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The Apothecary: You’re Fired


Posted by Dr No on 19 April 2012

fired.jpgOnce upon a time, there were no GPs, only apothecaries. These corner-shop chemists evolved over time into today’s GPs, but their shop-keeping origins are still present even in today’s super-surgeries, and all the more so in the small lock-up single handed surgery. The short appointment times (it’s usually only a shopping trip, for Heaven’s sake), and expectation that the shopper-patient will not walk away empty-handed (what shop-keeper would so disappoint his or her customer?) are two leading characteristics of today’s general practice that stem directly from its apothecarial trade roots.

Today’s GPs tend to be shy of their trade roots, not to mention more than a little miffed at the general presumption that they are country cousins to the hospital’s specialists. And so, over recent decades, they have followed the classical route to professionalisation, or, as our friends in the sociology line call it, ‘occupational closure’: defining a unique core body of knowledge gained by training (the vocational training scheme for general practice), the establishment of entry qualifications and lists of accredited registered practitioners (the MRCGP, and the GMC’s GP Register and locally held ‘Performers Lists’) – prior to these developments, any doctor could work as a GP – and the setting up of a professional association – the Royal College of GPs. By these steps, a line in the medical sand has been drawn, demarcating general practitioners from other medical practitioners.

Despite these achievements, GPs are still seen – and many still feel themselves to be seen - as country cousins to hospital doctors. And so, unsurprisingly, the RCGP wants to raise the bar, and so enhance demarcation, by extending mandatory GP training by a fourth, and possibly even a fifth, year. It has made its case in a series of windy documents that are long on waffle, short on substance and bereft of evidence. The GP, so the plan goes, will move closer to being a specialist in general practice, a notion of distinctly oxymoronic potential, with his or, increasingly her, training and status on a par with that of the hospital specialist.

Dr No is not persuaded that an extra year (or two) of training will produce better GPs. Despite assertions to the contrary, general practice is not some form of medical rocket science; it is instead the agreeably specialised but none the less generic practice of medicine which simply does not need extended years of training. Bolting on more years of training will simply increase the divide between those who are fully qualified, and those as yet excluded. There will, if training is extended, be more GPs in training grades, and less in career grades. More seriously, the real learning – which starts with unsupervised practice – will be delayed.

There are of course those who see the extension of training as a cynical ploy by the general practice establishment to extend the pool of sub-GPs (and so cheap GPs) available for exploitation by the establishment. While this may indeed happen as an unwelcome side-effect, Dr No suspects the primary motive of those who wish to extend GP training is to enhance professional standing and status, and so distance the profession from its trade roots; and in this objective, Dr No believes the College proposals will fail.

If GPs want to become more professional, they need not more training, but to change their behaviour, away from that of their trade roots, and put it on a more professional footing. They could start by declining trivial consultations, and give the time gained to extended consultations for patients who do need them; and by shunning pointless prescribing, the pill for every ill, doled out because that is what the shopper expects from the shop-keeper. They could, in short, fire the apothecary standing in the surgery shadows – and that would do far more to enhance their professional standing than any number of added years of training.

37 comments:

Your comments are unfair and incorrect. Sorry. The papers are heavy on evidence and short on waffle

"They could start by declining trivial consultations, and give the time gained to extended consultations for patients who do need them; and by shunning pointless prescribing, the pill for every ill, doled out because that is what the shopper expects from the shop-keeper" - strongly agree, Dr No - I think this one of the key issues at the heart of general practice.

I read that GPs now provide 250 million consultations annually - I simply refuse to believe that most of these problems require medical attention (and are often self inflicted) - nowadays too many doctors are simply pandering to unrealistic expectations.

Put it this way - the public are able to self-assess what constitutes an 'emergency' each time they call out an ambulance - yet, we all know that true emergencies account for less than 5% of A%E attendances.
Any experienced paramedic will tell you they are fed up with providing a glorified taxi service, similarly GPs are unable to the job they are really meant to do because they are too afraid of upsetting public expectation and so (as a body) are complicit with overprescribing of antibiotics, statins and antidepressants, and the like.

CG - the main document runs to 91 pages (92 pdf pages), allocated as follows: 1-8: Cover, Preamble, Contents etc; 9-14: Executive Summary; 15-29: Enhanced GP Training: The Need for Change; 30-48: Enhanced GP Training: Our Vision; 49-88: Enhanced GP Training: Challenges and Outcomes; 89-92: Acknowledgements, Postamble. These heading do not sound like the lead-ins to much in the way of hard evidence...

This document assures us there is however a lot of it about (evidence, that is), but does not contain it: instead, the reader is directed 'supporting appendices': "Together with its Supporting Evidence appendices, this document clearly demonstrates that there is a need for change in the present GP training framework..." (page 11)

Evidence (if there is evidence) for a 'need for change' is not evidence that the proposed change(s) will fix whatever it is that the 'need for change' has identified as needing fixing.

So far as Dr No can see, the Supporting Evidence documents present (partially) evidence-based lists of 'Training Priorities' - which is fair enough, and indeed there may even be a case for adjusting existing training if those priorities are not being met - but what Dr No cannot see is evidence that the College's proposed "new four-year GP specialty training programme [which] will use a spiral model of incremental skill acquisition and application (you are lucky Crippen isn't still around - he would have drilled holes the size of pancakes through that one, not to mention some of the other corkers in the documents) will 'fix' general practice training.

Dr No could go on, but would prefer readers judge the evidence, or lack of it, for themselves. The documents can be found via the links at the bottom of this page.

A&E CN - a few days ago DN left a comment on one of JD's post lamenting GP complicity in over-prescription: 'Things like antibiotics for viral infections, anti-depressants for dyscopia, statins for folk who are never going to have an MI. The list is long...' - which is to say he couldn't agree more with your comment.

The bottom line is GP behaviour (and of course patient expectations) have to change if GPs are to become more physician and less apothecary - and Dr No has yet to see any evidence that extending training will achieve that change. Changing the content of existing training, on the other hand...now, that might just be worth looking in to.

Steve field was the first one to ask for GP training to be extended to 5 years. That was during the HSC meeting on MTAS in 2007. Despite the utter neglect of that issue at hand and the plight of all the doctors affected, which was the reason for that meeting in the first place, he never put up a valid argument for why do a 'General Practitioner' need 5 more years of training on to of his 6 years in college plus 2 now, instead of one, foundations years on top as well!! It's mind boggling! And the whole so called document is just cods-wallop to be honest!

On top of the reasons you mention Dr No, this new shambles of a proposal will just result in putting more and more young doctors into straight jackets as happened before when MMC was first introduced and run throughs discarded, for life, those who couldn't pay for professional psychos to fill their white boxes for them! Not merit, not achievement, not past records, potential, you name it, No, white boxes with hypersatical situations devised by the descendants of Freud were allowed to 'choose' which young docs were pronounced appointable and which to kill at birth!

... and now it's happening all over again!

Why?

Because of a historical feud between hospital docs and GPs! Senior GPs never liked that consultants got, and succeeded at the extra training they could not have and/or pass! That's the real reason for this!

A straight jacket for the juniors because of the 'vested interests' and vanity of the seniors who are out of touch with their younger colleagues, and who are now able to employ them at peanuts as salaried doctors working by the piece instead of offering them partnerships as is the right thing to do! That's it; GREED!

And maybe someone can tell me, what will become of all the hospital doc trainees if they are unable to complete training for one reason or the other?! ... including inability to progress? Sit at home and do nothing?!

This is ridiculous! General Practice should do what it says on the tin; provide 'general medicine'! A medical degree plus 2 foundation years are sufficient, let alone those 3 more years they have to endure as sheap labour now, while the sharks fill their pockets, and bags, and boots ...!

Professor Sawdon, pleeease, enough! The juniors have had enough! :-(

Dear Dr No

I think that this desire for extra training is a naked power trip by the Ivory tower. I am sure that our Korean friend is in favour!

But do we need more training of this type for our budding GPs? Or do we just need some mentoring by senior partners, and for senior partners to see their juniors as colleagues rather than employeees?

Rather as the Foundation Schools were developed to upskill medical graduates to the level of competency of a senior medical student of decades earlier, this is another attempt to apply the wrong solution. Are there any competencies in F1and F2 that a senior medical student should not be competent at on qualification? Are there any skills that a GP needs that are not already possible after five years of medical scool, 2 years of foundation and three of GPVTS?

If the problem is crap medical education because lunatics have taken over the asylum, should we not fix medical education, not have a second course of crap?

No insult intended to general practice, hospital specialist training is at least as dire nowadays. I know all too well, and it scares me.

Dr phil

At a certain threshold additional training exists only to displace training that was given months or years earlier.

But if the GP power base does insist on it's Stalinesque 5 year plan - can they do a bit a more to help the next generation of GPs realise that attaching undue weight to trivial symptoms is ultimately depriving those in genuine need of appropriate health care - I'm fairly sure that Dr Rant has already pronounced on this matter?

...or Stalinism - same difference - the end result is a failed state/profession.

It seems Dr No may have touched a raw nerve here, and with hindsight he may have conflated two related issues into one post, something he tries to avoid. This happened because a post on getting rid of the consequences of apothecarial roots in GP (trivial consultations, over-prescribing because that's what the punter wants and no good shop-keeper wants to lose a punter) has been simmering away in DN's mind for some time; and then the news of the RCGP's 'progress' on extending GP training came along, made it topical, and provided a peg to hang it on. With hindsight, perhaps the post should have led on extending training, or even covered it in a separate post. But DN, silly bugger that he is, liked and stuck to the post's title, and that kept the primary focus on the apothecarial question.

Even a cursory look at the likely effects of extending training suggest that it may well have the potential to become MMC Mark Two, and those who advocate it Carol Black Mark Two.

Some time ago, DN completed his own vocational training in GP. The day release course he attended was exceptional, but the rest of the training less so, and he is rather inclined to suspect little has changed since.

It seems to Dr No that perhaps what GP trainees may need is not longer training, but better training. That better training might even include a specific module: How not to be an Apothecary.

General practice attracts women doctors because the specialty easily lends itself to two important flexibilities - mobility and part time work patterns. The other attraction is that GP training has historically been considerably shorter than for hospital specialties and this allows the female GP to delay having children till she is fully trained.

Lengthening the training time by two years could perhaps alter the predominance of females choosing to enter general practice, or even  lead to a higher proportion of women doctors opting out of medicine altogether.. If this happens will the males fill the gap? I can't for the life of me see how lengthening training will encourage more women to stay in General Practce, but do accept that this witch can be particularly thick at times. Perhaps someone will explain.    

Sent from my iPad

Claire, is the perceived need for longer training a result of a shift in medical education from profession to competency? Instead of being trusted to tackle existing problems or emerging new developments in medicine professionally, doctors face competency assessment. With exploding areas of individual competencies comes the need for more 'training' years. Theoretically maybe a plausible idea but look at the reality, the best box tickers, not necessarily the best performers pass easily.
DN, turning away punters without goodies? Telling them off for turning up as 'emergency'? How many doctors can't do without being 'needed', asked for and wanted, giving, and 'caring' by prescription? How many can't be asked to resist because they fear the next complaint, the GMC Gauleiters, the press? Fat chance for the remaining few who try to resist.

Maybe that's where I go wrong as a single hander. I often allow my punters to leave with nothing and often this leads to them becoming quite irate, especially when it's their poor babby with a cold for the past 3 days.

I admit to a level of professional isolation as a single hander but are you trying to tell me that other GPs give a script for EVERY consultation? Seems like you possibly did your GP training a long time ago, old timer.

In terms of giving appointments for the slightest thing, I think you'll find government policy has pushed this demand (to be able to see a GP within 48hrs no matter what trivia the punters have). Most of us are frustrated by this and its usually the single hander who has a good relationship with the punters (for unless said single hander pays stupid money for a locum to cover an occasional day off the punters see no-one else) and is thus able to take said punter to task on wasting my bloody time (!)

...mind you, I went into medical school when I was 18 and am now 42, so I too have been in medicine 24 years which is only 1 year less than Dr. No claims so I'll shut up on this one.

I'm not sure I agree with Dr No's comments about the style and substance of the RCGP's proposal to extend GP training (in the response to Clare Gerada above) - bearing in mind that it was written for a board made up of professional educators and policy makers, not for 'Joe GP'.

For example, the phrase 'a spiral model of incremental skill acquisition and application' is given as an example of a [non-evidence based] 'corker'. I agree it looks waffly at first glance, but it actually makes perfect, evidence-based sense to an audience of professional educators - the 'incremental skill acquisition' bit refers to a landmark paper by Dreyfus and Dreyfus (Dreyfus SE, Dreyfus HL (1980). A Five-Stage Model of the Mental Activities Involved in Directed Skill Acquisition. Washington, DC: Storming Media) and the 'spiral model' bit refers to another very influential paper by Harden and Stamper (Harden RM, Stamper N. What is a spiral curriculum? Medical Teacher 1999; 21: 141-143).

So the phrase actually combines two pieces of core educational evidence into one sound-bite! The proposal then makes the case for adopting this (evidence-based) approach to make GP training more effective. On a practical level, this means trainees all getting early experience in general practice, so they can get more out of their subsequent hospital posts, and also spending an extra 12 months doing the job they will end up doing independently (i.e. general practice). It all sounds like common sense, really, once you've translated it back into plain English.

"Although the Dreyfus model may partially explain the ‘acquisition’ of some skills, it is debatable if it can explain the acquisition of clinical skills".
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2887319/

They want to make SPECIALISTS...

...out of GENERAL practitioners?

Even a primary school kid can tell there's something wrong with that statement...

It reminds me of the phrase coined by woody to describe Buzz Lightyear's attempt to fly. "Thats not flying, thats falling with style!"

As I recall Buzz Lightyear was a self deluding fantasist with no insight as to the real situation. Perhaps it is quite an apposite description of our masters.

The problem is that medical educationalists are like other managers and obsessed with change, when wise doctors know that often cconservative management is better management. Its a climate of constant revolution that makes everyone miserable, and allows folly to be seen as progress.

I suppose it 5 years on from MMC, so time to repeat those follies.

The WD as always makes a very good point. Extra years of training could well persuade potential female GPs to get on their broomsticks and look for a career elsewhere. However, some may counter that given the projected over-supply of home-grown doctors within the next decade or so that may not be such a bad thing. Whether male doctors will take to posts rejected by their female colleagues is another matter.

Gora - Dr No suspects you may we be right (about competencies). We shall have to see whether The Prof replies - Dr No thinks she might just be rather miffed with DN at the momment...

"How many doctors can't do without being 'needed'" - the 'need to be needed' is too often the doctor's Achilles heel. It is a fascinating subject. It may well be that doctors who 'care so much that it hurts' are but one step away from a caring explosion, the consequences of which can be very messy. Those who don't explode are at risk of developing a caring psychosis - and that too can be very dangerous.

SFD - Dr No has always been by nature a low prescriber; not criminally low, just at the low end. Like you, he has had varied success in suggesting to patients that just because the last ball bearing prescription 'fixed' little Johnny's cold last time, it doesn't mean it will this time (in fact, it never will, because ball bearings don't cure viral infections...).

Ironically, an answer to how many consultations result in a prescription is given in one of the supporting evidence documents: '...GPs issue a prescription in over 50% of consultations...' (page 31).

Waffling with style: one supposes that may be what that lugubrious twit Stephen Fry does... Dr No hasn't read the papers but "A Five-Stage Model of the Mental Activities..." sounds more like a model than evidence and "What is a spiral curriculum" sounds precious close not to evidence, but to a (rhetorical) question.

Dr No will try to find the papers and see whether they bear out his hypothesis (Dr No's remark above can hardly be said to be evidence-based, given he hasn't seen the papers) but in the meantime he suggests with the utmost respect that "a board made up of professional educators and policy makers, not...'Joe GP'" is precisely the sort of Ivory Tower problem that Dr Phil (alias Boots) identifies above. If the punter GPs can't understand it, why should they trust it?

As it happens Dr No is not entirely naive when it comes to education. He spent two years as a lecturer at a well known London teaching hospital not a mile from the Palace of Westmenister some time ago, and even then the medical educators there were busy putting the whack in whacky. More recently, he became a YachtMaster Instructor, and it wont surprise anyone that instructing on a yacht is in many ways classic small group work; and the yacht being a yacht, it involves physical, mental and interpersonal skills...so he does know a little bit about adult education. And so far, bless their wonderful common sense, the RYA has not immersed YMIs in spiral models of incremental skill acquisition and application. If it did, probably even most determined instructors would get sea-sick!

Evidence base?!

What do you do at medical school if you don't lay the foundations for that then?! What are 3 whooole years of clinical, or 'integrated clinical for 5 years are for if not to graduate with enough knowledge to, at the very least, allow a new doctor to recognise the elementaries of 'general medicine'?! Which then makes me wonder, what's a medical degree for?! What are 2 years foundation instead of 1 for then? You know, they don't take your 4 months rotations in different specialities into account when you train for the current 3 years for GP! So say you did 2 rotations in medicine during foundation, you still do medicine again while traing for GP! And now, instead of organising to optimum effeciency instead of 'messy', they want to add a 4th year!

Is there an end to this Mucking Medical Careers fiasco?!

And look ... here a look in the crystal ball, let's see the future if this is left to continue ....

With MMC, or the infamous Modernising [Mutilating is a more meaningful discription; the truth!:] Medical Careers, a brain child of the Blair government's farcical plan 2000, or the reason for why we have an increase in medical school intake by 70%, why we had MTAS, and why we will soon have a huge bulge of qualified docs who will reach consultant level soon, but to dead end, no jobs! Unforgivable never ending mess that has done untold damage to the reputation and the previously excellent standing of British medicine! And now, instead of trying to fix as Professor Swodon has been trying with Prof Darzi were when he was minister [2007 -2009]. They both managed to improve the application process as well as lots in training itself, although there is still room for improvement since 20% of young docs do not even bother to apply to specialist training in the first place!

You know why? In part because of that ridiculous 'commitment to 'the' specialty' requirement on all application forms, when there are not enough jobs to go round! Hence, if you are 'committed' and you don't get it which is very likely, then 'commit' to a mental asylum instead! Or do the clever thing, and lie! Apply to all saying you are 'committed' on each application, get what you can get, then apply again next year for different specialties if you don't like your first 'commitment', commit again, another year ... and here we go round the Mulberry bush, the Mulberry bush ... or go abroad, or muck about locuming for a while, or leave medicine ... and this country loses 250 - 300 THOUSAND pounds spent to train each and every doc only to send them to atch 22 sphere at the end! That's the reality of British medicine at the moment! Ask any surgical ST2 trainee about their hopes for the future, and be sure to get a 'what future?' reply! Most specialties offer the same predicament for a future too! And now it's General Practice turn!

Well, let me tell you, this extra year traing is not needed for GENERAL medicine! And if those high up are effecient enough, there is plenty of room to lay the foundations for 'evidence base' during med school, then build upon during the foundation years! If done to 'original' sparkling British Standards, you can even cut out a year instead of adding a year, this is 'General Medicine' after all! Valued and respected in it's own right and without being jealous of others or feeling inferior to anyone, specially now with the new reform that aims to 'liberate' the NHS and not put young docs in straight jackets as this 4 year GP traing proposes!

This is a ridiculously expensive, to the country but not to GP partners, unneeded excercise, and is counter to what the new government reform stands for which is 'OPENNESS' and 'LIBERATION'! It also does not help young docs endeavour to innovate, but hinders their efforts through the sheer frustration of being locked into unneccessary enlengthened so called training for what is 'general', and NOT 'specialist'!

Let's see how many young docs never applied to training this year because of this mess! I already know a few, and what a loss, not only of money spent during our lean times, but of young but now unfairly frustrated talent too! :-(

I hope who care, are listening ...

Just that - Were any young GP trainee doctors consulted on this, or it is a 'top-down' imposition? If the later, I thought this methodology is now done with ... local local local 'empowerment' is the new NHS motto, in case you haven't heard.

Bo more closed doors, transparency please ... best consult those who will be 'in it', consult the young doctors ... and let's see what they say, and help 'you' too!

I wonder where all you have been
This document was written over the course of 12 months
It is evidence based - and has more references in it that most publications to the Lancet
As someone said it is for educators
We have surveyed our First5 twice and consulted widely
GPs need this extra year
They are telling us time and time again
Our length of training has not changed for 30 years, the NHS has.
Where have the closed doors been?

Dr No is wrong
His ascertains are unfair and incorrect
I always respect his writing - this time I don't.
This is NOT an MMC debacle - how on earth can it be? Its about giving our GPs of the future the extra training they have been asking for for 20 years (in fact most when asked want 5 years)
Its about raising our profession to that of the other specialists- about giving our young doctors time in paid training to bed down their skills and learn in a protected manner to do our you well

Clare

Nowadays the majority of GPs are female. Let's say GP training will extend to five years. Will this deter some women from entering the specialty? Will we lose them from medicine completely? If ithis is the case will it mean men will happily flock into general practice to fill the gap? Or will they unhappily flock into it because entering the hospital specialty they have set their heart on is impossible as hospital care is being transferred into the community but often to specialist nurses or others rather than GPs.

What if the women who get pregnant during their GP training choose to soldier on? Will they demand a part time training scheme plus maternity leave for two or more children? Will many of those who don't drop out require say 10 plus years of GP training before they are considered a to be fully independent medical practitioners?

It is has always been quite difficult to predict medical staffing requirements ... even more so now in a specialty predominated by women doctors set in a fast moving political climate that worships change. The unintended consequences of extending GP training could be far reaching.

Clare - the fact something has references, even lots of them1,2,3,4,5,6,7, doesn't make it evidence based. In the world of academic general practice and medical education, citing a paper may count as evidence, but it doesn't work like that for Dr No. The referenced paper must be relevant to the question and contain good quality evidence. Waffling with style about spirals doesn't meet that test.

Dr No and indeed others have already politely pointed out that professional elitism and isolationism amongst academic medical educators is unwise and dangerous. That's why we talk of Ivory Towers. Dr No in particular finds it worrying that those (plural) at the top of the tower appear to think it is just fine to have an elite club talking an arcane language, yet with the executive power to make substantial and unilateral changes to training. That, Dr No feels sure he does not need to remind anyone, is what happened with MMC. He just makes the point it could be about to happen again.

References:

1. A paper by somebody.

2. A paper that may or may not be relevant.

3. A relevant theoretical paper; no evidence included.

4. One of my best buddy's papers.

5. One of my own papers!

6. A paper that does contain evidence, but of no relevance to the central question.

7. A paper by Buzz Lightyear.

etc etc until one achieves a document with 'more references in it that most publications to the Lancet (sic)'.

There are many candidates for where the rot began in British medicine. I think that many would put it at the Griffiths report under Mrs T introducing the concept of general management. On the educationalist side I would place the critical point as the "tommorows doctors" report of the early 1990's. . This report turned undergraduate training upside down and promised us happier, more fullfilled doctors, better equipped for the modern world. The emphasis changed from learning facts to problem orientated learning.

This has manifestly failed, british doctors are less happy than their predecessors with their levels of knowledge and skills, and feel unprepared for the world of work as autonomous practitioners. By a decade ago this was becoming manifest, and the educationalists decided to create the Foundation programme to train doctors to a level that previously was expected at qualification. The Chaotic and inept MMC programme was then imposed...

Now we have this proposal to extend "Ttraining" as it seems that despite 10 years of training our brightest students cannot achieve a level of training to be confident practitioners independently.

It may be that Britons are much thicker than other nations, but in most other countries 10 years is considered plenty of time to gain these skills.

There seems to be no "Spiral of learning" amongst the educational establishment. On the contrary we see the same mistakes being repeated, time and again. There is little or no remorse or contrition or even acknowledgement that past schemes have failed in their objectives.

I am not a GP but the issues are similar in secondary care. Extending training is no substitute for sorting out the underlying problems. The failure of the educationalists has disenchanted not only the juniors, but also many of my training colleagues. A plan forced on a resentful bunch of doctors who do not buy in to the plan is doomed to fail. It will then be followed by a call to extend training further....

Boots

A succinct and commendably aimed toecap, Boots.

Anonymouse - it is general practice, not general medicine (=physicians in hospitals) we are talking about, but with that caveat, Dr No agrees that MMC has a lot to answer for, and extending GP training risks MMC-ing GP training.

Dr No is sure we can all agree that there is room for improvement in GP training - indeed there is always room for improvement. The crux of this debate is how to achieve that improvement. The Chiefs of Staff invariably want more bombs, and bigger bombs, when in fact what they may need is is smaller, smarter bombs. Or perhaps Dr No means troops. His metaphor machine seems to be on the blink this morning...

Instead of locking more trainees into longer training, it seems to Dr No to make more sense to get them ready for independent practice - ie at career grade - (scary perhaps, but also of itself rewarding) as quickly as it is safe to do so, and then expect these now independent practitioners also to know that there is no end to their learning. A key advantage to this approach is that it gets the trainees out of shorts and into long trousers at the earliest opportunity - and that is the stage, as Dr No noted before, when the real learning begins.

WD - Dr No strongly suspects that the until now relatively benign training and family-friendly possibilities of general practice have attracted women. With maternity leave and for example a 50:50 job share, training could - if extended as proposed - take over a decade: something that may be considered far less attractive than the current option to complete vocational training full-time (and far quicker, in three years) - and then think about the patter of tiny feet.

As for males filling the vacant slots - well - all Dr No can say is that wont be him. A few years ago, some deanery goons told him not only was he not fit to be a GP, he wasn't even fit to retrain as a GP (he had applied to a GP returner scheme after working in another but not too different specialty for a few years). It was then that the seeds of Dr No's Rhett Butler moment were sown...

Dr Phil " "tommorows doctors" report of the early 1990's. . This report turned undergraduate training upside down ... The emphasis changed from learning facts to problem orientated learning."

Hence a new problem was born as a result. That there is now huge variations in the teaching of medicine between one med school and another. I know that because, even within my family, one has loads more academic knowledge than the other, which in turn mean that comes F1 and one fits into practical hands on work faster than the other! Meaning that straight upon graduation, one doc is way better than the other in different aspects! Surely, that scenario then means that medical schools need to have similar or even the same curriculum that is more balanced, instead of this mixed approach, doesn't it? In our case, my daughter was the one more grounded in academia and her younger brother, having graduated with less academic knowledge found himself needy of that extra reading when working hands on - and just started reading on his own to correct that! That's positive professional jealousy, but not every young doc out there has a sibling to be jealous of! This is a problem because it creates graduate doctors who vary, a lot, in their knowledge, and hence, their approach to medicine and medical innovation, and jeopardises patient safety too, which is most paramount!

Of course, when you apply to med school, you can't choose since they are over subscribed, and you don't even know this variation exists! So, in effect, each school has it's own interpretation of the GMC's 'Tomorrow's doctor' report! And as Dr Phil said, this is where the mess starts, and if you have a messy situation at the bottom of the pyramid, then the tier that follows will be messy too right to the top, and it is ... the whole pyramid has been messed up!

Hence your situation Dr No! ... and what a loss!

Of course, sympathy without fixing will get everybody nowhere, the reason why such debate as ours here is essential to air views and real experiences at grassrouts as well as all other levels of that now wobbly pyramid. Suffice to say that sentiments aired are not directed at individuals but at a wrong situation that is now verging on catastrophe! This country has some of the best brains in the world, best commitment, best endeavour, best overall ability, best ... you name it - but all this is now going down the drains because of the faulty system! Why is it faulty is because there is no dialogue between the different establishments in charge of medical education and training any more. Each works for itself.

You know, I don't speak much about it as before, but I do hear things from the kids and their many friends. For but a small example, how this 'problem orientated learning' is signed off? - you just ask any passer by to sign it for you, into portfolio, and done! That's true! There, that's the doctors of tomorrow for you!

As for General practice, this should remain 'general'. Not only because you 'need' generalists, but because you also need a place for those who do not complete specialist training to go to, otherwise their expertise, including that of the time spent at specialist training, will be lost. One famous doctor who benefited from that flexibility is the previous CMO of course, who was a surgeon turned GP - then turned public health expert, and now, turned policy maker. You 'need' that flexibility in the system, it's in your interest to have it, because it eliminates 'Waste', where this continuous addition of years of training to GPs without considering what goes on in previous levels ensure the exact opposite!... at a huge cost, and contrary to the current ideology of 'a flexibile and more open system' too!

On his own blog, Dr Phil has many times written about how he swims with the flow despite not approving of what goes on from his 'professional' point of view as a senior and an educator. That's frustration! We don't want our professionals to be frustrated, but they are now and at all levels! ... including yourself Dr No, and thank you for sharing you personal experience of the now 'modern' mess.

Bottom line; problem oriented learning is a good thing when backed by a sound academic base and a proper method of assessment, all currently faulty.

Open up the debate, discuss, say how you feel everybody, it's only for the best to air all the high frustrations currently swishing around because of this mess - and no jobs, or GP partnerships at the end of it too! Sad!

... but let's hope

" ie at career grade - (scary perhaps, but also of itself rewarding) "

If you choose it, or if not able to progress further, but not as a ceiling above one's head for that's waste of ability, hence waste of potential for the doc as well as this country's standing, surely!

Oooops, did I say that?
No, I am not suggesting the Dr No or Dr Clare should. I respect both of them. Having different viewpoints and feeling free to express them must be a sure sign of a truly free society. Better still if there is no COI and I am not suggesting anyone had.

I am talking about my own experience recently of talking to a high earning lawyer who was very proud of his high level of Medical Insurance. It was a good opportunity for me to understand what his insurance is for: not for GPs, no but if he needs Knee work or shoulder work, he would ask his NHS GP to refer and he would get an appointment with one of the countries top Orthopods that also look after sportsman.

So it was clear to him that his GP that saw him from birth cannot sort our his knee or shoulder. This is not meant to be derogatory, quite the opposite. I relate well to my own and we often had great discussion about the state we are all in. Yes, he is retiring in the autumn and going on a long cruise.

Medicine has moved on from the days when we are supposed to be licenced to do everything once you can register and often this is abused by private OOH setups with lethal results. That few people actually died must be due to luck.

So, both Dr No and Dr Clare may have their points. But ask any lawyer, they insured for more complex hospital procedures.

It is OK for govt. to want to convince us that only GPs will be needed. We as doctors do realise that a few of us, not all, may one day need s Stent, Hip, Knee or bowel operation.

We need to keep good quality well trained specialists for that eventuality.

Am Ang - Debate is greatly to be welcomed, and we are priviledged that we can do it without being shot or censored.

The time when a doctor could go into general practice straight away without any specific relevant training - the Richard Gordon era - did indeed end some time ago. For the last three decades GPs have had to do a minimum of three post full registration years to get a vocational training certificate (and so become an unrestricted principal). The question here is whether they need to do more than a minimum of three years.

The fact that OOH setups abuse loop holes is not sound basis for arguing that current GP training should be extended (instead, close the loopholes). The only sound argument is that the extension, in that dreadful phrase, 'adds value'. Dr No's point is that, in the absence of evidence (in contrast to academic assertions) of 'added value', he believes extending post-graduate GP trainee years could do more harm than good. And, as we are wont to say, primum non nocere...

The hospital part of GP training has often had a tacky reputation - SHOs (ab)used to cover service requirements of little relevance to general practice. More recently, in his last clinical post, Dr No used to see something rather different - demoralised SHOs (including GP trainees) sitting around wondering - as Anonymouse relates - which box to get ticked today.

If Dr No had any say, as opposed to being a waffling blogger, he would push to improve the existing three years, rather than attempt to compensate for existing poor value by adding more potentially poor value. He does fully appreciate the RCGP proposals include plans to add value as well as years but he thinks it possible that may turn out to be doing too much at once. The 'easy' bit - adding the extra year(s) will happen, while the harder bit - getting trusts to add GP trainee value - will fall by the wayside (and here we should note that this problem - GP focused hospital training - had been long and intractable). The risk is that GP trainees will face more trainee years of the same poor educational quality.

How to get trusts to give GPs more relevant experience? Now, that is a question worth pursuing. The majority of Dr No's paediatric experience - for example - focused on getting blood out of neonatal stones - hardly a daily event in general practice; and a terrified SR (he had missed a few cases) tried to teach him that any child with a headache must have a lumbar puncture (luckily, Dr No had come across referral bias). Had Dr No instead learnt the basics of knowing a sick baby/child when you see one, he expects he would have been a better GP. But how to persuade trusts that training better GPs is actually in their interests - better GPs means less inappropriate referrals, for example? It has, as Dr No notes, been a long and intractable problem...

Meanwhile, Dr No has tracked down the Dreyfus and Dreyfus paper - it is indeed a model (chiefly of how USAF pilots learn to fly) - and a model is a description, not evidence that something works. The Harden and Stamper paper is behind a paywall, but from what he can gather - he might be quite wrong - it is a specific elaboration of the more general virtuous circle notion. Again, a notion, even a specific elaboration of a notion, is not evidence that something works...

But then again, absence of evidence isn't necessarily absence of effect. DN has both an open mind - and a hunch.

And those trainees in extra training - are they waving or drowning?

In our Borsetshire GPVTS scheme the majority of the trainees join a local practice on a permenant basis. This is a useful way to build bridges between primary care and secondary care, and potentially of good educational value. The needs of these trainees are quite distinct from our specialist trainees who are planning a specialist career, and needs to be tailored accordingly.
We put the GPVT into sessions most likely to skill them for assessment of patients presenting acutely, and also of the common conditions that they will encounter in General Practice. In these sessions they need to be supernumary and well supervised. at the beginning of the four month block they slow down their supervisor, by the end they are a significant benefit to the service.

The real benefit to our department is difficult to quantify, but I believe that our participation in the GPVT scheme has improved the quality of referrals both in terms of content and urgency as well as allowing many cases to be managed appropriately in primary care. Our GPVTs are ueeful points of contact in many practices even years later.

There is little reward within the NHS for our efforts in this area (though relationships with GPs are a good source of private referrals!). In my fifteen years within the scheme I have never had any meetings with the GPVT educational leads, any feedback or appraisal of what we are doing. It may be that they have been collating reports on us and are entirely in agreement with what we are doing, if so that would be nice to hear! More likely we are under their radar.

I have to push quite strongly within our department, as some of my Consultant colleagues are quite scathing about GPs generally (a foolish attitude for many reasons) and the pressure from our managers is always to use the GPVTs to plug service gaps with activities of low educational value.

It is a constant battle, and it does wear me down from time to time, but I am not a theoretical educationalist in a chateau behind the lines, I am a front line educator going over the top with the poor bloody Infantry. I would not want it any other way.

my analogy with the disconnect between medical educationalists and doctors (both trainees and trainers) with the first world war does not stop things from being improved. Whilst there is grumbling in the ranks and a worryingly high desertion and casualty rate, the bulk of the troops are still up for it if good leadership were provided.

Reform of training needs to focus on quality not quantity, it needs to be well focussed to career aspirations and tailored to the individual. If it fails to engage the trainers as well as the trainees morale will slump further. If trainees are promised by educationalists something that does not materialise because trainers are not engaged or have no time in their job plans we will have a future fiasco in the wings. I believe that reform needs to address the failings of undergraduate training as well as postgraduate training.

We do need generals to take a strategic view, but I would make the rule that no-one should spend more than 50% of their time out of the front line, not postgraduate deans, not College presidents and not medical directors. That contact with the front line is essential if meaningful action is to be relevant and realistic. Phantom battalions are shown to be just that when put to the test, and we see who the really effective troops are.

Sorry to take so long over this, but training is something I care a great deal about. If I have a further essay I shall put it on my own blog.

Happy sailing Dr No

Boots

I am not a GP but when the new contract was introduced and the OOH service opt-out followed, a few GPs expressed some views to me at the time. Initially, there was a kind of disbelief that they could be paid so much more for doing less work. The same was true of the consultant contract incidentally. Most doctors don’t delve into the underlying politics leading up to decisions like these, but the bizarreness of the situation focused the minds of some GPs. We were all being bought for a reason. Alan Milburn was no fool.

One insightful GP said to me at the time that he felt this was the beginning of the end of general practice as we know it, if not the beginning of the end of general practice in its entirety.

Perhaps fearing for the future of general practice may be one of the reasons that some GPs feel more training is necessary.

The Witch Doctor has blogged in the past about Mary Mundinger. She suspects she is off the radar of most UK doctors. She shouldn’t be. Even in her retirement, it appears she is still influential. She still has much to say about Primary Care in the USA. Here she is in March 2012. Her theme is “Let’s turn primary care over to nursing.”

http://www.bloomberg.com/video/88992941/

Boots - Dr No couldn't agree more. The type of GP trainee placements you provide, against the your local and it seems to Dr No general will and trend, are just the type of placements needed. GPs trainees get relevant experience, and in the fullness of time your department benefits from appropriate referrals (and all that that also implies); and also has useful secondary-primary care links. It is sad but no doubt unexceptional that your local GP course organisers appear indifferent to your efforts. Perhaps they spend too much of their time stuck in cabals, waffling with style. (Dr No was surprised - or was he? - that an earlier commenter appears to be saying it is just fine for medical educators to adopt some sort of rarefied high priestly approach, with a language all of their own, no need for Ordinary-Joe-GP to bother their tiny brains with such lofty concepts, just take it from us - we know...four legs good...).

The Angry Medic has kindly commented. Anonymouse has generously told us what she has heard from juniors. But otherwise, we have not heard from GP trainees - so far as Dr No can tell. If there are any GP trainees reading this, perhaps they might like to tell us what they think?

WD - the recent contract changes reminded Dr No of that Asda ad where the punter pats the wallet in their back pocket...and was left with a lingering question of just who had been had? He also notes MM's initials just happen to be the same as the first two initials of something entirely different. But then, that is the sort of conspiracy minded observation only black cats waiting for rats come up with! Instead, here is an accessible NY Observer article on the real MM.

"Dr No was surprised - or was he? - that an earlier commenter appears to be saying it is just fine for medical educators to adopt some sort of rarefied high priestly approach, with a language all of their own, no need for Ordinary-Joe-GP to bother their tiny brains with such lofty concepts" - what is even more surprising is that much of the educational theorising that is creeping into medicine seems redolent of the kind of guff the poor old nurses have been saddled with down the years - things like 'reflective practice' or Benner's 'novice to expert' (the latter seems to have shaped the Dreyfus model).

A low point in my nursing career was the time spent listening to a tutor (who had obviously not been near a patient for aeons) explaining this arcane sort of nonsense in the classroom - I must admit, I am none the wiser about 'reflective practice' even though ALL nurses are meant to include a small novel describing 'reflective episodes' in their clinical portfolios.

Despite these high minded ideals I suspect most NHS patients are more interested in a clean bed, edible food, prompt analgesia, and doctors and nurses who know what the hell is going on, rather than the thoughts of Benner or Dreyfus?

"Despite these high minded ideals I suspect most NHS patients are more interested in a clean bed, edible food, prompt analgesia, and doctors and nurses who know what the hell is going on, rather than the thoughts of Benner or Dreyfus?"

HEAR FUCKING HEAR. Unfortunately this sort of diarrhoea-inducing drivel is increasingly permeating every aspect of the NHS, from our (F1's) ePortfolio horseshit to your 'reflective episodes'. Soon even the fucking Rastafarian porters will be forced to fill up portfolios describing how wheeling fatasses from one floor to another whilst chewing on cheap weed from Bayswater has made them grow as human beings.

Dr No - I apologise for not yet being able to answer your calls for GP trainees' comments, as I am at least a year and a half away from starting GP training. But when I do, it sure as hell won't be in the NHS - I'm making like a bad cricket player and heading for Australia. At least there I get grateful hot Aboriginal chicks instead of Andrew Lansley ramming his crap up my arse.

I suspect the motives are likely cynical.

With the NHS reforms it is likely that GPs will become keener to pretend to become the equivalents of hospital doctors, so that they can farm out more work corruptly to themselves rather then referring it on as they should do.

Whatever you call them GPSIs, they are no substitute for proper hospital specialists, it is dodgy IMHO unless Primary care is working with Secondary care in providing specialist services.

On training, an area in which I am somewhat expert, I agree with a lot of the above.

There is a monumental disconnect between the idiots in Ivory towers running training and those training on the ground.

There was a brief improvement as everyone rebelled against the madness of MMC, but unfortunately we continue to be drowned as the idiots persist with their competency based methods and reflective bullshit.

We need the GMC out of training, we need more hours, more experience and better regulation to improve quality.

http://ferretfancier.blogspot.co.uk/2012/04/dr-no-nail-on-head-can-of-wo...

the problem with the continued reform of medical training

I'm coming late to this having thought about the woeful performance of so many GPs for some time. It was bought into sharp focus when I audited hospital referrals from my peers and discovered that little had changed since my junior hospital days when hand written notes saying things like, "?pancreas, please see and do the needful" were the comprehensive totality of a referral. The dark side of GP is that there are still doctors behaving like this, shutting their doors while they're either on the golf course or counting their ill-gotten gains. The fact that we're in a situation where 'independence' is the sine qua non of British General Practice rather than quality, has a lot to answer for.
Evidence confirms 2 things for me. Firstly that there is an awful lot of dreadful general practice and little or nothing is done about it, the PCTs failed, then CCGs will have no remit and Monitor has no reach. Training has to ensure that trainees that aren't good enough cannot practice and it has to be linked to lifelong learning.

Secondly since so much of our work is triage and gatekeeping, we simply have to get out of our silos and start working hand in hand with our specialist (hospital) colleagues. Evidence from A&E triage is that it works most effectively, safely and efficiently when handled by the most highly trained and experienced doctors. We ought to treat GP gatekeeping with the same level of concern.
If frontline medical educators all took their work as seriously as Boots (and too few others I have met and been trained by) and if collaborative working relationships were part of the NHS structure, 3 years would be ample training time.
Jonathon


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