Experience of general practice training in the United Kingdom

W C W Wong 黃志威

HK Pract 2003;25:181-184

Summary

Despite their similar goals, there is considerable difference between the training programme of family doctors in Hong Kong and the United Kingdom (UK). This paper describes the structure and assessment process of the British training programme whilst highlighting the local needs giving rise to such arrangements. The compulsory vocational training in general practice in the UK aims to equip doctors to practice safely and independently whereas the optional higher qualifications such as MRCGP prepares young doctors for future medical challenges and career development. The training programme is designed to be flexible and inclusive. It has benefited me greatly and I would therefore argue that postgraduate training should be introduced for all future community-based doctors.

摘要

雖然最終目標相似，但是香港的家庭醫生訓練與英國有很大不同。本文闡述了英國家庭醫生訓練的結構及評審步驟， 並指出這是為了要符合英國本地的需要作出的安排。強制性在職訓練目的是使家庭醫生安全、獨立地行醫， 而選擇性的更高學歷培訓如皇家醫學院院士課程，則為年青醫生迎接醫學挑戰及將來的職業發展作好準備。 訓練課程的設計是全面而有彈性的。此課程令本文作者得益不少，因此主張此類深造課程應推廣給所有將來以服務社區為主的醫生。

Introduction

Due to their historical links, some aspects of the health service in Hong Kong are similar to that of the UK.¹ Both UK and Hong Kong family medicine training programmes (commonly known as General Practice in the UK) aim to equip doctors with sufficient skills, knowledge and attributes to practice primary care safely and independently, but their development and direction have taken different turns. Training programmes first developed in the United Kingdom during the early 50s. Since then, thousands of doctors have gone through this system as it evolved to its present form.² Comparatively, the training programme incorporated by the Hong Kong College of Family Physicians has a much shorter history.

Background of the two programmes

Over a third of UK medical graduates choose to be General Practitioners (GP).³ Before being allowed to practise unsupervised primary care, they are legally required to complete at least three years of post-registration vocational training and pass the Summative Assessment approved by a statutory body, the Joint Committee on Postgraduate Training for General Practice. Although the number of graduates entering general practice varies from year to year, the actual proportion of doctors becoming a GP ten years after graduation remains rather constant.³ Therefore, the training programme has to be inclusive and flexible to accommodate career changes by doctors and trainees from different specialties and from overseas doctors of varying skills and experience. Since the number of female graduates has increased over the years, part-time training and career breaks have been introduced to meet their family and social needs. The situation in the UK is further complicated by the rules and regulations governing the training and eligibility of European Union trained doctors to practice within its member states. For example, one of the arguments for introducing Summative Assessment in 1998 was to bring the UK training in line with the rest of Europe.

It has been estimated that more than a third of the medical graduates in Hong Kong will eventually work in private practice providing primary care, but only a limited number will have the opportunity of vocational training. This is because Family Medicine is regarded as a speciality under the Hong Kong Academy of Medicine and only a limited number are admitted to the six-year training programme every year. It is particularly difficult for overseas graduates or those who have been practising for many years to participate. On the other hand, any doctor registered with Hong Kong General Medical Council is allowed to open his/her own clinic in Hong Kong, hence making training optional. It does not necessarily mean that doctors in Hong Kong are not interested in further training and development. For example, Continuing Medical Education programmes or Diploma in Family Medicine organised by the Chinese University of Hong Kong are usually well-subscribed.⁴ The Hong Kong College of Family Physicians has also tried to make the training more flexible by introducing a part-time programme and practice-eligible route, but it is a nearly impossible task for most practising doctors to accomplish since the Hong Kong Academy criteria are so stringent that they will have far too much work to catch up.

My experience of the UK programme

The debate over the right ingredients and length for a training course is an international one. Before the GP vocational training system was first established, the Royal College of General Practice had argued for five years of training, but had to settle for three due to limited funding.⁵ Doctors can either enrol into a hospital-based scheme or arrange their own scheme, which usually comprises four six-month approved hospital jobs from medicine, care of elderly, obstetrics and gynaecology, accidents and emergency, paediatrics, psychiatry or surgery. However, there are exceptions. For example, one person in my scheme had some of her experience in a homeopathy hospital counted as an equivalent experience for one of the six-month jobs. Although diplomas offered by the Royal Colleges such as Diploma in Child Health or Diploma in Obstetric and Gynaecology are popular among trainees during their hospital attachments, they are not obligatory. These qualifications can provide a means for in-depth studies into a specific field and a 'stepping stone' for future development in that field, but 'collecting' diplomas indiscriminatingly may confuse both colleagues and patients, and sometimes work against one's job prospect.

One year of community-based training in one or two practices is arranged before and/or after the hospital placement. A tutor is appointed to oversee the professional development of the trainee. Community-based trainees are entitled to weekly tutorials with their own trainers. These are usually problem-based learning. Consultation skills are taught through a combination of observing the tutors, being observed by the tutors and analysing video recording of consultations. Most of the trainees I know had a very strong bond with their trainers and such relationship assists effective learning to take place. Even the trainers get a weekly half-day release to attend their own workshops with locum fees reimbursed. These training posts are fully funded by the government in exchange for the trainees' service in the participating practices.

A trainee also has exposure to the administration and management of a clinic, which is not taught at all in medical schools. I was invited to the monthly partners meetings where important decisions such as the purchase of the community health centre and takeover of a neighbouring practice were made. Being a full partner in a GP practice is a heavy undertaking. Therefore, it is important to fully comprehend all the documents involved and know when to seek other professionals such as lawyers and accountants' help when necessary.

The UK Government has gradually realised that specialist training has been too service-orientated and supervision for junior doctors was insufficient.⁶ Such a message is spilling over to the GP training: Since April 2000 the funding for GP training in England and Wales has passed from Central Government to Deaneries in postgraduate schools so that a designated university department is responsible for the budgets of training doctors and to ensure the contents of the training fulfil their requirements.⁷ For example, relevant community experience such as day release to out-patient clinics or extended training opportunities beyond the three year minimum period is incorporated into hospital jobs. My Obstetric and Gynaecology posting with the Guy's and St.Thomas's Hospital, London included a six-week community component. I chose to work in a sexually transmitted disease (STD) and family planning clinic, and joined Community Midwives on visits.

Some GP trainees feel marginalised by their specialist colleagues during their hospital attachments. This new arrangement allows the GP course organiser to take up the issues to relevant bodies and in extreme cases to transfer the GP trainee post to another hospital if the situation does not improve. To achieve this end requires a good relationship and communication between the course organisers and the trainees, and between hospitals and community doctors.

In the UK, extra teaching is arranged in several different ways. Half-day study release is held throughout the training usually in form of Balint groups, where difficult cases are discussed and support is sought among the peers. 'Away' days or study camp is held yearly with activities to promote 'bonding' among the peers. Members of the group decide what areas interest them and invite speakers on their own accord. Some funding is also available for trainees to enrol in part-time or correspondence courses relevant to general practice, for example, I did a diploma in Medical Ethics and Law with this fund. Despite these arrangements, some peer support groups have very poor attendance. This usually results from poor organisation by the trainers and lack of ownership of the programme by the trainees, rather than the actual demands of their duty.

Assessment

Assessment is an essential part of any training process to encourage learning and to determine whether sufficient progress is being made. In the UK, both Formative Assessment and Summative Assessment are used. The former is used to measure progress at regular intervals based on direct observation with assessment tools such as presentations, video/simulated surgeries and questionnaires by the trainee while the latter is a final test of competence to be completed at the end of the training period. Summative Assessment not only seeks out doctors who fail to reach the minimum standard required of a GP, but also lifts the burden from the trainers as the sole assessor. It consists of 4 main components, each carrying 25%: MCQ, a series of video consultations, an audit and a trainer's report and aims to test for clinical knowledge, consultation skills, ability of self-monitoring and overall performance respectively. It can be done in modules or at the end of the training.

According to the Education Committee of the General Medical Council in 1980, due to the explosion of medical knowledge and the limited time available for the ever-expanding medical curriculum, the new doctors are only expected to attain a standard capable of being trained.⁸ Therefore, the membership examination of the Royal College of General Practice (MRCGP) is designed to equip the young doctors with the ability to deal with the ever-changing and demanding world of medicine and prepare them for other career developments such as becoming a trainer or academic. It lays emphases on consultation and problem solving skills, critical appraisal and recent medical development rather than medical facts and knowledge as in other specialities. It requires students to be familiar with articles published in the major medical journals such as the British Medical Journal and the British Journal of General Practice for the preceding year. This can only be achieved by reading regularly over a period of time so that a habit of effective information storing and retrieval system is formed. At the same time, students are strongly advised to form a peer study group to look at different case scenarios and 'hot issues'. The examination places a lot of emphasis on 'options' since there is often no one single 'correct' approach in GP so long as the chosen action is justified. Candidates should learn to take full advantage of the doctor-patient relationship and skills such as use of time factor in family medicine.

Is my training worthwhile?

It is a difficult question to answer as one can never know 'enough' in medicine and we are constantly confronted with difficult dilemmas in our practice. However, it is more important to know where and how to acquire the necessary information and equally, to realise our limitations as a GP and know when to seek assistance. The training for the Royal College membership taught me how to effectively extract useful information from a journal and acquire the habit of managing my learning portfolio. My GP training was put to good use when I worked as a volunteer in China and helped Save the Children Fund to set up a STD/HIV clinic at the China/Burma border by gathering the necessary information from Medline, textbooks, limited journals and contacts from the United Kingdom and adapting them for local use. At the end, I have successful regenerated the clinic.⁹ My training also facilitates better communication with my colleagues and patients. More than once, advanced consultation skills such as use of silence, reflection, the concept of ideas, concerns and expectation have saved me from many 'helpless' situations.

The British training system evolved over the years to supply a large, well-trained work force within limited resources for their health needs. It is designed to be flexible and inclusive to accommodate doctors of different experiences and home circumstances. I therefore argue that, to benefit both doctors and patients in Hong Kong, some form of postgraduate training should be introduced for all new community-based doctors. It seems to me that this will only happen if the government takes the initiative and matches it with sufficient resources. With due consideration to the currently practising doctors, legislation should be enacted to enable and ensure all future doctors undergo further vocational training before a licence is granted for independent practice.

Key messages

1. In the UK, it is a legal requirement to complete three years of postgraduate training before practising as a general practitioner.
2. The training programme is designed to be flexible and inclusive to accommodate family commitment and career changes.
3. Family medicine training has to be relevant for future doctors to work in a community and sufficient resources earmarked for their training is the only way to achieve this goal.
4. College membership is optional and is designed to prepare doctors to deal with the ever-changing and demanding world of medicine.