Training for general practice: a national survey.

OBJECTIVES--(a) To compare current vocational training in general practice with that ascertained by a survey in 1980; (b) to compare the training of trainees in formal training schemes with that of trainees arranging their own hospital and general practice posts. DESIGN--National questionnaire survey of United Kingdom and armed services trainees who were in a training practice on 1 April 1989. Questionnaires were distributed by course organisers. SETTING--Research project set up after an ad hoc meeting of trainees at the 1988 national trainee conference. SUBJECTS--2132 Of the 2281 trainees (93%) known to be in a training practice on 1 April 1989. RESULTS--1657 Trainees returned the questionnaires, representing 73% of all trainees known to be in a training practice on 1 April 1989. Between 1980 and 1989 there were significant improvements in the trainee year, and there was also evidence of improvements in general practice study release courses. There was no evidence of improvement in other aspects of training. General practice trainees spent an average of three years in junior hospital posts, which provided very little opportunity for study related to general practice. Training received during tenure of hospital posts differed significantly between trainees in formal schemes and those arranging their own hospital posts. During the trainee year training was almost the same for those in formal schemes and those arranging their own posts. Regions varied significantly in virtually all aspects of general practice training. CONCLUSIONS--The trainee year could be improved further by enforcing the guidelines of the Joint Committee on Postgraduate Training for General Practice. The poor training in junior hospital posts reflected the low priority that training is generally given during tenure of these posts. A higher proportion of general practice trainees should be attached to vocational training schemes. More hospital trainees could attend general practice study release courses if these were designed specifically with the needs of hospital doctors in mind.     

Evidence based general practice: a retrospective study of interventions in one training practice.

OBJECTIVES--To estimate the proportion of interventions in general practice that are based on evidence from clinical trials and to assess the appropriateness of such an evaluation. DESIGN--Retrospective review of case notes. SETTING--One suburban training general practice. SUBJECTS--122 consecutive doctor-patient consultations over two days. MAIN OUTCOME MEASURES--Proportions of interventions based on randomised controlled trials (from literature search with Medline, pharmaceutical databases, and standard textbooks), on convincing non-experimental evidence, and without substantial evidence. RESULTS--21 of the 122 consultations recorded were excluded due to insufficient data; 31 of the interventions were based on randomised controlled trial evidence and 51 based on convincing non-experimental evidence. Hence 82/101 (81%) of interventions were based on evidence meeting our criteria. CONCLUSIONS--Most interventions within general practice are based on evidence from clinical trials, but the methods used in such trials may not be the most appropriate to apply to this setting.     

The hospital component of vocational training for general practice.

Trainees and educationalists in general practice have some grounds for suggesting that the hospital component of vocational training should be restructured and teaching improved. However, the implications for other trainees and secondary care have to be considered. Changes that are needed include a curriculum for senior house officers in each specialty; appointment of training consultants with the necessary skills; and a different attitude by everyone towards study leave, including arrangements for funding. The optimum duration of hospital posts for trainees in general practice might be shorter than now, but the effects on others must be considered and competencies guaranteed in a briefer training period. Changes in the regulations for vocational training could help to improve specialist experience if trainees in general practice were allowed to be supernumerary. Alternatively, senior house officer posts for trainees in general practice could be split between secondary and primary care, thus encouraging a broader perspective.     

Careers in academic general practice: problems,constraints, and opportunities.

Changing priorities in the NHS have underlined the crucial importance of academic general practice in providing quality training and research to underpin developments in general practice. Unfortunately, several problems and constraints mean that the full potential of general practitioners to make a contribution to teaching and research has not been realised. These issues are examined and recommendations for improvements are made. Obstacles to career development for academics in general practice should be removed. The funding of academic general practice should be the same as for other medical disciplines. Vocational training for general practice should be extended to include research and audit methods, particularly for doctors interested in an academic career. Above all, the long term objective should be to integrate undergraduate and post-graduate general practice to increase the overall effectiveness of teaching and research and hence the quality of service general practice.     

Roles,risks, and responsibilities in maternity care: trainees' beliefs and the effects of practice obstetric training.

OBJECTIVES--To document the content of practice obstetric vocational training, the beliefs of general practitioner trainees about the roles of midwives and general practitioners in maternity care, and the risks of providing such care; and to ascertain if undergoing such training affects their beliefs. DESIGN--Confidential postal questionnaire survey. SUBJECTS--Random one in four sample of all general practitioner trainees in the United Kingdom on vocational training schemes or in training practices in autumn 1990. MAIN OUTCOME MEASURES--Beliefs scored on seven point Likert scales and characteristics of trainer and training practice. RESULTS--Of 1019 trainees sent questionnaires, 765 (75.1% response rate) replied; 638 (83.3%) had done some part of their practice year. Of their trainers, 224 (35.1%) provided full obstetric care. 749 (99%) and 364 (48%) trainees believed that midwives and general practitioners respectively have an important role in normal labour; 681 (91.7%) trainees believed that general practice intrapartum care is a high risk "specialty." Those trainees whose trainers provide full obstetric care were significantly more likely to believe that both midwives and general practitioners have an important role in abnormal labour and to see the provision of intrapartum care as an incentive to join a practice. CONCLUSION--In this series most general practitioner trainees believed that both midwives and general practitioners have important roles in maternity care. Exposure of trainees to the provision of full obstetric care while in their training practice resulted in a more positive attitude towards the provision of such care by general practitioners.     

Vocational Training for General Practice: A Comparison of the Views of Trainees and Teachers

The views of 89 vocational trainees were compared with those of 45 doctors concerned in schemes of vocational training for general practice. Both groups agreed over most points, except on the desirability of compulsory vocational training: 42 of the trainees thought this to be desirable compared with 35 of the teachers.The composite scheme favoured by both trainees and teachers offered an initial period in general practice together with an organized course of seminars throughout the training period. The subjects in which most considered hospital experience essential were paediatrics, general medicine, and obstetrics and gynaecology.     

Training for excellence in the inner city: an interview with Richard Savage and Clare Vaughan. Interview by Douglas Carnall.

Recruitment to general practice is at its lowest level for 30 years, and many vocational training schemes report difficulty in attracting new trainees. Spurred on by the aging population of south London, and with the advantage of pounds 1.3m of development money resulting from the Tomlinson report, the south London organisation of vocational training schemes (SLOVTS) has perhaps been able to cope better than most. Its chair, Richard Savage, a general practitioner and course organiser, and Clare Vaughan, an assistant adviser, have devised and implemented many innovative training posts for general practice over the past two years, and their approach seems to be bearing fruit: most of the doctors who have finished the training scheme are now entering practice in south London. They talked to Douglas Carnall about the causes of the crisis and the measures they have implemented to counter it. Clare Vaughan died in the week following the interview (see obituary, p 555).     

Approval of trainers and training practices in the Oxford region: assessment.

This is the second paper of three on criteria for approval of trainers of general practitioners drawn up for the Oxford region. This paper describes assessment of trainers and training practices by a team of general practitioners who visit for one day.     

Evaluation of extended training for general practice in Northern Ireland: qualitative study

Objective To evaluate participants'' perceptions of the impact on them of an additional six months'' training beyond the standard 12 month general practice vocational training scheme.Design Qualitative study using focus groups.Setting General practice vocational training in Northern Ireland.Participants 13 general practitioner registrars, six of whom participated in the additional six months'' training, and four trainers involved in the additional six months'' training.Main outcome measures: Participants'' views about their experiences in 18 month and 12 month courses.Results Participants reported that the 12 month course was generally positive but was too pressurised and focused on examinations, and also that it had a negative impact on self care. The nature of the learning and assessment was reported to have left participants feeling averse to further continuing education and lacking in confidence. In contrast, the extended six month component was reported to have restimulated learning by focusing more on patient care and promoting self directed learning. It developed confidence, promoted teamwork, and gave experience of two practice contexts, and was reported as valuable by both ex-registrars and trainers. However, both the 12 and 18 month courses left participants feeling underprepared for practice management and self care.Conclusions 12 months'' training in general practice does not provide doctors with the necessary competencies and confidence to enter independent practice. The extended period was reported to promote greater professional development, critical evaluation skills, and orientation to lifelong learning but does not fill all the gaps.     

住院医师/专科医师通科培训必要性的探讨

当前医学生临床实践活动在时间上不能保证,质量上又明显下滑的情况下,增加住院医师/专科医师通科培训是十分必要的。不仅能弥补临床实践的不足,而且也能为医学生向住院医师平稳顺利过度作铺垫。住院医师/专科医师培养是医学生向临床医师角色转换的一个重要的过度阶段,因此,培训时间、学习内容安排的科学、合理与否将直接影响培养效果。住院医师/专科医师通科培训应为培养具有较高临床综合能力的医学人才奠定基础。     

Part-time medical training: 15 years' experience in the Oxford region.

Part-time training of doctors with domestic commitments has taken place successfully in the Oxford region since 1966; 249 doctors have now passed through such training schemes and a further 120 are currently training part-time. Two training schemes are now offered for doctors at senior house officer and registrar level: one of six to eight sessions a week for those undertaking recognised training aiming for consultant or principal in general practice posts, the other of one to two sessions a week providing ad hoc training for those unable for personal reasons to follow a recognised training programme. For doctors at senior registrar level, part-time training entails five to eight sessions a week. Of the 115 doctors who have left the schemes and are now in career posts in the United Kingdom, 19% are now consultants, 30% in other hospital posts, 27% in general practice, and 18% are clinical medical officers; overall, 71% of those in career posts are working part-time. This experience shows that part-time training can be successful and that there is a continuing need for part-time career posts.     

Is the Jarman underprivileged area score valid?

A recently published validation of an underprivileged area score, which is intended to reflect factors that increase general practice workload or pressure on their services, was incomplete; a validation based on criteria other than the opinion of general practitioners is also required. Areas with higher mortality from diseases where general practitioner intervention can reduce mortality substantially are likely to have a greater need for general practice services. Similarly, the need for general practitioner services should be higher where the incidence of such treatable conditions is higher. This paper describes the association between Jarman''s score and (a) mortality from causes that are amenable to general practice intervention and (b) incidence of two diseases where general practice intervention is important. Using these data the score appears to have external criterion validity and thus is likely to reflect, at least crudely, the need for general practitioner services.     

Research in general practice. Sources of advice.

Regional advisers, faculty secretaries of the Royal College of General Practitioners, heads of academic departments of general practice and primary care, and heads of RCGP research units were invited to complete a semistructured questionnaire to determine the nature and availability of current sources of advice for general practitioners participating in research activities and the demands placed on the available sources in the United Kingdom. The principal source for research advice was university departments of general practice, yet these have insufficient resources to cope with requests and few have spare capacity to stimulate research. Regional advisers and faculty secretaries do not seem to be kindling a spirit of inquiry and they seem somewhat complacent about both the lack of requests for research advice from general practitioners and the difficulties of academic departments. Proper development of research capability in general practice and primary care is unlikely to occur without more resources to create training posts in academic departments and a greater spirit of inquiry in vocational training programmes, which should lead to both review (audit) and research.     

Counsellors in English and Welsh general practices: their nature and distribution.

OBJECTIVE--To establish the prevalence of counselling services in English and Welsh general practices and factors associated with their distribution; to describe qualifications, working arrangements, and case mix of "counsellors." DESIGN--Postal questionnaire and telephone interview survey of a sample of about one in 20 general practitioners in England and Wales. SETTING--English and Welsh general practices. SUBJECTS--1880 general practitioners of whom 1542 (82%) completed questionnaires. MAIN OUTCOME MEASURES--Prevalence and distribution of practice counselling services; counsellors'' qualifications and funding; types of patients referred. RESULTS--586 counsellors were distributed among 484 of the 1542 practices. Three types of counsellor predominated: community psychiatric nurses (187); "practice counsellors" (145); and clinical psychologists (95). Practice characteristics which independently predicted the presence of a counsellor were for community psychiatric nurses four or more partners (odds = 1.72, 95% confidence interval 1.18 to 2.26); for practice counsellors stress clinic (odds = 2.22; 1.83 to 2.61), training practice (odds = 1.70; 1.24 to 2.16), and health region (chi 2 = 55.94; df = 14; p < 0.001); and for clinical psychologists list size of > or = 10,500 (odds = 1.79; 1.09 to 2.49), training practice (odds = 1.78; 1.31 to 2.25), health region (chi 2 = 48.31; df = 14; p < 0.001). 197 counsellors had training in counselling. The qualifications of 85 were unknown to the general practitioner. The principal source of funding was the district health authority for community psychiatric nurses (150) and clinical psychologists (58) and the family health services authority for practice counsellors (76). All counsellors were referred a wide range of problems. CONCLUSIONS--Counselling services are wide-spread in general practice, but a high proportion of counsellors lack qualifications, and many may be referred problems outside their knowledge.     

The academic base for general practice: the case for change.

University departments of general practice and the postgraduate education system for general practice have developed separately over the past 30 years. This separation is now impeding the academic development of the discipline and causes difficulties with recruitment and career progression. These problems could be eased by the creation of integrated departments. This would establish a critical mass for research and educational development, allow human and other resources to be used more flexibly and effectively, and provide a strong base for undergraduate education, vocational training, higher professional training, and continuing education. It could encourage collaborative ventures with other disciplines and also lead to higher standards of patient care.     

THE PLACE AND TRAINING OF THE GENERAL PRACTITIONER

Training for the medical student whose goal is general practice should aim at equipping him to maintain the close personal relationship with the patient which is considered the ideal basis for the treatment and prevention of disease. Preparation for general practice should anticipate graduate experience on a par with that which is currently considered necessary for the various specialties. Internship should be such as to fit the general practitioner to the peculiarities of the kind of community in which he will practice. Ability to recognize his own limitations and situations in which special consultation or referral are indicated should be developed in the student.The University of Colorado School of Medicine has adopted a course of training, from pre-medical education through internship, designed for the student who is to specialize in general practice.     

Is the distribution of training practices appropriate for the needs of general practice?

The distribution of practices that train general practitioners in the west of Scotland was examined. The concentration of training practices is lowest in conurbations that are grossly deprived. Several topics require debate: should trainees be given experience in such areas as an elective? Should the criteria for selecting training practices be similar in all areas? Should practices in deprived areas be encouraged to apply to become training practices?     

What do Wessex general practitioners think about the structure of hospital vocational training?

OBJECTIVES--To assess the views of general practitioners about the structure and content of hospital vocational training and its relation to the training year. DESIGN--Postal questionnaire. SETTING--Wessex, England. SUBJECTS--General practitioner trainees undertaking practice training year (n = 144), course organisers (n = 22), and a random sample of two thirds of trainers (n = 135). RESULTS--Questionnaires were returned from 86% (260): 84% of trainees (121), 92% of trainers (124), and 68% of course organisers (15). Most respondents in all groups (84.3%, 95% confidence interval 79.7% to 88.8%) wanted more jobs lasting two and three months to allow a greater range of hospital specialties to be experienced and some of the training year to be carried out before hospital jobs (66.3%, 60.4% to 72.1%). Most hospital specialties were rated at least 6 out of 10 as "useful" for general practice training. A substantial minority of training posts did not have regular weekly teaching (166/541; 30.7%, 26.8% to 34.6%) and had no half day (224/541; 41.4%, 37.3% to 45.6%), and over half gave no study leave (293/541; 54.2%, 50.0% to 58.4%). CONCLUSIONS--The structure of hospital training should be reviewed as it does not reflect the views of most trainees, course organisers, or trainers. Individual posts need closer supervision to ensure the availability of basic training requirements. More trainees should be allowed to spend a short time in the general practice before hospital rotations and to choose a greater range of shorter jobs.     

A career structure for general practice.

Training for general practitioners usually provides little experience in research, business management, or dealing with chronic disease. It is these areas that could provide scope for further training after becoming a general practitioner principal and provided career goals. Formally recognised research practices, perhaps with one partner coordinating research but all participating, and district research facilitators could increase both the quality and the quantity of research in general practice. Recognising the different skills of doctors in the partnership and referring patients to the most appropriate partner will improve care for patients as well as provide career development. Further training could be aimed at filling gaps in the practice''s pool of skills. Good management skills are becoming more important as practice teams get bigger and fundholding spreads. Some doctors may wish to become full time or part time managers and the idea of accredited courses for management has been raised.