Helen Salisbury: With fewer patients in surgery, how do we train GPs?

A busy day in general practice can be a joy—listening carefully and asking the right questions, using practised examination skills to reach a differential diagnosis. This week I felt as though I was flexing intellectual muscles at risk of atrophy during lockdown. Gradually we’re beginning to see more patients face to face, partly because people who were reluctant to come in are now less fearful but also because our threshold for asking patients to attend has fallen. Factors in this risk equation include the low local prevalence of covid-19 and the fact that we have, in many cases, reached the limit of what we can do remotely.

Like many practices throughout the UK, we recently welcomed new trainees—the GPs of the future. Our task is to equip them with the knowledge and skills to become independent, safe practitioners, capable of building relationships and caring for patients while also looking after themselves. We may also hope to pass on some of the attitudes and values that first drew us into general practice. The trainees in turn have to reflect on their progress and be assessed and examined in multiple ways before being badged as competent.

I’m concerned about how our current mode of consulting will affect our ability to manage this process. Previously, trainees observed and then performed the long practised GP routines of greeting, history taking, examination, and management planning with the patient. Now this pattern is fractured. The initial consultation is done as a phone call and, if examination is required, this is either attempted by video or, more often, arranged for a later time. If it can’t be managed on the same day it’s sometimes passed to another doctor or, if patients have a fever, cough, or breathlessness, they are directed to a coronavirus “hot” clinic.

It will be harder for trainees to build an understanding of how patients present in the community and how the history and symptoms relate to clinical findings. As family doctors, one of the many vital skills we hope to pass on is how to assess febrile children. Trainees must learn how to tell which of the many grumpy toddlers they may see in a day needs hospital care, and which can safely be looked after at home. I’m not confident that this will be possible when so many families receive telephone advice and safety netting rather than face-to-face assessments.

Remote consulting is harder, and decisions must be made with less information. Perhaps we should regard it as a refinement, a meta-skill to be developed after mastering the basics of GP consultation, rather than the starting point. Nevertheless, as GPs retire and need to be replaced, we probably can’t afford to pause training to give the covid-19 cohort an extra six months to catch up. The question is: will we be able to sign off our trainees as competent if their opportunities to develop and demonstrate their skills continue to be limited by the lack of ordinary practice?