The new GP curriculumBMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7579.s206 (Published 02 December 2006) Cite this as: BMJ 2006;333:s206
- Clare Wedderburn, associate director
Bill Irish and Clare Wedderburn have mixed feelings about new guidance
Box 1: Curriculum statements
Being a general practitioner
The general practice
Personal and professional responsibilities
3.1 Clinical governance
3.2 Patient safety
3.3 Ethics and values based medicine
3.4 Promoting equality and valuing diversity
3.5 Evidence based medicine
3.6 Research and academic activity
3.7 Teaching, mentoring, and clinical supervision
Management in primary care
4.1 Management in primary care
4.2 Information management and technology
Healthy people: promoting health and preventing disease
Genetics in primary care
Care of acutely ill people
Care of children and young people
Care of older adults
Gender-specific health issues
10.1 Women's health
10.2 Men's health
Care of people with cancer and palliative care
Care of people with mental health problems
Care of people with learning difficulties
15.1 Cardiovascular problems
15.2 Digestive problems
15.3 Drug and alcohol problems
15.4 ENT and facial problems
15.5 Eye problems
15.6 Metabolic problems
15.7 Neurological problems
15.8 Respiratory problems
15.9 Rheumatology and conditions of the musculoskeletal system (including trauma)
15.10 Skin problems
What do general practitioners (GPs) need to know? If you think about it for long enough, the sheer breadth and diversity of knowledge is enough to make your head spin. All of us can remember feeling totally overwhelmed when we first started out as greener-than-green GP registrars. Embryonic GPs still desperately search for a definitive GP textbook containing everything they need. Sadly there isn't one and probably never will be.
Explicit national curriculum
For the first time, however, general practice does at last have its own explicit national curriculum. Published at the beginning of 2006, the new version from the Royal College of General Practitioners (RCGP) will underpin GP training across the entire United Kingdom. It is different from its predecessors, as it also sets out to be the blueprint for the new MRCGP licensing exam, and in the future will almost certainly become the basis for revalidation of all practising GPs.
Will it, however, be of any practical help to would-be GPs, or indeed to any of us currently working in UK general practice? Well, the problem is that any curriculum is doomed from the moment it is written—either too short and lacking in enough detail to be of any use, or far too long to be workable.
Well, the implications of this are huge. The new curriculum is so much more than a simple guide for educationalists. For the first time, there is a need to justify all GP educational provision against the curriculum. Totally overwhelming in its size, but also in its expectations; is it any wonder that it has been received with a mixed reception from the educational fraternity?
Educationalists have been effectively training doctors for decades. Those involved in postgraduate medical education have always made up their own lists of “what a GP really should know.” Their efforts may have been patchy and sometimes tended towards the amateurish. Scrawlings on the backs of envelopes or, if you're lucky, fancy Excel spreadsheets. But generally, educationalists have not been far off the mark, successfully teaching doctors the art of general practice and churning out competent and confident GPs. So, will more paperwork and tick box exercises really improve the product, and is the need for such an explicit curriculum totally justified?
Is it worth a read?
Well, try downloading your own copy but just don't hit the print button.1 It really is a dauntingly huge document. Three and a half kilograms on the bathroom scales and frankly about as user friendly as the new GP contract. Fun and froth it certainly isn't. Most trainers and course organisers have dipped in and (rapidly) out of it. We on the other hand attempted to work through it from cover to cover. By page 300 we required strong coffee, and in later still more desperate moments, the odd glass of alcohol to numb the pain.
The first thing to strike you is that the whole curriculum document is based on EURACT (European Academy of Teachers in General Practice), an obscure educational group at the lunatic fringe of the European branch of WONCA(the World Association of Family Doctors). The college hopes that such an international dimension is de facto a “good thing,” and no doubt a great marketing opportunity. It risks alienating a huge chunk of the British educational establishment, however, who are far more familiar with the General Medical Council's Good Medical Practice.2 This is a mistake.
Having said that, the EURACT headings are reasonable and logical, divided into a series of 15 distinct curriculum statements (box 1). Each statement has some fairly involved subheadings. But it is possible to navigate around this huge document with surprising ease.
The initial bits cover generic issues such as communication, risk management, and ethics. The latter ones tend to be more specific, relating to clinical areas such as ENT or cardiology. Against each of these curriculum statements are a further six “core competences” (box 2), which attempt to map out the skills a GP needs in each given area.
Frankly it is a bit of a shame that the document is still so rough around the edges. The styles vary, presumably because of its multiple authors. The suggested learning opportunities are parochial, quirky, and narrow, and many of us would disagree with its emphases. It is crying out for further review and development, which we sincerely hope that the RCGP will continue to commission.
Well to be honest, not much. There are a few surprises though. The requirement that all new GPs must hold the European Computer Driving Licence (section 4.2), and a need to be competent in prescribing opiate replacement therapy (section 15.3) rather jump out. What is perhaps more intriguing is the lack of emphasis in areas that have previously been thought of as “core” to GP training. For example, there is no specific requirement to do family planning training to the level of the Diploma of the Faculty of Family Planning. Something that many male GP registrars will certainly welcome, if perhaps not the national family planning fraternity.
Box 2: Domains of competence
Primary care management
Person centred care
Specific problem solving skills
What's in it for GP trainers and course organisers?
The Modernising Medical Careers project is to blame for many a GP educationalist's woes. It has certainly catalysed the entire GP curriculum review. Medical education has been turned on its head. New three year integrated training programmes provide an incentive to redefine the whole provision of postgraduate medical education. Learning opportunities in ST1, ST2, and ST3/GPR years will be mapped against the EURACT headings.
Certain areas are still considered core to training. Other areas can be shunted to post certification requirements, for GPs to develop as specialist interests or perhaps as part of continuous professional development (CPD). Among the biggest challenges is the decision of when specific topics will be taught and learnt. For example, clinical areas such as neurology versus generic skills (risk management, etc). There is then the where and how that goes along with all of this. An exciting prospect, or a complete headache? Probably both.
Joining up exams and teaching
Let's face it, there is nothing like a good scary exam to make medical students and junior doctors focus on their learning. The trick has always been to devise an assessment tool that assesses important knowledge and skills. If you get it right, the key stuff will be learnt and everyone is happy.
Of course, taking it one step further, if the new GP curriculum underpins the content of specialist training programmes and blueprints the assessment we are really in clover. This has certainly never been the situation until now, and certainly educators and those in training both have huge amounts to gain from such new joined up thinking. Let's all hope that the new MRCGP, introduced from 2007, really does reach the parts that its predecessors—summative assessment and the old MRCGP—never quite reached. Equally, let's hope that we never hear course organisers again muttering that they “train registrars to be good GPs, not to pass a bloody exam.”
GPs in training
Are we just being naive? Well, there is probably a bit of wishful thinking here. Certainly people training to be GPs will welcome a comprehensive guide detailing what they are expected to know, and what they will be assessed on. For formative assessment (working out what you do and don't know) it will be a godsend.
In reality, however, assessing some parts of the curriculum is truly very difficult, expensive, or just plain unreliable. There will always be areas that although mentioned in the curriculum itself will prove tricky or impossible to assess, and will risk being sidelined by the hard-pressed GP registrar.
Old lags and revalidation
The curriculum does clearly define the competences we expect in a new doctor entering the world of general practice. What has been less discussed, but seems obvious when you consider it, is that the same document must define what is necessary to continue to work as a GP in the United Kingdom. The people responsible for devising CPD programmes for established GPs now have a guide for devising the content of ongoing medical education. Revalidation of all doctors is clearly on its way. We still don't know what form it will take, but patients and the government clearly expect it. In the same way that it spawned a new MRCGP, the new curriculum will inevitably soon define our revalidation process. We don't know what form it will take, but we now already know what we are expected to know.
The new GP curriculum might not be anyone's first choice in bedtime reading. It is a daunting document, and frankly one that is still far from refined enough for anyone to be truly happy with. It is, however, the most important document to have come from the RCGP for many, many years, and one that will have profound implications for all of us—GP specialist trainees, established GPs, and jobbing educationalists such as ourselves. Bedtime reading it may not be, but an essential read it will become for us all at some point in the near future. ■