tool that can be enhanced by techniques that are familiar to hi‐fidelity electronic simulation. Simulation has two broad strands: the first exchanges the patient for an actor in the clinical encounter, and the second introduces some form of technology to the encounter. The strand concerning actors is well developed, and generally focuses on ‘the consultation’. Where simulation draws on technology, the spectrum is broad: it may be relatively low‐tech, for example computer‐based scenarios to test prescribing, through to more high‐tech approaches to learning practical skills using sophisticated manikins that replicate patient signs and symptoms. Over the years simulation has radically changed medical training, and is set to continue to do so in the future.

The application process for general practitioner trainers in United Kingdom deaneries: similarities and differences.

A survey was undertaken of the application and reapplication forms used by all the UK deaneries for general practice (GP) specialty training. The aim of the survey was to identify similarities and differences between deaneries in terms of the content and nature of the information requested, and the relationship of that information to the Postgraduate Medical Education and Training Boards (PMETB) Quality Assurance Framework (QAF). The details requested on the application forms were compared to the guidance set out in Generic Standards for Training, in order to see if they reflected the areas and standards required by the PMETB for the quality assurance of medical education and training. Although many similar areas of information were requested in the application process, great variation was found across some items which were not attributable to regional or contextual differences. The survey also found that the majority of domains of Generic Standards for Training are not well covered in the paper application process. Although deaneries may view their application processes for trainer approval as robust, this paper makes a number of recommendations and argues for the development of a standardised form for the appointment of general practice specialty training (GPST) trainers across the UK, based upon the PMETB QAF.

Fostering resilience with GPs: a workshop approach

In recent years, change within the NHS and to the way care is delivered has seen the intensity and complexity of the workload of general practitioners (GPs) increase and broaden beyond the face-to-face clinical encounter. The cumulative effect of such ‘shifting sands’ can be significant for the individual and lead to ‘periods in which workload, adverse events, emotional demands and the lack of supportive relationships (to name but a few factors) may act as stressors that can undermine professional practice’.[1] Fostering resilience in the workforce is an area of interest across a range of professions, and currently forms an important area of development for medical educators, particularly with trainees. There would seem to be a clear need for there to be space and time within continuing professional development (CPD) for clinicians to pause and focus on their professional context and themselves, as well as to address learning needs or focusing on clinical outcomes. The formative element of appraisal goes some way to bring these aspects of professional development to the fore; however, there is also a need for ways and means to act upon and address them. A recent paper [2] in the British Journal of General Practice by Cleland and colleagues called for educators and learners to ‘think differently’ and move away from the ‘competency tick box’ and towards ‘medical education’ ... ‘redesigned explicitly to support and reward the development of both professional identity and the life-long and self-regulated learning skills required to underpin life-time professional practice’. We were particularly struck by the seeming absence of ‘well-being’ as key part of professional practice, and a lack of acknowledgement of the centrality of the self in well-being. An awareness of these issues prompted the GP programme directors to plan an educational session for GPs in practice which sought to place the individual doctor at the centre of educational activity.[3]

The world turned upside down: the case for thinking differently about undergraduate education

In 1985 Julian Tudor Hart observed: ‘… our medical schools teach and our students learn better than ever before’, 1yet he also noted that there was a ‘… crisis of structure’. In response to that crisis he went on to make a case for ‘turning the world upside down’, arguing for a reversal in undergraduate medical education to see the preponderance of teaching time spent in the community rather than in hospital. The change he advocated did not occur; however, the discipline of academic general practice was recognised as playing a key role in the medical school curriculum and the education of medical students. Fast forward over 30 years. Although general practice has become embedded in the medical school curriculum, most teaching continues to remain hospital centred and hospital focused. The ‘crisis of structure’ …

The drama of communication

It is our opinion that communication skills, in and outside the world of medicine, are important in this digital age, as these skills are crucial both to the consultation and to caregiving. 1,2 In this article we will refl ect on the importance of ‘the basics’ of communication and consider how educators can draw on drama to help postgraduate specialty trainees explore and develop their interpersonal skills. Such learning is intended to heighten the trainees’ capacity for insight, as well as being entertaining and enlightening.

The audio-COT (consultation observation tool): developing a new assessment tool for GP training

The use of the telephone in primary care is an increasingly popular way of managing the clinical workload, as well as being an integral mode of communication between primary care clinicians and colleagues in secondary care and the wider community. Over recent years, the number of telephone consultations has quadrupled from 3% of total consultations in 1995/1996 to 12% by 2008/9. This equates to almost 36.5 million telephone consultations annually in primary care,[1] used both in-hours and ‘out of hours’ (OOH) for consultations. The importance of the telephone as a mode of consultation is recognised: the Medical Protection Society has stated ‘it is absolutely imperative to make telephone consultations ... clinically safe and effective’.[2] Evidence from current clinical practice suggests that in addition to developing face-to-face communication skills, GP trainees also need to develop telephone consultation skills. However, using the telephone in the clinical setting may not be something with which trainees are accustomed and comfortable. At present, general practice (GP) trainees may be presented with one telephone consultation case in their summative GP Clinical Skills Assessment examination,[3] yet there is currently no mandatory formative assessment of telephone consultation skills during training. The Committee of GP Education Directors (CoGPED) suggests that OOH competence should be triangulated through the assessment of evidence from several sources, something that might include a consultation observed tool (COT) assessment of a telephone consultation – an ‘audio-COT’ assessment.[4] In spite this recommendation, there is no formal audio-COT assessment tool available to support learning. Further, there is currently no formal recommendation by the Royal College of General Practitioners (RCGP) for a formative assessment of telephone skills during day-to-day clinical work. Some practices can be shown to rely heavily on the use of the telephone, for example using the ‘STOUR’ method for undertaking consultations in GP,[5] others less so. Given that trainees may move between practices over the course of their training, and practices may use the telephone to differing degrees to manage the clinical workload, trainees may be unprepared to use the telephone. A formal approach to the assessment of trainees’ telephone consultation skills should increase their confidence and may benefit patient safety.

Do Integrated Training Programmes Provide a Different Model of Training for General Practice Compared to Traditional Vocational Training Schemes

In the United Kingdom, traditional vocational training schemes (VTSs) for general practice generally comprise four hospital posts lasting six months each, followed by a year in a practice which has been approved for training. It has long been argued that this training model does not fully prepare future GPs with the knowledge and skills needed for their career. Early evidence suggests that integrated training programmes (ITPs) provide a different model of training, which may better prepare trainees for a career in general practice. In Wessex, an ITP that Education for Primary Care (2007) 18: 685–96 # 2007 Radcliffe Publishing Limited