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Core curriculum for General Practice Training

Attempts to state the core curriculum for General Practice have ranged from the single sentence "All human life is here" approach to books of lists broken down into minute detail. The object of this document is to try and take a middle line and provide a check list against which Trainers can produce a curriculum which takes into account the individual and changing needs of their Registrars without missing out whole areas.

Definition

A familiar definition of a General Practitioner is the one published by the RCGP in 1969:

A General Practitioner is a doctor who provides personal, primary and continuing care to individuals and families. He may attend his patients in their homes, in his consulting room, or sometimes in hospital. He accepts the responsibility for making an initial decision on every problem his patient may present to him, consulting with specialists when he thinks it appropriate to do so. He will usually work in a group with other General Practitioners, from premises that are built or modified for the purpose, with the help of para-medical colleagues, adequate secretarial staff and all the equipment which is necessary. Even if he is in single handed practice, he will work in a team and delegate when necessary. His diagnoses will be composed in physical, psychological and social terms. He will intervene educationally, preventively and therapeutically to promote his patients health.

Professor Pereira Gray has defined the main features that characterise British General Practice as

Primary Care
Family Care
Domiciliary Care
Continuity of Care
Preventative Care
Personal (holistic) Care

In this definition, the essentials of each feature are as follows:

Primary Care refers to the role of the General Practitioner as the first point of contact with the NHS for most patients. The function of the General Practitioner as the gatekeeper for access to secondary care is recognised as one of the distinguishing characteristics of British General Practice. Because of this, GP's need to be able to recognise early signs and symptoms of disease and the often unstructured presentation of problems in General Practice.

Family Care refers to the fact that most families register with the same GP and that he is thus able to gain insight into family dynamics and their influence on disease and illness, and the importance of formulating management plans in the light of these insights. Patterns of behaviour and of illness can often be related from one generation to the next.

Domiciliary Care acknowledges the community setting of General Practice with doctors and their teams having access to patients in their homes. It recognises that the role of the doctor working in a community setting is different to that of a hospital doctor.

Continuity of Care recognises the long term commitment of a GP to his patient - from the cradle to the grave. It also recognises the contractual obligation of a GP to provide care to his patients for 24 hours a day and seven days a week.

Preventative Care emphasises the proactive role of the GP in health education, health promotion, illness prevention and screening as a change away from the more traditional reactive role. It underlines the need to develop an understanding of the theoretical framework of preventative care and the need to develop team strategies for prevention.

Personal or Holistic Care describes the intimate nature of the doctor/patient relationship and the increasing willingness of General Practitioners to acknowledge the unique nature and qualities of his individual patients.

THE CONTENT OF GENERAL PRACTICE

Having accepted the parameters laid out in the preceding page, it is possible to break down the content further and to consider the areas of Clinical Knowledge and Performance, the Practice, Professional Values and Professional Life. It should also be recognised that the agenda for General Practice must take account of the concerns of Patients and of the Government. Finally the overall context of training for General Practice must also recognise the needs of Doctors generally and the specific needs of trainers and registrars.

Clinical Knowledge and Performance

The following core content must be addressed by all the elements of the training process if the General Practitioners produced by the Mersey region vocational training are to fulfil the Objectives already laid out.

1. Factors Influencing Disease and Illness

1. Local and community epidemiology

2. The natural history of disease and illness

3. The range of normal

4. Normal development processes

5. Normal senescence

6. The needs of special groups such as pregnant women, children, etc.

7. Cultural, educational, political, religious and ethical influences.

8. Family expectations and dynamics

2. The Nature of Disease and Illness in General Practice

1. Minor and self limiting illness

2. Diseases commonly or mainly seen in General Practice

3. Chronic Disease and disability

4. The early prevention of disease

5. Psycho-social and environmental problems

6. Life threatening events

7. Problems requiring urgent decisions and actions

3. Continuity of Care

1. Ante-natal, intra-natal and post-natal periods

2. Neonatal period

3. Babyhood

4. The Toddler

5. School age

6. Puberty

7. Adolescence

8. Marriage

9. Middle age

10. Old Age

11. Dying

12. Bereavement

4. Diagnosis

1. The need for selective history taking

2. The need for a selective approach to the physical examination

3. The need for a selective approach to diagnostic tests

4. The need to work with incomplete diagnoses and an ability to keep options open

5. The need to make inclusive diagnoses encompassing physical, psychological social and environmental factors

6. The need to establish priorities for action

7. The need to seek further advice when necessary

5. Management Plans

1. The use of therapy within the consultation including listening, explaining, reassuring etc

2. The use of referral for specific therapy, e.g. counselling and physiotherapy

3. The use of referral to specialist colleagues

4. Rational prescribing and drug therapy

6. Anticipatory Care

1. Health education

2. Health Promotion

3. Screening

4. Case Finding

5. Preventative Measures

6. Immunisation

7. Specific Skills

8. The Consultation

1. The setting

2. The ways in which patients present their problems

3. The tasks to be achieved in a consultation

4. The appropriate use of time and resources

5. The doctor's own communication skills

The Practice

Practice organisation is an important area of new knowledge for General Practitioner registrars. They need to gain an understanding of the following areas

Professional Life

Medicine is a profession and membership of that profession places doctors with constraints within which they are bound to work. These include statutory constraints from bodies such as:

1. The National Health Service Executive

2. The Regional Office

3. The Health Authority

4. The General Medical Council

5. Civil law

They also include professional constraints from bodies such as:

1. The Local Medical Committee

2. The Royal College of General Practitioners

3. The British Medical Association

4. The Joint Committee on Postgraduate Training for General Practice

5. The Defence Organisations

Registrars need also to understand the function of such organisations as

1. The University Department of General Practice

2. The Mersey GP Education Committee

And of such people as:

1. The Postgraduate Dean

2. The Director of Postgraduate General Practice Education

3. The Professor of General Practice

4. Course and Scheme Organisers

5. Clinical and GP Tutor

Professional Values

Registrars should leave training with positive attitudes and values including

1. A willingness to seek self understanding and be self critical.

2. A commitment to continuing professional development including continuing education

3. A willingness to make a contribution to a wider professional life and society as a whole

4. A willingness to teach others

5. A willingness to contribute to research and the furtherance of understanding where appropriate

6. A willingness to review and evaluate his work with a commitment to change where indicated

7. A willingness to work within an accepted ethical framework

The Concerns of Patients

General Practitioners need to be aware of the concerns of their patients. Some common themes expressed by patients are

1. The doctor showing interest and concern

2. The doctor's skills in communication

3. The need for the doctor to be accessible

4. The need for a doctor to have time for each individuals particular problem

5. The ability of the doctor to work as part of a team

The Demands of Government

The Government has a duty to safeguard the spending of public money and to see that health policies they perceive as appropriate are carried out. As a result, they demand

1. The achievement of certain targets in health care

2. The availability and achievement of regular health checks

3. The insistence that a doctor be available for a minimum period of time

4. The availability of 24 hour emergency cover for patients

5. Audit of work activity and outcome

6. Some control over prescribing

The Needs of Doctors Generally

While fulfilling the needs of others, a doctor should not forget his own needs. These include

1. Time for his family and for recreation and refreshment

2. Time and scope for professional development

3. Support from colleagues and other professionals

4. Looking after his own health and welfare

5. Time for personal development and self actualisation (Maslow)

The Needs of Registrars

In order to achieve the Aims of Training, registrars need the following

1. A model of good practice

2. Extensive clinical experience as near to that of the average GP and under supervision

3. Practical and theoretical teaching of adequate quantity and quality

4. Sufficient time to study and carry out research

5. Critical scrutiny and regular feedback, encouragement and support and the opportunity for self assessment

6. Career guidance

Source: Core Curriculum for GP

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