Teaching and Learning in Primary Care in the UK
Delivered at the Yokohama City University Medical School on 12.11.2001
(Please note that at the end of this page there is a list of links to the web sites of many of the organisations referred to in the lecture)
Good evening ladies and gentlemen. I am very honoured to have been asked to come to speak to you this evening about the training in Primary Care - or general practice as it is often called - of medical students and qualified doctors in the United Kingdom.
May I first introduce myself and tell you a little about my own background in medicine
I received my undergraduate training at The London Hospital, one of the colleges of the University of London, between 1964 and 1969, qualifying with my bachelors degrees in Medicine and Surgery in 1969 and becoming fully registered with the General Medical Council of the United Kingdom (GMC) in 1970. At Medical College I had the honour to be taught, briefly, by my own father, who was a specialist in Rheumatology, and a most distinguished physician and teacher. Some of you may already know, and all of you will be interested to hear, that my father was born in Yokohama in 1906, and lived here as a small child, and I know how delighted he would have been that I should have returned to his place of birth, of which he often spoke so affectionately, to meet such a distinguished audience today.
My decision to enter primary care as a general practitioner was made early in my career. I undertook vocational training - which at that time was not a mandatory requirement - in the early 1970s and joined a group of general practitioners in south east London in 1976. I have continued to work within this practice for the past twenty five years.
In 1980 I sat and passed the examination for Membership of the Royal College of General Practitioners. This examination is a well researched and validated instrument for determining the achievement of a higher level of skills and knowledge in primary care doctors, and it is usual although still not obligatory for general practitioners to prepare for and pass this examination. Passing the examination set me on the road towards teaching and training within my profession. Initially I would have undergraduate medical students attached to me for two weeks at a time to learn about the way general practice functions and the work that general practitioners do. I went on to become a qualified GP trainer in 1984, and I will explain the structure and content of training to be a general practitioner later in my talk. In 1989 I was appointed a GP Course Organiser by the University of London. Course Organisers are responsible for overseeing the training of a group of about twenty qualified doctors through approved junior hospital attachments and experience in an approved training practice - again, more of this later on.
In 1991 I commenced my studies for a Masters Degree in general practice in order to reflect upon and learn from all my accumulated years as a doctor, and graduated in 1993 from the University of London.
In the year 2000 I was elected a Fellow of the Royal College of General Practitioners.
Since that time I have become active in one of the pilot studies for revalidation of doctors. The particular scheme I am involved with has been developed by a working party from the Royal College of General Practitioners and is called "Accredited Professional Development" Again, more of this later.
Primary Care in the Undergraduate Curriculum
I will now talk rather briefly about the role of primary care doctors in the teaching of medical undergraduates, and I would ask you to appreciate that although the practice where I work is very active in undergraduate teaching - indeed, one of my partners has held a leading role in its development - I myself am no longer involved in this work, confining myself wholly to the teaching of postgraduates.
The requirements for training to be a medical doctor in Britain are laid down by the General Medical Council of the United Kingdom. Members of this audience may wish to make a note of the Web Site of the GMC, and you will find there far more detail about its wider functions as they pertain to setting standards of practice and ensuring that these standards are maintained.
Essentially, the, the General Medical Council licenses doctors to practise medicine in the UK. Its purpose is summed up in the phrase 'protecting patients, guiding doctors'. United Kingdom law gives the GMC four main functions:
Keeping up to date registers of qualified doctors
Fostering Good Medical Practice
Promoting High Standards of Medical Education
Taking action against doctors whose fitness to practise is in doubt.
I will talk further about the General Medical Council when I come on to the topic of revalidation of doctors later in this presentation.
The contribution by general practitioners to the training of medical undergraduates is in a state of flux and development. Traditionally, students were attached to general practitioners for brief spells not long before they were to sit their final examinations. Various factors have brought about changes to this rather simplistic "taster" in general practice in recent years.
Patients with acute and chronic medical and surgical problems are managed as in-patients for a far shorter time, if at all, than was the case in the past.
General practitioners are managing far more acute and chronic medical conditions in the community than used to be the case. Examples include the management of diabetes, hypertension, asthma and peptic ulceration.
About one half of all qualifying doctors in the United Kingdom will go on to become general practitioners.
General practitioners have now achieved a proven track record of being able to provide effective medical education to include clinical medicine and surgery in a community setting. This has proved popular with both undergraduates and the Medical Schools, and its success is evident in examination results.
Let me show you a brief overview of the training provided to undergraduates in the immediate district where I work. Our teaching hospital is Kings College Hospital which is a part of Kings College of the University of London. Besides the clinical components of Chest Medicine, Abdominal medicine and surgery, and Neurology and Psychiatry, much emphasis is placed on the learning of the skills of communication, the overall management of chronic disease, and the role of the Primary Care Team.
I am sure that I do not need to tell you that poor communication technique is a criticism that has been levelled frequently against some members of the medical profession in recent years. The tendency by doctors to involve patients more actively in decision making, and a better informed and more exacting public has brought about the need for doctors in training to take seriously the arts of listening and talking to the patients whom they work with. Experienced general practitioners are well placed to impart the theory and practice of communication, and several of the major works in this field have been written by doctors working in primary care.
Most medical students find their time in general practice a rewarding and enlightening experience. For some of these it is the catalyst that determines the path of their own career in medicine, for many will decide that primary care is the field in which they would like to work as qualified doctors. General practice teachers recognise this and would nurture and encourage their decisions. For there is a shortage of good general practitioners in the UK, particularly in such environments as the inner cities where I myself work. While the recruitment of doctors into primary care is not, and should not be a stated objective of undergraduate teaching, it is perhaps a reflection of the enthusiasm of the teachers and the quality of the experience offered to undergraduates in the community that such commitments are made at such an early stage in medical careers.
National Health Service Primary Care in the United Kingdom
As I have already said, about half of all medical graduates in the United Kingdom will decide to make general practice their chosen career. Before I go on to tell you about the structure and process of postgraduate training in general practice, I thought I should say a few words about the way primary care works in the United Kingdom.
Primary care doctors are, essentially, general physicians working in the community from health centres or clinics. Perhaps ninety percent of the work they undertake is without any input from hospital specialists, although they will be expected to refer patients to hospital where this is appropriate. Every UK citizen is entitled to register with a general practitioner of his or her choice, and all consultations with the doctor are free at the point of contact. The greater part of all prescribed drugs are free as well. The National Health Service in the United Kingdom is funded by direct taxation. Most general practitioners work in groups, with greater or lesser support from ancillary staff such as nurses, midwives, physiotherapists and psychologists, and sharing out of hours responsibility among one another. I myself work in a large team of eight doctors of whom three are men and five are women, in a purpose built clinic in a densely populated part of south London. Between us we have 24 hour responsibility for some 15,000 patients, the greater number of them living within a kilometre of our surgery premises.
Most of our patients are seen by appointment in the surgery, with a facility for seeing more urgent problems quickly and without an appointment. Visiting patients at home has also been a tradition in the United Kingdom in those situations where the patient is too infirm or sick to be brought to the surgery. Many doctors, however, consider home visiting to be an inefficient way of delivering health care, believing that they should be available to see patients at the clinic if at all possible rather than using valuable time making their way through dense traffic in the car. It is also argued that the standard of care delivered away from the clinic is likely to be inferior given the diagnostic and technical facilities that modern medicine depends on and that cannot be readily transported to the patients home.
There is a sharp contrast between practice in a rural or remote area and that in an urban setting. Rural general practitioners are likely to have training in emergency procedures that their colleagues in the cities may have little need of, given the ready access in towns to Accident and Emergency centres in the large general hospitals.
Perhaps the most important difference between the hospital specialist and the community generalist is that patients attending hospitals in the UK are usually referred by another doctor - the general practitioner - often with an established medical condition or disease, whereas in the community patients refer themselves to their doctor with a set of symptoms that may or may not have their origins in organic disease. So the general practitioner talks about the presenting problem as opposed to illness. It follows that one of the most essential skills of the GP is that of determining what is and what is not a consequence of a disease process. Thus good communication skills, as I have already alluded to, are the one prerequisite of safe and effective clinical practice for the primary care doctor.
You may already know that some interesting data has been collected and analysed to demonstrate that general practitioners working sessions in hospital Accident and Emergency Departments refer significantly fewer patients to specialists, and fewer x-rays and blood tests than do the full time A and E doctors. Later in this talk I will show you a list of references to the literature published on these studies.
Postgraduate Training for General Practice
I am now going to proceed to outline to you the structure of postgraduate training as it pertains to general practice at this time, and comment briefly on how it is likely to evolve in the future. I will also tell you how, in south east London, we have pioneered innovative training with the help of our local health authority in an attempt to address the problem of recruitment and retention of good quality general practitioners in our locality.
The content of Postgraduate general practice training the UK is laid down by the General Medical Council and administered by the Joint Committee for Postgraduate Training in General Practice (JCPTGP)
The Joint Committee was set up in 1976 by the Royal College of General Practitioners and the General Practitioners Committee of the British Medical Association as an independent body representative of the profession.
In 1979 the Joint Committee was appointed by the Secretary of State for Health as the body responsible for administering the NHS (Vocational Training) Regulations that came into operation in 1981.
In 1994 the Joint Committee was designated the Competent Authority for certain sections of the EC Directives relating to the supervision of training programmes and the issue of certificates.
Role of the Joint Committee:
Issue certificates of and to doctors who satisfactorily complete the required training for general practice. A Joint Committee certificate is licence to practise as a GP in the UK. All doctors who want to work in general practice in the UK must have a Joint Committee certificate, unless they fall into one of the categories that makes them exempt.
Issue certificates of Acquired Rights to eligible doctors
Set the standards of general practice training throughout the UK and the Armed Services. This includes the approval of posts and trainers, the supervision of training and the monitoring of deaneries in providing training programmes
Act as Competent Authority in the UK for all the purposes of Title IV of European Council Directive 93/16/EEC (which deals with arrangements for training and employment of general practitioners in the European Economic Area (EEA), except for the recognition of certificates issued by another member state of the EEA
Web Site of the Joint Committee Click Here
The structure and content of GP Vocational Training
The required experience for eligibility to practise as a general practitioner in the United Kingdom has changed little over the past quarter of a century or so. There is general agreement among medical educationalists that it no longer meets the requirements for present day primary care, and it is likely that there will be some radical changes to vocational training over the next few years.
No doctor may enter vocational training until he or she has completed one year working in an approved post at a pre-registration house officer. Upon graduation from medical school, a doctor is granted provisional registration by the General Medical Council and will proceed to full registration upon satisfactory completion of an approved pre-registration appointment. These are normally undertaken in hospital in both medical and surgical positions. A small number of pre-registration house officers may be attached to an approved general practice in lieu, for a period of four months.
At the present time, training for general practice is made up of working as a senior house officer for two years in hospital posts that have been approved by the Royal College of General Practitioners and the Postgraduate Deanery for that area, and one year working with an experienced general practitioner who is an approved trainer within a practice that has met certain criteria deemed important for the training experience.
Some doctors will have accumulated considerably more experience pre-registration posts alone before deciding that they wish to train as general practitioners. If this experience has taken place in hospital in posts that have been approved for the purposes general practice training, then the doctor may be able to gain exemption from further hospital experience and apply directly to join a training practice for one year.
Appointment to a Vocational Training Scheme or to a Training Practice is made subject to the candidates being able to demonstrate eligibility as determined by criteria laid down by the General Medical Council and European Union law, and by interviews undertaken by a panel appointed by the Postgraduate Dean for designated geographical areas. At the present time, vocational training for general practice is a popular option for junior doctors and there is much competition for places on schemes.
Newly appointed doctor joins a teaching practice for the first three months before moving on to the hospital and community specialist rotation. This component lasts two years after which time the vocational trainee returns to an approved practice for the final nine months of training.
I would like to say something now about the content of vocational training in my particular geographical area, and its recent past history. As I have indicated, vocational training is in a state of flux as it attempts to evolve to keep up with seemingly endless change and development in the world of primary care. For many years it was recognised that the experience offered to young doctors in training for general practice was often quite inadequate, even inappropriate, for their needs. As an example, a junior doctor might be required to spend long hours in a special care baby unit in his or her paediatric attachment. Now while this experience might be relevant for a doctor intending to specialise in childrens medicine, is it of little use to a doctor who, after completion of training, might never see an incubator again.
Recognising this, the course organisers for the three vocational training schemes in south east London came together about eight years ago to form an association called the South London Organisation of Vocational Training Schemes, which name is usually shortened to its acronym, "SLOVTS". The initiatives proposed by SLOVTS were and continue to be given much support and financial input by the Lambeth, Southwark and Lewisham Health Authority (LSLHA), who quickly accepted our proposal that high quality training might well have a positive effect on the recruitment and retention of high calibre general practitioners in south east London. For it has long been recognised that urban and inner city communities have suffered a chronic shortage of good quality GPs.
All three schemes working under the SLOVTS umbrella have achieved considerable success in creating innovative hospital posts designed specifically to meet the educational needs of aspiring general practitioners. Built in to each post are carefully designed teaching programs and formative assessment processes developed with the help of professional educationalists employed by SLOVTS.
SLOVTS has gained a considerable reputation nationally in the UK and competition for places within its three vocational training schemes is very keen. Potential vocational trainees recognise that the organisation offers very considerable advantages in terms of experience and teaching. We understand that similar initiatives are under consideration in other parts of the UK.
I should say at this point that SLOVTS does not concern itself only with immediate postgraduate training for general practitioners. Another of its successful initiatives is the Vocationally Trained Associate scheme. Through this, young doctors who have successfully completed vocational training can apply for an additional years experience in an approved practice during which time is set aside for further study and to learn research method. Many Vocationally Trained Associates will study for higher examinations such as that for membership of the Royal College of General Practitioners.
SLOVTS has a tradition for undertaking and commissioning studies for publication in the medical literature.
A word now about the learning experience for vocational trainees during their attachment to a training practice. This is very much a "learning by doing" experience: the trainee - referred to as a "GP Registrar" while in post in general practice - will be responsible for the care of her or his own patients, under the supervision of an experienced GP Trainer who has been specially trained and approved for this purpose. The system may be compared to an apprenticeship. Teaching and learning plans are based not so much on a set curriculum but upon the particular learning needs of each GP registrar. Learning needs and learning plans are drawn up by the GP registrar and the trainer together. Tutorials are held regularly and are based upon problems and issues encountered by the registrar in her or his day to day work.
Teaching is based not so much on formal lectures and giving of information and knowledge, but on encouraging learners to identify for themselves their learning needs and limits of competence and then to seek out for themselves the means to address these needs. The tutor or trainer will act as a guide rather than an information resource, and help the learner to seek out sources of quality and up to date information for themselves, be they the current literature, the Internet, standard text books, or a visit or telephone call to a specialist colleague.
The development of good communication skills is a central part of all GP training. Many GP educators, myself included, have studied and taught in this field to a considerable extent. I have already drawn attention to the fact that people often present to general practitioners with life problems, fears and anxieties that they present in terms that they believe will be acceptable to the doctor. Thus it is that an elderly person may present with an array of vague symptoms that reflect fear associated with social isolation. Or a child frightened by his experiences at a new school may be brought to the doctor by his parents, worried that his abdominal pain is caused by an inflamed appendix. I would contend that many children have been submitted to surgical procedures, with all their documented morbidity and mortality, that might have been avoided had the doctor been trained only to listen. All doctors are aware of the numbers of normal appendices removed at surgery, and one cannot help but wonder if this was the result of poor clinical judgement in the first place. But these examples serve to illustrate but a small part of the spectrum of listening and questioning skills that need to be acquired by the effective, safe and compassionate doctor.
I am often at pains to emphasise to my own students that the ability to listen is perhaps the most significant attribute of the good doctor. Indeed, the majority of their patients would agree with this: studies have repeatedly shown that what patients most value in their family doctor is his or her willingness to listen to them. My own experience over many years is that patients are much more inclined to be forgiving of clinical errors if they believe that they have been afforded the simple, yet profound, courtesy of being listened to. The great physician, Sir William Osler - a contemporary, incidentally, of my great grandfather Dr Stuart Eldridge - reminded us of the same in his oft quoted dictum "listen to the patient. He is telling you the diagnosis" . Even after the passing of almost one hundred years, we and those whom we teach do well to ponder often over these words.
By what means do we help our students to develop good communication skills? It is certainly important that they become familiar with the wide literature now available to them, and I have referred earlier to these. One example is the use of an instrument for the analysis of the consultation in the context of the exchange of information between doctor and patient devised by Pendleton and his co-authors. Now, this is important in the study of recorded consultations that are now widely used for both learning and assessment in training in primary care. The criteria can be used as a framework or loose score sheet for commenting upon each consultation, and to increase the understanding of the practitioner of the consultation dynamic and the way in which he or she tends to react in particular circumstances. But the Pendleton model, although currently the most used at the present time, is not the only system by which consultation and communication techniques may be studied. I expect that you will be aware of the seminal work undertaken by Michael Balint and his wife to encourage the general practitioner to study the emotional impact that their patients had upon them. This work was undertaken not much less than fifty years ago, yet is valued now as much as it was when its publication first created such an impact upon the way doctors thought about their dealings with their patients.
Before a general practitioner is allowed to practise independently he or she must, at the end of their vocational training, have demonstrated competence as a doctor by passing a modular examination called Summative Assessment.This consists of four modules - a multiple choice examination, an audit or practice based research project, a video tape of a series of the doctors consultations, and a detailed report drawn up by the GP trainer. Most GP registrars will pass this hurdle with little difficulty, but it does, nevertheless, generate a lot of anxiety and there is some concern that the anticipation of the examination and preparation for it actually impede the learning process for the doctor. I am myself an examiner for the video component of Summative Assessment. We require candidates to provide recordings that cover a range of clinical and psychological problems, and of sufficient challenge to enable them to demonstrate competence. If the examiner is not satisfied that competence had been demonstrated, he or she will refer the tape on for a further opinion from a second level assessor. The failure rate, in the end, is around about five percent. Doctors who fail Summative Assessment may apply for a further extension of their GP training.
Higher Training in General Practice
All doctors in the United Kingdom are expected to engage in learning activities throughout their professional careers in order to keep up to date with medical advances and to remedy any areas of deficiency that may become apparent. Many will study for higher degrees and diplomas, and there is an increasing trend among new GP principals to study for and sit the examination for Membership of the Royal College of General Practitioners. Perhaps at this point I should refer briefly to the Royal Colleges associated with the various specialities within the medical profession in Great Britain and the Commonwealth. The older colleges date back as much as 450 years in the case of the Royal College of physicians, and only 50 years in the case of the Royal College of General Practitioners. Essentially, the function of the Colleges is to conduct training, education, examinations and research in medicine, and to advise the Government, the public and the profession on health and medical matters.
The RCGP was formed in November 1952 with the aim of establishing an academic headquarters for general practice in order to raise the standards and status of general practice, to persuade other doctors to enter the profession and to encourage medical students to regard general practice as a specialism which could offer them an interesting and rewarding career.
In 1967 the College of General Practitioners was granted the Chartered status and in 1972 it was awarded the Royal prefix. This coincided with its 21st anniversary, when HRH the Prince Philip, Duke of Edinburgh was elected as President of the College. His Royal Highness has continued as Patron since then. The College was honoured again when HRH the Prince of Wales accepted the Presidency during the Colleges 40th anniversary year in 1992.
Interestingly, general practice has lagged behind other specialities in not making membership of its Royal College a requirement for independent practice, and there has, traditionally, been a significant faction among the ranks of my colleagues that has resented and resisted the notion that it should be so. But recent generations of younger doctors have shown an increasing desire to pass the examination and some of us feel that it is only a matter of time before general practice falls in line with the rest of the medical profession. At present, it is mandatory only for those doctors wishing to become GP tutors and trainers. Time does not permit me to explain further the function of the Royal Colleges of the medical profession in the UK, but you may wish to find out more for yourselves on the college web site .The membership examination is a measure more of excellence than minimal competence, and failure rates exceed considerably that of summative assessment. Like Summative Assessment, it is a modular examination and the general principle is that a candidate need only re-sit those module that he or she has failed. Although the examination bears a similarity with that for Summative Assessment, the level of ability that candidates are expected to demonstrate is much higher for the membership examination. There is an additional written paper, and this will always include a critical evaluation of a published piece of research. And there are stiff oral examinations mostly held at the Royal College in London.
There are other diploma and higher degree examinations that established general practitioners may go on to sit. The more popular diplomas include those for Obstetrics, Child Health, Geriatric Medicine, Dermatology and Sports Medicine. A minority of doctors will go on to meet the far greater challenge presented by studying for higher degrees and completing research for a doctoral thesis.
In recent years the British universities have set up Masters Degree courses that are particularly attractive to experienced general practitioners. I thought I would say a few words about the M.Sc. course that I myself joined in 1991. This is a part time course exclusively for general practitioners, which originated at the Department of General Practice at Guys Hospital Medical School - one of the colleges of the University of London. The components of the course include Research Method and Statistics, Clinical Reasoning, Social Science as applied to Medicine, the Process of Learning and Medical Ethics. Examination for the degree consists of the submission of eight assignments as a part of a portfolio built up throughout the course, a written examination at the end of the course, oral examinations and the completion and write up of a substantial piece of research relating to general practice. It is customary for students to submit their research projects to one or more of the major peer references medical journals for possible publication.
Graduates from the Masters course will often go on to do further research or engage in other academic activities and teaching. Some have contributed to or written text books relating to general practice. Most, myself included, find that the experience of working for the Masters degree has a profound affect upon the way they understand themselves, their patients and they way that doctors and patients work together. I would go further and say that, for me the two years spent on the course were the most significant in the whole on my medical career.
Information Technology in Teaching and Practice
When I first became a general practitioner, the concept of using a computer in ones day to day work was an alien one. My own group practice was one of the first to install a computer on the premises - a bulky and ponderous machine which held, essentially, a database of all the patients registered at the practice, and their ages and sexes. Beyond keeping this record, its other main purpose was to print out repeat prescriptions. Twenty years later, every doctor and nurse in the building has their own computer terminal on their desks, and there are five terminals in the reception area alone. I hardly need tell you the revolution that this particular information technology resource has had upon the way in which we work and learn. Perhaps I can illustrate this by telling you something of the way the technology has impacted upon my own work: Every day, when I start work at the surgery before my patients start arriving, I check my electronic diary so that I can remind myself of commitments, telephone calls to be made and letters and reports to be written. I read whatever e-mail messages may have arrived overnight. I send e-mails to colleagues and learning groups with which I am involved, all over the country. I may order a new medical text book via one of the Internet book shops.
When my patients begin to arrive, I will know that they are in the waiting room because the secretary downstairs has checked them in on her own terminal. Before I call my first patient in I can look at her medical history, recent medication and health check status on my own terminal. During the consultation I can enter all the details of her complaint, and draw up and print out a prescription for her. The computer will remind me if we lack some essential data on her, such as smoking status, and if she is due for a routine health check such as a blood pressure recording or a cervical smear. The results of any recent blood tests or x-rays from the laboratory at the local hospital will be available through an electronic connection. The computer will alert me if there is a history of drug allergy, or if the drug I might wish to prescribe for her condition might interact adversely with other current medication. If I think that I need to brush up on my knowledge of her condition, or the latest treatment for it, I can access the information I need on a variety of databases via the Internet, either while she is in the consulting room or after she has left. If I want to give her some printed self-help advice, there is a huge range of useful material stored on the hard disk that is immediately available to me. If I decide to refer her to a specialist colleague at hospital, I can arrange an appointment from my desk, again via an electronic connection, and ensure that the appointment is given within a desired time scale and at a time convenient for my patient. If I would like to review her case again myself, I can make an appointment for her on my own terminal, perhaps together with a reminder that I will need to have the results of whatever tests I have ordered, to hand.
Should an emergency such as a cardiac arrest occur in the surgery, I can use a "smart" defibrillator that will not only determine the type of heart attack the patient has suffered but will also guide me as to the necessary action to take.
If I am "on call" for emergencies out of hours I can take patients electronic records with me on a lap top computer. I can be contacted quickly by my mobile telephone in an emergency
At the end of a days work I can analyse what I have been doing by feeding data from my consultations into a spread sheet or statistics program. By this means I can study my prescribing and hospital referral patterns and compare them with those of my colleagues.
All of this might have seemed unimaginable to me twenty years ago, and yet all the indications are that we are only at the start of the information technology revolution in primary care. But it is reassuring that the face to face contact with the patient has been little affected by all these advances. It does not seem even remotely probable that the general practitioner will one day be replaced by a machine. Rather, it has been the experience of most of us that this sophisticated technology has enabled us to work more safely and efficiently, and has freed up more time to give to our patients.
I have already alluded to the benefits that information technology has brought to teaching and learning in primary care. Both the undergraduate and postgraduate student are constantly having to access, store, process and retrieve information. This has always been the case. But in the past it could be a time consuming and frustrating business. I well remember the hours spent in the medical school library, searching through the heavy volumes of Index Medicus in order to undertake a literature review for one essay or another that I had been required to write. My own registrars now have immediate access to databases world-wide with sophisticated search techniques built in to them. The databases contain not only references to the literature, but also in many cases an abstract of the relevant publication. Many journals are now published "on line", not least the British Medical Journal which has been published electronically for the past six years now. Our library shelves are at last becoming less burdened with an ever expanding and increasingly dusty collection of medical literature: the student merely searches on the Net and prints our the paper that she wishes to read.
Our own vocational training scheme provides its members with laptop computers for the storage and analysis of information, and to build up a learning portfolio. They are also expected to create presentations on various relevant topics to bring to our regular study afternoons. They use a program by Microsoft called "Powerpoint" to project the presentation on to a screen. For those of you who are not familiar with this technology, it bears some similarity to a slide show, but is immensely more versatile, using movie and sound clips as well. The whole presentation can be stored on a floppy disk or a CD ROM.
By the time they complete their training, the doctors preparing to become general practitioners will be familiar with generating spreadsheets to present their data, and with the use of simple statistics programs for tests of significance etc.
The Revalidation of Doctors and Accredited Professional Development
In recent years increasing concerns have been raised about the continuing fitness of doctors to practise, highlighted by a small number of cases of failing doctors or frankly dangerous, even criminal activities. Two such instances in particular are worth noting because of the impact they have had upon the medical profession and the effect they have had on the trust of the public in doctors as the whole.
The first concerns the care of children who received complex heart surgery at the Bristol Royal Infirmary between 1984 and 1995. In 1998 the setting up of a Public Inquiry was announced following hearings by the Professional Proceedings Committee of the General Medical Council which began to hear allegations against three doctors in October 1997. The public inquiry took place between October 1998 and July 2001. It emerged that standards of practice and management had lapsed to such an extent that childrens lives had been put unnecessarily at risk, and indeed, many had died either during surgery or in the immediate postoperative period. The morbidity and mortality rates were significantly above those which might generally have been associated with such procedures.
The second concerns the case of Harold Shipman In January 2000 Shipman, a general practitioner in Hyde, Greater Manchester was convicted of murdering 15 of his patients and of forging the will of one of them. The events in Hyde were particularly shocking because they struck at the bond of trust which exists between doctors and their individual patients and which is at the heart of good medical practice throughout the world.
The Chief Medical Officer for the Department of Health in the United Kingdom made the following comment following an inquiry into the activities of Shipman following his conviction: Everything points to the fact that a doctor with the sinister and macabre motivation of Harold Shipman is a once in a lifetime occurrence. That does not mean that we should dismiss the need for action beyond the investigation of the events themselves. There is much to be learned from this tragedy. The first duty of a health service is to protect patients from harm.
May I now quote Sir Donald Irvine, the President of the General Medical Council, who remarked as follows in his delivery of the Lloyds Roberts Lecture at the Royal Society of Medicine on the 16th January 2001:
It was the vivid portrayal of the Bristol tragedy all those children and parents, real people, not statistics or cases that drove the message home, assisted by the dramatic media presentation which compelled everyone to listen and act ...The GMC published the new Code Good Medical Practice in 1995 and its new Performance Procedures came into action in 1998. And by that summer it was clear that the regular systematic assessment of doctors performance was now essential to give patients proper protection. Revalidation is the instrument for making this happen. The majority of the GMC and the Royal Colleges were determined that this should happen. The hospital specialists and public health doctors committees of the BMA were disappointingly negative. Fortunately the profession is now coming together in a more positive consensus around this proposal.
Propelled by such examples of scandal and tragedy, the periodic revalidation of all medical doctors in the United Kingdom has now been approved, and comes into effect from April 2002
The process of revalidation has been laid down by the General Medical Council. As I said earlier in this presentation, a major function of this institution is the maintaining of high standards of professionalism and care in doctors
The GMC has determined that revalidation will normally have three stages:
1. A folder of information describing what the doctor does and how well the doctor does it. This will be regularly reviewed - annual appraisal will fulfil this in many sectors.
2. Periodic revalidation - a recommendation by a group of medical and lay people that the doctor remains fit to practise, or that the doctor's registration should be reviewed by the GMC.
3. Action by the GMC - in the majority of cases, revalidation of the doctor's register entry. In a minority, detailed investigation under our fitness to practise procedures, which can lead to restrictions upon practice, suspension, or erasure.
With regard to general practitioners, the Royal College of GPs was anxious to become actively involved with revalidation as soon as it became apparent that the legislation would almost certainly be passed to bring the process into existence. As a result the College has developed and is now piloting its own system of revalidation, Accredited Professional Development. I was invited to become involved with the pilot at the beginning of this year.
Accredited Professional Development (APD) is a professionally led system for all general practitioners across the UK to demonstrate their continuing professional development and prepare evidence for revalidation. This new framework has been designed by Professor Janet Grant and Professor Dame Lesley Southgate for the Royal College of General Practitioners.
Essentially it consists of three activities:
A continuous module: keeping up to date and improving care
Discrete modules which are each undertaken at least once every five years
Facilitation: a peer review at least once a year, considering participation in APD and all aspects of professional behaviour described in the recently revised Good Medical Practice for General Practitioners published by the RCGP but based on Good Medical Practice by the General Medical Council (GMC). The peer review will serve as an annual appraisal
I have been appointed as one of a group of about twenty facilitators in the south east of England, where the pilot scheme for APD is currently taking place. At the present time I work with a group of five general practitioners who have applied for and been accepted on to the pilot scheme. The project is at the same time a challenging and exciting one, and we are optimistic that we will be able to stimulate our own ongoing learning and maintain our enjoyment and enthusiasm for our work. And we hope that the public whom we serve will be reassured by our efforts and our determination to maintain the standards they have a right to expect of us, and that they will continue to place their trust in the medical profession as they have done for so many years.
Ladies and gentlemen, this brings me to the end of my presentation to you this evening. I hope that it has been of interest to you. I should be delighted to try to answer any questions that you might now like to put to me.
Links to Web Sites for various organisations referred to in the above lecture:
British Medical Association (BMA)
DEPARTMENT OF HEALTH
JOINT COMMITTEE FOR POSTGRADUATE TRAINING IN GENERAL PRACTICE (JCPTGP)
LAMBETH SOUTHWARK AND LEWISHAM HEALTH AUTHORITY
ROYAL COLLEGE OF GENERAL PRACTITIONERS
GENERAL MEDICAL COUNCIL
DEPARTMENT OF GENERAL PRACTICE and PRIMARY CARE (There are details of the Msc Course on this web site)
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