Innovations in general practice training and education - challenges for the 21st century*

M R Kidd

HK Pract 2007;29:427-436

Ladies and gentlemen, I am delighted to be here today and I thank you for your invitation and your kind hospitality.

This is a very unsettling time in the world with the war in Iraq. It is also an unsettling time for all general practitioners and health care workers here in Hong Kong with the current outbreak of atypical respiratory tract infections. At such an unpredictable time, it may seem irrelevant to talk about innovations in general practice education. However the dedication of general practitioners is to all our patients, and our commitment is to deliver high quality of care to all the people who trust us to meet their medical needs. Their needs and concerns can be even greater at times of local and international crisis. Our commitment to high quality care is underpinned by high quality education and training. And for education to remain relevant, it needs to be innovative, as I will outline in this talk.

One of the questions every young aspiring academic needs to consider is the area of their future research expertise. In 1988, I joined the Department of General Practice at Monash University where I had a wonderful mentor, Professor Neil Carson, who is well known to many of the people here. Neil said to me, "Why do you want to be an academic, Michael?" I said, "I want to be a medical educator". And he said, "What do you feel passionate about?" I said, "I want to use education to bring about major improvements in health care". He said, "Okay, if you want to be a great medical educator, how are you going to do that in a way which is different and new?" I said, "I really enjoy working with computers". He said, "Okay, let's see how you and I can work together on ways we can use computers to deliver health education messages to doctors and health care workers and members of the public all around the world".

And that's what we did and what I am still doing fifteen years later.

I want to talk with you about innovation. Let's talk about new things. General practice education and training around the world is facing many challenges. Innovation in general practice education occurs at all levels: medical student education, training of our registrars, and also continuous professional development for general practitioners.

What I would like to do first is to discuss approaches to innovation in the past, outline some of the key issues about what is happening now in general practice education in Australia, and then finish up by talking about what we can learn about general practice education from the TV series, Star Trek.

So what is innovation? The Oxford Dictionary defines innovate as "to bring in novelties and make changes". It comes from a Latin word "novus" for new.

Let's look at some of the attitudes from the past about innovation.

We first go back over four hundred years. Michel de Montaigne (1533-1592), was a French essayist who wrote, "I am disgusted with innovation, in whatever guise and with reason, for I have seen very harmful effects of it". So he saw innovation over four hundred years ago as being a threat.

William Shakespeare (1564-1616) wrote wonderful words on just about every important aspect of human existence, including innovation. In "Othello", Cassio says, "I have drunk but one cup tonight..... and, behold, what innovation it makes here". Shakespeare saw innovation as wonderful ideas shared between people, in this case over a few drinks.

Edmund Burke (1729-1797) was an Irish Protestant political writer who wrote, "A spirit of innovation is generally the result of a selfish temper and confined views". So Burke did not think much about innovation.

Ralph Waldo Emerson (1803-1882) the American essayist, poet and philosopher wrote, "Is it not manifest that our academic institutions should have a wider scope; that they should not be timid and keep the ruts of the last generation, but that wise men, thinking for themselves, and heartily seeking the good of mankind, and counting the cost of innovation, should dare to arouse the young to a just and heroic life". This is a very appealing sentiment that applies very much to our own roles as general practitioners and academics, working to support the next generation.

Winston Churchill (1874-1965) said, "Without tradition, art is a flock of sheep without a shepherd. Without innovation, it is a corpse". Perhaps we could replace the word "art" with the word "education". We certainly need innovation for education development.

Peter F Drucker wrote in the Harvard Business Review in 1986, "Innovation is the specific instrument of entrepreneurship..... that act that endows resources with a new capacity to create wealth". So he saw innovation as a way to make money.

So what have we learned from the past about innovation?

Some people saw innovation as a threat, while others saw innovation as a necessary cost in order for progress to be made. Others saw innovation as a necessary part of life, and as an opportunity to move ahead. Others saw the risks of innovation for innovation's own sake.

The past century has seen some wonderful innovations in medicine. Here is a list of some of the major innovations published by Le Fanu at the end of last millennium:

Professor Max Kamien was the Foundation Professor of the Department of General Practice at The University of Western Australia. He wrote about innovations in general practice education in Australia in the Medical Journal of Australia in 2001. His list included:

I was planning to also outline some of the innovations in General Practice education here in Hong Kong. Then I opened up the wonderful booklet your College has produced for this conference outlining the history of your College over the past 25 years. I urge you to read this history, as it outlines the wonderful innovations which have occurred in general practice education here in Hong Kong over the past 25 years.

Now let's see what's happening right now in innovations in general practice education. I conducted an Internet search. I went to "Google" which is the most popular search engine for young people in Australia. I put in the keywords "innovation, registrar, education, general practice". And then hit "I'm feeling lucky". The site which came up is the homepage of the Monash University School of Rural Health and their Gippsland Regional General Practice Training Programme. The website outlines the innovations of this programme:

1. This full regional training programme is notable for its innovation in quality education and training.
2. It is responsive, flexible, individualised and learner-centered, and most importantly facilitates each registrar's progress towards graduation as a competent unsupervised general practitioner.
3. Strong emphasis is put on involving general practitioner supervisors and supporting them as the primary teachers in the programme.
4. Emphasis is also placed on vertical integration with appropriate linkages between undergraduate education and vocational training for registrars and continuing professional development established general practitioners.
5. An education profile is developed for each post specifying its educational objectives and outlining the plans for specific teaching sessions and skills development associated with each training post.
6. An individual roster is developed for each registrar allowing for a mix of clinical and educational experiences to address each registrar's specific training needs.

I did another search with "Google", this time putting in "Innovation, Education and General Practice" as search words. The top site was the General Practice and Primary Care Research Unit at The University of Cambridge, which is not surprising as this is one of the most innovative centres for general practice education with a wonderful established training programme for medical students. Instead of having medical students based in hospitals, their students are based in general practice and follow patients from general practice to hospital and then back out again into the community. Their medical students perform just as well in their final assessment tasks as graduates who have undergone traditional hospital-based training.

I next chose another search engine, "Altavista". When I put in "Innovation, Registrar, Education, General Practice", the top site was the education programme of the General Practice Education and Research Unit based in the Northern Territory of Australia. The Northern Territory is a sparsely-populated area containing a lot of desert. The outline of this unit's programme follows:

1. This programme has developed a reputation for innovation, and for providing a caring and supportive environment, in which general practice registrars gain the knowledge, skills and attitudes required to provide quality primary care in a multidisciplinary environment.
2. Registrars learn to respect diversity and to work effectively with indigenous people and also with people who do not have English as a first language.
3. Registrars learn to take care of their own needs as doctors in a collegiate environment that is not a "victim to distance".
4. A guiding principle of general practice training in the Northern Territory is that training should be the same wherever the registrar chooses to practice, whether this is in the main city of Darwin or in a remote community clinic.
5. Education is provided in a manner that is equally accessible, either by a face-to-face meeting or by teleconference.
6. The programme greatly enhances the willingness of registrars to travel to more remote settings. They know they will not miss out the education that others are receiving.

Another innovation is medical student education in Australia, where four out of our eleven medical schools have moved to graduate entry courses, similar to those in Northern America. These universities take students who already have a university degree instead of students straight out of high school. Teaching is based on adult learning principles and problem-based learning. Early clinical experience and small group teaching are introduced right at the start of training. Information technologies are utilised, and evidence-based medicine is a strong focus of the education programme. Learners are engaged as participants in the design of learning. Self-directed learning is encouraged, and teachers function as facilitators, rather than as didactic instructors. A climate conductive to learning is established, with students encouraged to ask questions. Each learner's past experiences are utilised. These students are graduates and many of them are in their 20s, 30s and 40s. They include lawyers, architects, musicians and graduates from other health sciences and many professional fields. This is Australia's new generation of medical students.

Another innovation in general practice education in Australia is the PriMeD programme developed by a medical education company called Med-E-Serv. PriMeD provides online education programmes for general practitioners. PriMeD provides education not only for doctors in Australia, but is available through the internet to doctors all around the world. PriMed contains 200 hours of online learning activities. The programme comprises learning units, each with learning goals which cover a specific topic and each takes approximately 15 minutes to complete. Units covering similar topics are linked together in workshops taking between two and ten hours to complete. Doctors work in an online group with a facilitator. Topics include clinical issues, communication skills training, medico-legal issues, practical research skills and quality care initiatives. An action learning approach encourages interaction with peers. Active practice reflection is designed to facilitate positive changes in clinical practice. Emphasis is placed on case studies of "real life" problems. Immediate online confidential feedback is provided for self-assessment.

Finally, I would like to share with you the Quality Assurance and Continuing Professional Development (QA & CPD) Programme established by The Royal Australian College of General Practitioners. This programme runs in three year cycles. In order to satisfy the standards expected by the College, education activities must be based on adult learning principles, reflect evidence of what works and involve peer and self-review processes. The QA & CPD programme was started for RACGP members in 1987 and expanded in 1989 when participation in quality assurance and continuing medical education became one of the requirements for professional registration of all Australian general practitioners. Currently almost 20,000 general practitioners are enrolled in the programme. A points system was introduced in 1993 to improve the fairness, effectiveness and accountability of the programme.

The programme is designed by general practitioners, for general practitioners. Emphasis is placed on active learning by each participant with a focus on educational activities with a demonstrated benefit of bringing about change and improvements in the quality of clinical practice. Education activities are self-directed and participants can determine their own learning pathway after identifying their own learning needs. Individual integrated learning programmes can be planned and active participation in one's own learning is encouraged.

So what about the future? At the beginning of this presentation I promised to tell you about what we learn about general practice education in the future from Star Trek.

Did you know there have been eight Starfleet doctors on Star Trek, including Dr "Bones" McCoy? Did you know that each one of them, including the Hologram Doctor, has been a general practitioner? Starfleet GPs can manage anything and everything. They provide continuing whole person care. They have access to wonderful technology to support diagnosis, treatment and care. They do not have the ability to refer people to specialists (after all, they practise medicine deep in outer space). They have to be able to manage anything they encounter. Most importantly, there is little a well-trained Starfleet GP cannot do if he or she just has a good tricorder.

A tricorder is the hand-held device used by doctors in the Star Trek series. The modern day equivalent is the Palm Pilot. Palms and other hand-held Personal Digital Assistants (PDAs) can be used to assist us today in delivering high quality care to our patients. Our medical students and hospital resident staff are using new technology as a part of their everyday learning and patient care. Instead of using notebooks to record each patient's clinical details on ward rounds, and reminders of tasks to be undertaken, modern medical students and residents now can store their patients' information and their own task reminders in their PDAs. These new doctors are using new technology in innovative ways. However it is important to make sure this new technology will not place at risk our patients' privacy, and the security of their personalised health information. Our new generation of young doctors will surely have much to teach us about the future of innovation in medical education.