General Practice

Commentary The hospital component of vocational training for general practice

BMJ 1994; 308 doi: (Published 21 May 1994) Cite this as: BMJ 1994;308:1339
  1. T J Bayley
  1. Postdraduate Education and Training, Business Support Section, Postgraduate Office, Faculty of Medicine, PO Box 147, Liverpool L69 3BX.

    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.

    Dissatisfaction with the hospital component of vocational training for general practice is forcefully expessed by many trainees and educationalists in general practice.*RF 1-3* There is also concern that implementation of the Calman report on specialist training4 may have unwanted effects on senior house officer posts available for vocational training for general practice; that attention to providing experience for those planning a career in the specialty will detract from the needs of trainees in general practice; and that less satisfactory posts will be allocated to vocational training schemes. Several surveys confirm that trainees and teachers in general practice consider that change is necessary; some suggest radical restructuring of the hospital component of the vocational scheme; few however, consider the views of trainees in other specialties who share the same training opportunities of consultants who supervise senior house officers.

    The principal complaints of trainees, course organisers, and trainers in general practice are that:

    • Teaching in the hospital component is not relevant to the needs of general practitioners

    • Teaching is poor and irregular

    • Study leave is often refused or trainees are refused leave to attend relevant courses

    • The duration of senior house officer posts is too long.

    Relevant teaching and competent learning

    Action has and is being taken to make vocational training for general practice relevant. In conjunction with sister colleges and specialist societies, the Royal College of General Practitioners has produced curricular requirements relevant for training senior house officers for a career in general practice in most of the “first list” specialties.*RF 5-10* This should form the basis for enhanced teaching and learning. The curriculum for senior house officers in these specialties is an important first step in deciding the appropriate clinical competence for a future general practitioner. It should also give clear guidance to consultants and course organisers on the range of experience that should be provided.

    Assessment of the competence of trainees, whether seeking a career in general or hospital practice, will become a prominent feature of postgraduate training of the future. The Joint Committee on Postgraduate Training for General Practice has set a timescale for award of its certificate of completion of training, based on assessment of competence; it will be introduced in 1996. The implication of assessing clinical competence is, however, ill understood: the trainee should not move on to the next phase of training until the defined competence has been achieved. For a few this may mean longer rather that shorter periods in some posts and delay in certification.

    Success in training general practitioners has been built on trainers who have learnt how to teach and are expected to maintain that ability and hone their skills. Hospital teachers are increasingly aware of the need to acquire these skills if they are to help implement the Calman report and in undergraduate education. Postgraduate deans have recognised the urgency of developing the teaching skills of educational supervisors and are using their budgets to “teach the teacher.”

    Expert teachers should answer the criticism that teaching is poor - provided that consultants have contractual time for the purpose. Unlike trainers in general practice, hospital specialists are not paid to teach. When a consultant is teaching the employer can justly claim that it pays so called “opportunity costs” as the teacher either will not be contributing to its business or has a smaller case load.

    Regular teaching requires recognition of the responsibility in a consultant's contract. Nominal time for teaching is frequently eroded by other duties; few NHS managers recognise teaching as needing a “fixed” session. The professionalism of teaching is a feature of the arrangements for education of other health care workers: nurses are taught by full time teachers but doctors in training are not. Trained teachers - consultants with contractual time allowed for teaching - should meet the criticisms of trainees in general practice, particularly if these consultants are aware of curricular requirements and work in conjunction with the local course organiser. By extension, some consultants will not, in the future, be trainers - as is the case in general practice.

    Study leave

    Requests for study leave from trainees should have equal call on the budget. It is accepted by postgraduate deans and clinical tutors that trainees in general practice may ask to attend a course in a specialty different from that of their current placement. Most people would expect study leave to be granted to give trainees the opportunities to develop a career of their choice. Some consultants may need to be reminded of this. But, equally, senior house officers should declare why they are asking for study leave each time.

    Study leave for one senior house officer also has its implications, usually more work for others on the firm. Difficulty with recruiting satisfactory locums to cover those on study leave is often the reason for refusing requests, particularly in smaller units. The gap left in on call rotas and partial shift working systems causes problems with reduction in hours of work in departments that have small numbers of doctors in training grades, and clinical directors may regard meeting the requirements of the new deal as more important than allowing study leave.10 One solution would be for senior house officers to be given a financial and contractual allowance for study leave which they might “spend” and for the allowance to include not only educational costs and travel and subsistence but also a sum to pay for locum cover. Recent guidance on the work of task forces - giving them power to redeploy or establish new senior house officer posts with agreement of the postgraduate dean11 - should provide the means of dealing with the problems.

    Duration of posts

    The suggestion that trainees be allowed to spend two or three months in placements to gain a wider experience of relevant hospital specialties is frequently made; its implications have not, however, been considered. Shorter and more placements have the potential attraction of a broader hospital component but the competencies achieved may be less than optimal. Whereas a three month attachment in dermatology may be appropriate for future general practitioners, such a short time in general medicine is unlikely to be enough for them to become sufficiently competent. Although an attachment of two months is claimed to be sufficient for acquiring necessary diagnostic and therapeutic management skills, it is doubtful that this time takes account of the need for familiarisation with a new specialty, hospital, or consultant. In the internal market, short attachments are educationally risky as it may not always be possible to achieve the objectives of the trainee or training programme because of variation in case mix and workload, as well as changes in contracts.

    Shorter attachments allow less time for developing competencies. If these are to be assessed in each post, it may be apparent that longer periods are needed in some specialties. If assessment suggests that the trainee has yet to achieve agreed competencies, can his or her attachment be prolonged? Will this delay certification?

    Frequent changes in training grades also have consequences for the firm or clinical directorate. Induction of a novice every two or three months is an important task for consultants and other staff. The needs of doctors in other training grades are likely to be affected by the necessity of teaching a new senior house officer at frequent intervals; and they will probably have to take greater responsibilities at the time of change. The effect on consultants' workload has also to be considered, as does how this affects fulfilment of service contracts.

    The balance between service and training components of the senior house officer post has probably never been more fraught. Arguments for time away from patient care, where so much learning occurs, have to be balanced against making service experience more educational. Reduction in junior doctors' hours of work, the demands of purchasing authorities on providers, the expectations placed on supervising consultants, and impending implementation of the Calman report's recommendations on specialist training are a few of the factors which have combined to make a difficult problem worse. During the nonhospital component of vocational training trainees are supernumerary in that their presence is not necessary for delivery of the service, though they do contribute to the practice workload. The same cannot be said of senior house officers. Until it is possible either to discount the contribution of hospital doctors in training grades to service or to develop approaches such as service based learning,12 the educational contrast between the vocational training year(s) and learning as a senior house officer will be stark.

    Options other than more and shorter hospital placements for trainees in general practice should be considered. One option would be to restructure posts in the hospital component to provide time, concurrently, in a training practice as well in a specialty, with the aim of broadening the perspective of the trainee. Redeployment of trainees or additional senior house officer posts may be needed to achieve this. Another option would be to have core training for general practice with choice of training in different specialties. The core (say two thirds) would be in general practice and the modules of specialty training would be as a supernumerary senior house officer to provide defined educational objectives. The second option would require overdue change in the vocational training regulations but would have educational and, for NHS trusts, financial advantage.

    Understanding of the needs of and goodwill towards trainees in general practice during the hospital component of their training is probably greater than at any time since the vocational training regulations were enacted. A balance between the expectations of trainees, the realism of providing for their needs in the context of others' training requirements, and the directives to reduce hours of work is plainly necessary. Desirable change in the hospital component of the vocational training for general practice will require careful management as attempts are made to improve the training of other senior house officers with different objectives - or the gains of the past 15 years could be lost. To avoid the differences in perceptions that can arise between trainees and consultants, each senior house officer deserves a curriculum that matches, as nearly as possible, the aims and educational objectives for attachment in that specialty, the training actually provided, and his or her individual needs.13


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