Letters

Postgraduate education for general practitioners

BMJ 1997; 315 doi: http://dx.doi.org/10.1136/bmj.315.7121.1543 (Published 06 December 1997) Cite this as: BMJ 1997;315:1543

Centrally funded scheme would not necessarily be better

  1. Jamie Bahrami, Director of postgraduate general practice educationa
  1. a Department for NHS Postgraduate Medical and Dental Education (Yorkshire), University of Leeds, Leeds LS2 9JT
  2. b Corbridge Health Centre, Corbridge on Tyne, Northumberland NE45 5JW
  3. c 463 Springfield Road, Belfast BT12 7DN
  4. d Exeter Postgraduate Medical Centre, Exeter EX2 5DW

    Editor—The conclusions of the report by the West of Scotland Postgraduate Medical Education Board on general practitioners' attendances at postgraduate education activities are open to debate.1 The implied assertion that a centrally organised scheme is better than an open and free education market (working to professional standards) requires more evidence. After all, one of the most important reasons for introducing the postgraduate education allowance was to encourage personal responsibility for learning and development in general practice education and a move towards the concept of the purchaser-provider partnership.

    Despite some of the limitations of the postgraduate education allowance, many exciting methods of education are now available to general practitioners. Distance based learning programmes, practice based educational activities, personal education plans, and portfolio learning now dominate continuing medical education and professional development. In addition, through the postgraduate education allowance system, skills have increased among a wide variety of providers, not all of whom can be tarred with the brush of promotional greed. A centralised system of education, as reported in the west of Scotland study, sounds like a minor variation of what was available before the postgraduate education allowance came into effect; that system was centrally directed, poorly attended, and, generally, irrelevant.

    The more worrying conclusion of this study is that, somehow, when general practitioners choose an educational activity outside the central scheme, they do so purely for financial gain. This hints at a strange belief that people in the “centre” know better what is good for general practitioners than they do themselves. If that is the case then we need to clarify our commitment to the adult learning model, which has been the main plank of criticism (at times unfairly) of the postgraduate education allowance system. Either we genuinely believe in this model and respect the professional integrity of our colleagues who choose what is relevant to them or we do not, in which case we should seek more central control and power.

    In summary, the postgraduate education allowance system, though by no means perfect, has brought about many positive changes in continuing medical education in general practice. It has enabled innovation in new methods of learning, encouraged personal responsibility for continuing professional development, and given the profession the opportunity to set standards for accreditation and monitoring. Maybe it is time to move on from the postgraduate education allowance, but surely we do not want to go back to the discredited days of centrally funded and organised postgraduate education.

    References

    1. 1.

    Interdisciplinary education would help improve teamwork

    1. W F Cunningham, General practitionerb
    1. a Department for NHS Postgraduate Medical and Dental Education (Yorkshire), University of Leeds, Leeds LS2 9JT
    2. b Corbridge Health Centre, Corbridge on Tyne, Northumberland NE45 5JW
    3. c 463 Springfield Road, Belfast BT12 7DN
    4. d Exeter Postgraduate Medical Centre, Exeter EX2 5DW

      Editor—In his editorial Toon identifies the difficulties that general practitioners face in trying to learn within a system that encourages the “never mind the quality, feel the width” philosophy of education.1 Although he rightly highlights the fact that patient care should be central to the educational system, he fails to broaden the debate to discuss the range of educational methods currently available, including the important but underdeveloped area of practice based interdisciplinary education.

      Any new system must recognise that there is limited evidence that these educational methods change people's behaviour. Nevertheless, while we are waiting for relevant research to be commissioned we need to take a commonsense approach to encourage those methods which are more likely than not to produce this change.

      Health care based in general practice is now a team activity, and there is general agreement that one of the main ways to produce effective teamwork is to encourage widespread interdisciplinary education.2 Our primary healthcare team has been organising regular programmes of practice based interdisciplinary education since 1991. We have confirmed that this type of education has advantages in terms of the relevance of material covered to our day to day work, the incorporation of audit activity, short times from having ideas to implementation, and the ability to keep people involved by the use of small groups.3

      It would be exciting if our initiative was reproduced on a national scale, with primary health care delivered by well organised teams with access to expert educational advice. The teams would thus be able to identify their own learning needs and to commission their own education. This would require our present system of postgraduate education to be turned on its head and would demand a rethink of the present inadequate support structures.

      Those who commission the education of the future should ask that patient need determines the curriculum and that primary healthcare teams are the participants. Such education is crying out for development, and adequate resources need to be found. Only when these working groups become learning groups are patients likely to benefit directly from the education of doctors.

      References

      1. 1.
      2. 2.
      3. 3.

      Lectures have many advantages

      1. James Barbour, General practitionerc
      1. a Department for NHS Postgraduate Medical and Dental Education (Yorkshire), University of Leeds, Leeds LS2 9JT
      2. b Corbridge Health Centre, Corbridge on Tyne, Northumberland NE45 5JW
      3. c 463 Springfield Road, Belfast BT12 7DN
      4. d Exeter Postgraduate Medical Centre, Exeter EX2 5DW

        Editor—Toon's editorial about educating doctors seems to fall below the standards of objectivity expected in a peer reviewed journal.1 The subtitle—“a choice between self directed learning and sitting in lectures struggling to keep awake”—does not suggest that the author is approaching the subject with an open mind. Denigration of the lecture system of learning may be fashionable, but anyone advocating its abandonment should state clearly the advantages of the proposed replacement. I think that some positive aspects of attendance at lectures should be pointed out.

        Firstly, lectures provide a rapid means of updating oneself on subjects, which is valuable to general practitioners working long hours, who are rightly expected by their patients to have a wide background knowledge of all aspects of medicine. General practitioners might have difficulty absenting themselves from their practices for lengthier forms of updating.

        Secondly, regular lectures provide a meeting place for general practitioners, who might otherwise be professionally isolated.

        Thirdly, lectures provide the opportunity to meet specialists, who might otherwise simply be signatures at the end of hospital letters.

        Fourthly, lectures provide the opportunity to question the approach taken by individual consultants and their units.

        I submit that these aspects are important to morale and knowledge among general practitioners and are thus ultimately of great value to patient care. To measure the success of education solely in terms of changed clinical behaviour is far too narrow.

        Toon seems to forget that general practitioners who use lectures also use other forms of self education, notably reading. He cites the paper of Murray and Campbell, who conclude from the fall in the numbers subscribing to the courses that they run that general practitioners are guided by financial considerations in their choice of formal postgraduate education. The data are compatible with that conclusion but also with other possible explanations, including geography, timing, workload, and the quality and relevance of the material offered. Murray and Campbell do not consider any of these, except to note that the fall in attendance at their courses was greatest for the health promotion topics (might this have been due to saturation coverage in previous years?) and that subscribers to their scheme had a greater appetite for material on the provision of services.

        Authors should avoid the risk of being thought to imply that general practitioners who do things differently from the way in which they would like to see them done are lazy or greedy.

        References

        1. 1.

        Meetings in postgraduate centres can be helpful

        1. Phil Taylor, General practice clinical tutord
        1. a Department for NHS Postgraduate Medical and Dental Education (Yorkshire), University of Leeds, Leeds LS2 9JT
        2. b Corbridge Health Centre, Corbridge on Tyne, Northumberland NE45 5JW
        3. c 463 Springfield Road, Belfast BT12 7DN
        4. d Exeter Postgraduate Medical Centre, Exeter EX2 5DW

          Editor—Toon draws attention to the inappropriateness of the current postgraduate educational allowance system of funding for continuing medical education for general practitioners.1 He adds that the NHS has a right to expect that the education it pays for will improve patient care.

          To encourage general practitioners to obtain the education that is most likely to lead to improvements in the care of their patients, a programme must be designed to cater to their educational needs. One way of achieving this is to help general practitioners to develop their own personal learning plans. I am strongly in favour of this approach but do not believe that it is suited to all general practitioners.

          I believe that a formal educational programme based in postgraduate centres can, if well designed, provide a complementary and satisfactory means of fulfilling those educational needs. The challenge, however, is to plan such a programme systematically. In Exeter we now have a regular programme, during which an expert, normally a local consultant, attends a seminar based meeting to comment and advise on clinical scenarios presented by the audience. The precise content of each meeting is therefore determined entirely by the participants, although the expert can draw the audience's attention to issues that he or she sees as important. This approach has received high marks on our feedback forms.

          Having addressed the problem of making meetings in Exeter relevant, we are now debating how best to plan the content of the whole programme. We are setting up a committee—called “Improve Practice”—with representatives from primary care audit, the local research and development support unit, secondary care, and healthcare teams. This committee will meet regularly to review current issues of best practice in which education can facilitate improvements in patient care. I have written to all the local specialists offering to try to design an educational package if they can identify an area within their specialty in which the care of patients in primary care might be improved. In return, the specialists have agreed to receive constructive criticism about their practice.

          One of the problems of the postgraduate education allowance is that it allows the Department of Health to think that it is adequately financing general practice education; in reality, little money exists for the development and planning of ambitious programmes. For example, general practice clinical tutors are paid one session a week to design programmes, organise meetings and courses, and run those courses—in my case for 200 general practitioners. Proper investment in education has potential for achieving considerably better value for money.

          References

          1. 1.
          View Abstract