The exceptional potential of learning in general practice

Four papers in this edition of Medical Education report the results of research carried out in the context of general practice.1–4 At first glance, their setting appears to be the only thing they have in common. Two of the papers concern undergraduate medical education1,2 one is about general practice training3 and one concerns continuing professional development.4 One of the papers is from the United Kingdom1 (UK) and the other three are from the Netherlands.2–4 We would argue that this somewhat disparate group of papers have something else in common – they illustrate the exceptional potential of learning in general practice. Over the past decade or so, across the world, increasing numbers of medical schools have adopted a greater community orientation. They have recognised that medical schools have a duty to serve the community in which they are based, and that they may be more likely to produce doctors who will want to work in that community if they have had experience of learning in it as a student.5 In the UK and the Netherlands, community based experience predominantly involves teaching and learning in general practice. The proportion of time that medical students spend learning in general practice has been increasing in the UK. In 1986, university departments of general practice had educational responsibility for between 20 and 40 sessions per medical student during the entire five year undergraduate course. In 2001, they had responsibility for an average of 120 sessions (interquartile range 80–132). Academic general practice now contributes, on average, 9% of undergraduate teaching in UK medical schools.6 This trend is likely to continue given the expansion of medical school places in the UK, the pressures on secondary care of increasing specialisation, more rapid throughput of patients and so on, along with the ideological drive towards community oriented medical care and medical education. Indeed, all four of the new British medical schools established in the past five years, have a major community dimension in their curricula, with students spending significant amounts of time learning in general practice and other community settings.7 The first paper from Birmingham, examining the impact and potential of placing students in practices not traditionally involved in teaching, is therefore timely. Interviews were carried out with members of the practice team and not only with the general practitioners (GPs).1 The study confirmed the predominantly positive findings of a recent systematic review of community based teaching (Williams E, Williams ML. A systematic review of community-based undergraduate medical education. Presentation at Association for the Study of Medical Education Annual Scientific Meeting 2004, Liverpool, UK). They confirmed that community placements offer important learning opportunities for students, benefits to GPs and patients, and potential benefits in recruiting GPs to traditionally hard to recruit in areas. The second paper discusses an ‘Adoption Programme’ in general practice for students at an early stage of their course in the Netherlands.2 Adopting GPs invite suitable patients to the practice or arrange appropriate family visits that link with the parallel theoretical course and skills' programme. Students undertake specific assignments and have time for discussing their experiences with their GP and a practical ‘coaching’ group. This enables students to embed their clinical experience in their theoretical knowledge. They also have an opportunity to reflect on their attitudes towards patients. The authors of this paper explore the underlying causal model of the learning process in the adoption programme and have distinguished the two primary learning processes as action (carrying out the assignments) and reflection on action (discussion and feedback). They found that the feasibility and execution of the assignments was clearly influenced by the adopting GP. They concluded that, to fully exploit the educational possibilities inherent in the adoption programme, patient encounters and feedback and reflection need to be very carefully planned. GPs also need adequate training for their teaching and coaching activities. The third paper by Maiburg and colleagues describes using standardised patients (SPs) as ‘known’ patients in general practice to assess GP trainees.3 A previous problem with using SPs in general practice has been that they have to be ‘new’ patients and this influences the kinds of problems seen and increases the chance of their detection by trainees. The painstaking detail needed to prepare the patients, their records and the practice to try to avoid detection is described. It is interesting that some patients even underwent unintentional examinations to avoid detection including rectal examination and blood testing. The authors concluded that using incognito SPs as known patients was feasible but labour-intensive. The final paper in this group of four describes the process of setting a standard for assessment of performance in the real practice of GPs.4 In this study, GPs were observed in their consulting room with a video observation system for a week. A trained GP observed selected consultations and scored them using a validated instrument – the MAAS-Global scoring system. Two established standard setting approaches, an Angoff and a Borderline regression method were compared. In the Angoff, a panel of eight GPs determined the minimum standard during a 7 hour meeting. In the borderline approach, 41 GPs who had been extensively trained over two 3 hour, sessions were involved in rating consultations. Both the Angoff and borderline regression procedures produced a credible standard for the assessment of doctor–patient communication in day-to-day general practice. The authors conclude that the choice of method depends on the intended purpose of the standard. These four interesting and carefully performed studies provide evidence of continuing educational innovation in the general practice setting, and of the useful learning, teaching and assessment opportunities that can be provided. Of course, it could be argued that similar opportunities are possible within hospitals but, given the constraints already mentioned on hospital teaching, these studies would be inherently more difficult to carry out. It is, therefore, likely that teaching and learning in general practice will increase. This transfer will need to be well resourced to attract further GPs to become involved in teaching and training, particularly given the other pressures on GPs' time due to new contractual demands and transfer of care from secondary to primary care. The most common concern voiced by interviewees in the Birmingham study was about lack of resources and inadequate financial reimbursement to cover the costs of teaching.1 This issue needs urgent attention if teaching in general practice is to further expand. Without additional resources for practices and academic departments of general practice, which develop and organise this teaching, the full potential of learning in general practice will not be realised.