Teaching general practice: a rallying flag for undergraduate education

Is general practice simply a vehicle for delivering the generic skills, knowledge, and professionalism that students must acquire during their time at medical school? Or is it an academic discipline that needs to be taught to medical students in its own right? For several years this has been the subject of much debate in the UK.^1,2 Most specialties (for example psychiatry³ and obstetrics and gynaecology⁴) have produced their own national undergraduate curricula. General practice has been the odd one out; that was until October 2018 when the Royal College of General Practitioners (RCGP) and the Society for Academic Primary Care (SAPC) published Teaching General Practice: Guiding Principles for Undergraduate General Practice Curricula in UK Medical Schools.⁵ This is the closest we have come to having a national undergraduate curriculum for general practice in the UK.

IMPORTANCE OF THE NEW GENERAL PRACTICE CURRICULUM GUIDANCE

The UK is struggling to recruit new GPs. In 2016 Health Education England and the Medical Schools Council set up a task force, led by Professor Val Wass to examine the factors operating when graduates decide whether to train as GPs. Her final report By Choice, Not by Chance ⁶ identified several deterrents to graduates opting for general practice; among them the lack of a visible curriculum for general practice and the paucity of undergraduate teaching about general practice as an academic discipline.

The RCGP and SAPC guidance takes a wide view of the term curriculum; it includes a list of the academic principles that define the special nature of general practice as well as a summary of the methods by which teaching might be delivered. The latter is something that is often lacking from other undergraduate curricula. The list of principles is divided into three sections: person-centred care, population-centred care, and providing care in a highly-efficient way in community settings. This style of presentation makes clear the pervasive tension experienced by GPs in having responsibility for the individual patient in front of them and for the whole population that they serve.

Highlighting the efficacy of primary care is important too. This is something that established GPs take for granted but may not be clear to medical students or indeed the wider population. In her seminal paper from 1994 Professor Barbara Starfield⁷ demonstrated that the high-income countries whose healthcare systems embrace general practice the most, are also the most cost effective. This message has been reiterated in repeated reports from the Commonwealth Fund.⁸ The curriculum guidance also gives rightful prominence to the psychosocial factors of health and to the role of general practice in reducing health inequalities.

CONSULTATION SKILLS

Key to the delivery of person-centred care is the GP consultation. In most medical schools the teaching of communication skills is led by GPs using a framework developed by the UK Council of Communication Skills.⁹ This can lead to a misconception among students that the main attribute of general practice is effective communication within the consultation. Of course communication skills are vital but within the consultation GPs have to make diagnoses and quick decisions. The new curriculum guidance identifies both these skills, though it could do more to stress the theory underpinning the diagnostic process. GPs are experts in making diagnoses, both minor and major, and use a variety of strategies, most notably probabilistic reasoning in doing so.

PRESCRIBING

Curiously, the guidance lists social prescribing as one of the key principles of person-centred care but does not highlight prescribing medication as a key skill for GPs to teach. All medical graduates in the UK have to pass a national prescribing exam, the Prescribing Safety Assessment (created by the British Pharmaceutical Society and Medical Schools Council), before they can start work as doctors. The authors of this exam recognise the important role that GPs have in prescribing and therefore set a large proportion of the questions in general practice. To ensure our students are prepared for this exam and their future work it would be prudent to include prescribing as a key principle within the curriculum guidance for general practice.

The guidance might encourage those who lead GP teaching at medical schools to develop new learning objectives. For example, the guidance lists multimorbidity as a key principle within the undergraduate curriculum. This is certainly a hot topic in general practice, yet in 2016 a survey of the undergraduate handbooks for primary care at all UK medical schools¹⁰ showed that only 20% of medical schools included multimorbidity in their handbooks.

POTENTIAL IMPACT OF THIS GUIDANCE

The guidance should help those who lead general practice teaching in medical schools to persuade their colleagues of the importance of teaching within general practice. When schools are designing their curricula (which they all do periodically) this document will be an essential reference for what should be taught about general practice and how. It will also be useful to all GPs who teach in their individual practices, to remind them of the key principles that they should highlight to students during a teaching session. Importantly the guidance may act as a rallying flag behind which GPs can stand when negotiating with politicians and the GMC, in its role as the regulator of medical education.

The guidance is commendably succinct and well presented. Perhaps the quest for brevity is the reason why it shies away from highlighting any specific diseases that GPs should teach to medical students. Other undergraduate curricula consist mainly of lists of diseases and conditions. There are certainly many conditions and illnesses that are managed almost exclusively in general practice. Does the omission of such a list serve to emphasise that GPs deal with everything or does it weaken the document?

THE NEXT STEPS

To increase its utility to both teachers and students the guidance might be enhanced by an inventory of key research papers in general practice demonstrating the evidence base behind each of the principles. To bring it life, the guidance might also benefit from an album of notable GPs: pioneers and role models, such as Dr Julian Tudor Hart, who might inspire our students and GPs of the future.

To teach all the principles set out in this document a medical school will need to find time in its 5- or 6- year undergraduate programme. This might mean reducing the time given to other specialties which promote their own undergraduate curriculum. There is only so much that can be squeezed into a 5-year programme. Medical schools will also need to identify more GPs who want to teach, or persuade current teachers to do more. And here lies a problem: the current primary care undergraduate teaching tariff (that is the money for paying GPs to teach) has not increased for several years. This tariff is set by the Department of Health and is currently about 30% less than the tariff for teaching in hospitals, despite evidence that the actual costs of delivering teaching in hospitals and general practice are about the same.

Everyone agrees that we need more GPs. Giving general practice greater prominence in the undergraduate curriculum should encourage more students to choose general practice as a career. This new curriculum guidance from the RCGP and SAPC is timely and should help to generate that greater profile for general practice; but are the resources there to deliver it?

Provenance

Commissioned; not externally peer reviewed.

Competing interests

Andrew Blythe was involved in the very early stages of the development of this curriculum guide