• Contents page •

Being a Family Doctor

Introduction

Rationale for the curriculum statement

This is the first in a series of curriculum statements produced by the Royal College of General Practitioners (RCGP) that define the learning outcomes for the discipline of general practice in order to practise medicine as a family doctor[T1]  in the National Health Service in the United Kingdom.  This statement covers the core competencies required to become a GP, and outlines the elements of the discipline that distinguish it from others.  Specific clinical areas of application of these competencies are dealt with elsewhere.  This “core” statement underpins all such specific statements.

The curriculum statement is based on the framework statement of the discipline of general practice developed by WONCA Europe, and formally launched during its meeting in London in 2002[1]. The WONCA framework was subsequently endorsed by the RCGP and the Joint Committee on Postgraduate Training for General Practice (JCPTGP) here in the UK.  In developing its new curriculum a number of models were considered by the RCGP, including those put forward from the Oxford Region[2], and the model developed by the Royal Australian College of General Practitioners[3].  The decision to use the WONCA Europe framework was taken because of its international applicability and acceptance by the national colleges and associations of family medicine in 30 countries in Europe.  But there is a further imperative for using a Europe-wide model.  The United Kingdom is, like other European Union and EEA countries, subject to EU Directive 93/16⁴ which promotes free movement of doctors through mutual recognition of training.  Directive 93/16 only defines training length and placement, and these are now exceeded by almost all member states. The content and assessment of training are left to individual countries to determine, and therefore, for the protection of patients, it is self-evident that family doctors should receive training that will equip them with the necessary skills to practice, and that the competences should be defined in a Europe wide context.

The WONCA Europe Definition contains a description of eleven fundamental characteristics of the discipline of general practice, a role description of the specialist in family medicine (which are in Appendix 1), and the competency framework derived from these.  The eleven characteristics of the discipline relate to eleven abilities that every specialist family doctor should master.  They are not specific to any particular type of health care system, nor to any pathological conditions. 

In the competency framework the eleven characteristics of the discipline were clustered into six independent categories of core competencies, with three areas of implementation, and three background features.  This gives rise to a complex three-dimensional matrix which comprehensively covers the domain of family medicine.  This is explained in more detail in the next few pages of this section.

Further work carried out by EURACT, the education network organisation of WONCA Europe has further analysed the six categories of core competencies and this has greatly assisted design of this curriculum.[4]

Relation to Good Medical Practice for General Practitioners

 “Good Medical Practice for General Practitioners” was developed by the RCGP and the General Practitioners Committee of the BMA[5] from the General Medical Council’s (GMC) publication "Good Medical Practice".  It provides a framework against which general practitioners can judge their own performance and can be judged.  Any curriculum for general practice training must address the issues in this document, but as a curriculum statement it is incomplete.  Each of the curriculum statements produced by the RCGP has however been mapped to statements in "Good Medical Practice for General Practitioners" to ensure that coverage of the professional expectations of the discipline is complete. An illustration of this cross-referencing is provided in Appendix 2.

UK health priorities

General practice is a key element of all health care systems in Europe and is recognised by health service providers as being of ever increasing importance[6].  International evidence[7] indicates that health systems based on effective primary care with highly-trained generalist physicians (family doctors) practising in the community, provide both more cost effective and more clinically effective care than those with a low primary care orientation.

In the United Kingdom general practice has been a fundamental element of health care provision since the inception of the National Health Service.  This has been emphasised by some of the changes to NHS organisation such as the development of the primary care led NHS, the development of GP fundholding, and more recently the emergence of primary care trusts (PCTs) and other primary care organisations (PCOs) as being major commissioners of health care for their local populations in England and Wales.

Originally it was possible to enter general practice without specific training, but mandatory vocational training was introduced by regulation in 1979[8].  Society has changed over the last 30 years and there has been an increasing role for the patient as a determining factor in health care and its provision.  The opinion of the clinician is no longer regarded as sacrosanct and a new dialogue is emerging between health care consumers and providers.  The expectations of patients, the interest of politicians and the media the impact of new information systems such as the internet and the increasing cost and complexity of health care delivery have resulted in a climate of almost continual change.  The future general practitioner has not only to be aware of this but to  able to thrive in such an environment.  It is important that the discipline of general practice continues to evolve as the health care systems in which it operates change, and that it responds to the health needs of patients.  Family doctors must continue to practise medicine as clinical generalists, applying the eleven fundamental characteristics, and also to be involved in the continuing development of their health care system.   As individual professionals they  must be able to adapt and grow in order to meet these new challenges.

The content of the competence list

The WONCA 2002 definition develops the eleven characteristics of the discipline into clusters of six independent categories of core competencies, three areas of implementation, and three background features of the discipline. These provide the framework for the development of the curriculum for general practice the modules to acquire the core competencies, and also a framework for specific content areas in general practice.  This is shown in more detail below:

1. Primary care management
2. Person-centred care
3. Specific problem solving skills
4. Comprehensive approach
5. Community orientation
6. Holistic care

Areas of Implementation

To practice the specialty, the competent practitioner implements these competencies in three important areas.  These areas  will need to be incorporated into all of the learning outcomes.  The three areas of implementation are:

1. clinical tasks
2. communication with patients
3. practice management

Background Features

As a person-centred scientific discipline, the three background features should be considered as fundamental.  These are:

a)      Contextual:  using the context of the person, the family, the community and their culture

b)      Attitudinal: based on the doctor’s professional capabilities, values and ethics

c)      Scientific: adopting a critical and research based approach to practice and maintaining this through continuing learning and quality improvement

The interrelation of core competencies, areas of application and fundamental background features characterises the discipline and underlines the complexity of the specialty. 

Learning Outcomes

In order to demonstrate competence as a general practitioner, the learner will need to acquire knowledge, skills and professional attitudes in a number of areas.   The scope of these core competencies are described below.  From the end of basic medical education to the completion of  specialist training it is envisaged that learners will develop progressively in all these competency areas from a state of being a novice to that (in some cases) of becoming an expert[9].  Successful completion of training will be judged to have occurred once a learner has been considered competent.  Competence is defined as a stage on the way to expertise characterised by the development of a knowledge base that is increasingly “coherent, principled, useful and goal orientated”[10]. 

In cases where duplication would occur (for example the referral process could be placed in paragraphs 1.1.3, 1.1.4 and 1.1.5) the competency concerned has been described in only one place.

Core competencies

 Primary care management

The work of the general practitioner is primarily is focused on populations with a low prevalence of serious disease. Thus the physician must develop concepts of health, function and quality of life in the populations served as well as models of disease. This finds expression in the preventive and health promotion activities of physicians and in risk factor management. It is also expressed in decisions made in palliative and terminal care.  Family doctors are also increasingly challenged by the need to be conscious of health care costs. An understanding of cost-efficiency is therefore a learning issue for physicians in training. General practitioners work with specialists in secondary care, and use the diagnostic and treatment resources in hospitals.  In caring for patients with a work with an extended team of other professionals in primary care both within their own practice and the local community. Thus the context of primary care education must promote learning to integrate different disciplines into a team for optimal primary care management within the complex team of the NHS.  They must learn the importance of supporting patients in making decisions about the management of their health problems and how to support the patient in understanding how that care will be delivered by the NHS team as a whole.

This competency is concerned with the ability :

1.1.1        to manage primary contact with patients, dealing  with unselected problems;

This will require:

a)      knowledge of the epidemiology of problems presenting in primary care

b)      mastering an approach which allows easy accessibility for patients with unselected problems

c)      an organizational approach to the management of chronic conditions

d)      knowledge of conditions encountered in primary care and their treatment

1.1.2        to cover the full range of health conditions

This will require:

a)      knowledge of preventive activities required in the practice of primary care

b)      skills in acute, chronic, preventive, palliative and emergency care

c)      clinical skills in history taking, physical examination and use of ancillary tests to diagnose conditions presented by patients in primary care

d)      skills in therapeutics including drug and non-drug approaches to treatment of these conditions

e)      ability to prioritize problems

1.1.3        to co-ordinate care with other professionals in primary care and with other specialists

This will require

a)      knowledge of the organization of an NHS general practice, and its place within the wider health service

b)      understanding the importance of excellent communication with patients and staff

c)      skills in effective teamwork

1.1.4        to master effective and appropriate care provision and health service utilisation

This will require:

a)      knowledge of the structure of the health care system and the function of its components in relation to primary care

b)      understanding the processes of referral into secondary care and other care pathways

c)      skills in the management of the primary/ secondary care interface

1.1.5        to make available to the patient the appropriate services within the health care system

This will require:

a)      communications skills for counselling, teaching and treating patients and their families/carers

b)      organizational skills for record keeping, information management, teamwork, running a practice and auditing the quality of care

1.1.6        to act as advocate for the patient

This will require:

a)      the development and maintenance of  a relationship and a communication style characterized by partnership with the patient

b)      skills in effective leadership, negotiation and compromise

Person-centred care

The patient-centred approach can be seen as a prerequisite to the patient centred clinical method upon which family medicine as a discipline is based. In his nine principles of family medicine, McWhinney[11] quotes three of them as basic elements: commitment to the person rather than to a particular body of knowledge, seeking to understand the context of the illness, and attaching importance also to the subjective aspects of medicine.  A person centred approach is more a way of thinking than just a way of acting.  It means seeing the patient always as a unique person in a unique context, and taking into account patient preferences and expectations at every step in a patient-centred consultation. (Stewart)[12]  Both a shared management of problems with the patient and a disagreement over the equitable use of limited resources may raise ethical issues which challenge the doctor. The ability to resolve these issues without damaging the doctor/patient relationship is important.

Person centred care puts a great importance on the continuity of the relationship process. Continuity is a large, multidimensional issue that includes a lot of different aspects.  It can be split up in three types of continuity (Haggerty[13]) The personal continuity of seeing the same doctor, the episodic continuity of ensuring that information is always available when taking over or referring, and the continuity provided by the discipline that guarantees organised care for 24 hours. McWhinney11 stresses that the key word is the responsibility, not the personal availability at all times.

This competency is concerned with the ability:

1.2.1        to adopt a person-centred approach in dealing with patients and problems in the context of patient’s circumstances

This will require

a.       the basic scientific knowledge and understanding of the person, his growth, aims and expectations in life. 

b.      the development of  a reference frame for understanding and dealing with the family dimension, the community, social and  cultural dimension in a person’s attitude, values and beliefs.

c.       mastering patient illness and disease concepts

d.      skills and attitudes to apply these in practice

1.2.2        to apply the general practice consultation to bring about an  effective doctor-patient relationship, with respect for the patient’s autonomy.

This will require:

a.       the ability to adopt a patient-centred consultation model that explores the patient’s agenda of ideas, concerns and expectations, integrates the doctor’s agenda, finds common ground and negotiates a mutual plan for the future

b.      the ability to communicate findings in an understandable way, including helping patients to  reflect on their own concepts, and find common grounds for further decision making.

c.       the attitude to make decisions with respect for the autonomy of the patient

d.      the awareness of subjectivity in the medical relationship, both from the patient’s side (feelings, values and preferences) and from the doctor’s side (self-awareness of values, attitudes and feelings)

1.2.3        to communicate, set priorities and act in partnership

This will require:

a.       skills and attitude to establish a partnership type of relationship with the patient

b.      skills and attitude to achieve a balance between distance and proximity to the patient

1.2.4        to provide longitudinal continuity of care as determined by the needs of the patient, referring to continuing and co-ordinated care management.

This will require:

a.       understanding and mastery of the three aspects of continuity : the personal continuity as the lifetime coach, the episodic continuity to make the appropriate medical information available for each patient contact, the continuity provided by the discipline that guarantees organised care for 24 hours a day and 365 days a year.

b.      understand and achieve an appropriate work/life balance which addresses the needs of the patient.

Specific problem solving skills

Specific problem solving skills relate to the context in which the problems are encountered, the nature and natural history of the problems themselves, the personal characteristics of the patients presenting with these problems, personal characteristics of the doctors who manage them, and the resources they have at their disposal to manage these problems. Problem solving in general practice is highly context-specific.  The importance of problem solving when faced with early undifferentiated illness helps the learner to focus on a problem-based approach rather than a disease based approach.  Differences between general practice and hospital problems solving strategies can be difficult for some learners to understand or accept, particularly as most learning will have occurred in a secondary care setting. Conflicts should be identified and analysed.[14] 

There are models of general practice problem solving which should be considered. The concept of the hypothetico-deductive model was described by Marinker in the RCGP text which underpinned early general practice training in the UK.[15] There are a number of subsequent consultation frameworks which may assist learners in understanding this topic (Pendleton[16], Stott and Davis[17], Neighbour[18]).

A useful model in teaching is the concept of pattern recognition or learning scripts[19] which can be employed in teaching about specific cases encountered to make the problem solving strategy of the doctor evident.

Use of time, incremental investigation and coping with uncertainty are part of the attitudinal change that may be necessary in those learning general practice. There is a growing body of literature on these topics to support teachers who encourage learners to reflect on these unique aspects of problem solving[20]

This competency is concerned with the ability:

1.2.5        to relate specific decision making processes to the prevalence and incidence of illness in the community

This will require:

a)      Knowledge of prevalence and incidence of disease

b)      Knowledge of the practice community (age sex distribution, prevalence of chronic diseases)

c)      Skills to apply specific decision making (using tools such as clinical reasoning and decision rules).

1.2.6        to selectively gather and interpret information from history-taking, physical examination, and investigations and apply it to an appropriate management plan in collaboration with the patient

This will require:

a)      Knowledge of relevant questions in the history and items in the physical examination relevant to the presenting problem

b)       Knowledge of the relevant context of the patient including family and social factors

c)       Knowledge of available investigations and treatment resources for the problem

d)       History taking and physical examination skills and skills in interpreting data

e)       Willingness to involve the patient in the management plan.

1.2.7        to adopt appropriate working principles. e.g. incremental investigation, using time as a tool and to tolerate uncertainty

This will require:

a)       adapting attitudes characteristic of a generalist  orientation, including curiosity, diligence and caring

b)      adapting a  stepwise  procedures in medical decision-making,  using  time as a diagnostic and therapeutic tool

c)      understanding the inevitability of uncertainty in primary care problem solving and developing strategies to tolerate uncertainty.

1.2.8        to intervene urgently when necessary

This will require:

a)      specific decision  making skills for emergency situations

b)      specific skills in emergency procedures in primary care situations

1.2.9        to manage conditions which may present early and in an undifferentiated way

This will require:

a)      knowledge when to wait and reassure and when to initiate additional diagnostic and therapeutic action

1.2.10    to make effective and efficient use of diagnostic and therapeutic interventions

This will require:

a)      knowledge of positive and negative predictive value of symptoms and signs and findings from ancillary tests obtained in clinical data collection

b)      understanding of cost-efficiency and cost-benefit of tests and treatments, and the number needed to treat or harm for specific treatments.

Comprehensive approach

General practitioners need to be able to address multiple complaints and problems in the patient they care for.  When patients seek medical assistance, they become ill as a person and often cannot differentiate between different diseases they may have. The challenge to address all the multiple health issues in an individual is an important one, because it requires the important skill of  interpreting the issues and prioritising them in consultation with the patient.

The family doctor should aim at an approach to the patient where the main focus would be in promoting their health and global well being, rather than specific diseases, which is often in sharp contrast with the specialist approach in treating as many medical problems as possible. Adequate handling of risk factors by promoting self-care and empowering patients is an important task of the general practitioner. The aim of the family doctor is to minimise the impact of patient’s symptoms on his well being by taking into account his personality, family, daily life and physical and social surroundings. Adoption of an evidence-based approach should provide the patient with currently best documented treatment, and should provide the doctor with currently best documented evidence for diagnostics and treatment.

Coordination of care also means that the general practitioner is adequately skilled not only in managing disease and prevention, but also in caring for the patient and providing palliative care in the end phases of the patients’ lives and providing rehabilitation. The physician must be able to coordinate patient care that is provided by other health care professionals and care provided by other agencies.

This competency is concerned with the ability:

1.2.11    to manage simultaneously multiple complaints and pathologies, both acute and chronic health problems in the individual

This will require:

a)      Understanding of the concept of co-morbidity in a patient

b)      Skill to manage simultaneous health problems of a patient through identification, exploration, negotiation, acceptance and prioritisation

c)      Skill in using the medical record and other information

d)      Skill to seek and attitude to use best evidence in practice

1.2.12    to promote health and well being by applying health promotion and disease prevention strategies appropriately 

This will require:

a)      The ability to understand the concept of health

b)      The ability to promote health on an individual basis as part of the everyday encounter

c)      The ability to promote health through a health promotion or prevention programme within the primary care setting

d)      Understanding the role of the general practitioner in health promotion activities in the community

e)      Understanding and recognising the importance of ethical tensions between the needs of individual and the community. and acting appropriately

1.2.13    to manage and co-ordinate health promotion, prevention, cure, care and palliation and rehabilitation.

This will require:

a)      To understand the complex nature of health problems in general practice

b)      To understand the variety of possible approaches

c)      To use different approaches in an individual patient and to modify these according to individual patient need

d)      To coordinate the team in practice

Community orientation

General practitioners have a responsibility for the community in which they work, which extends beyond the consultation with an individual patient. The work of the family doctor is determined by the makeup of the community and therefore the doctor must understand the potentials and limitations of the community in which s/he works, and its character in terms of socio-economic and health features. The general practitioner is in a position to consider many of the issues and how they interrelate and the importance of this within the community. In all societies health care systems are being rationed and doctors are being involved in the rationing decisions, and have an ethical and moral responsibility to influence health policy in the community.

This competency is concerned with the ability:

1.2.14    to reconcile the health needs of individual patients and the health needs of the community in which they live in balance with available resources.

This will require:

a)      To understand the health needs of the communities through the epidemiological characteristics of the population

b)      Understand the interrelationships between health and social care

c)      Understand the impact of poverty, ethnicity and local epidemiology on health

d)      To be aware of inequalities in health care

e)      Understand the structure of the health care system and its economical limitations

f)        To work with the other professionals involved in community policy related to health and to understand their roles

g)      Understand the importance of practice and community based information in the quality assurance of his practice

h)      To understand how health care system can be used by the patient and the doctor (referral procedure, co-payments, sick leave, legal issues etc.) in their own context

i)        To reconcile the needs of the individual with the needs of the community in which they live

Holistic care:

Medicine is an intrinsic part of the wider culture. It is based on a set of shared beliefs and values, as with any cultural practice. The term holism has many interpretations in medical practice, including alternative or complementary practices, which terms are often used in literature.  The definition of holism that is widely accepted for medical care, and will be used in this document, implies “caring for the whole person in the context of the person’s values, his family beliefs, their family system, and their culture in the larger community, and considering a range of therapies based on the evidence of their benefits and cost” [21]  Holism, as Pietroni states, involves  a  “willingness to use a wide range of interventions… an emphasis on a more participatory relationship between doctor and patient; and an awareness of the impact of the `health’ of the practitioner on the patient.”[22]

Holistic care can only be interpreted in relation to an individual’s perception of holism. If we accept that holism will always be individualistic, then even therapies or interventions offered to the patient will have a different meaning to different people. This is the reason why it relates so closely to family medicine. The holistic view acknowledges objective scientific explanations of physiology, but also admits that people have inner experiences that are subjective, mystical and for some religious, which may affect their health and health beliefs.[23]

The recognition that all illnesses have both mental and physical components and that there is a dynamic relationship between components of systems (general systems theory) led to criticisms of the biomedical model and to the development of the biopsychosocial model of modern medicine.[24] The position of the biopsychosocial model was spelt out most clearly by George L. Engel[25],[26] (3,4) who argued that for psychiatry to generate a fully scientific and inclusive account of mental disorder, Understanding the illness (not disease) as a process, which gives equal importance to biological, psychological and social determinants for pathogenesis, diagnosis and therapy, forms the holistic approach with its consequent implications to practical measures.

Using a bio-psycho-social model as the basis for cure and care implies the acceptance that many factors influence our understanding of what it is to be human.  Family doctors accept a large diversity of factors to be of importance. Examples of factors could include:

As the list of factors could be endless, it is also important to stress that a basic awareness and understanding of one’s own limitations as a doctor are crucial.  Keeping in mind the fundamental autonomy of the patient, there is a limited opportunity for the general practitioner to intervene and there is always a limit to the degree of influence that can be handled by one person in a therapeutic environment.  At the same time, the integration of influencing factors is crucial and constitutes the added value.

This competency is concerned with the ability:

1.2.15    to use a bio-psycho-social model taking into account cultural and existential dimensions.

This will require:

a)      Knowledge of the holistic concept and its implication on the patient’s care

b)      Ability to understand a patient as a bio-psycho-social  whole

c)      Skills to transform holistic understanding to practical measures

d)      Knowledge of the cultural and existential background of the patient, relevant to health care

e)      Tolerance and understanding to patients’ experiences, beliefs, values and expectations that may affect health care delivery

2.  Three areas of implementation

To practice the specialty the competent practitioner implements these competencies in three important areas.[27] [28] [29]  These are largely covered in the core competences listed above, but it will be useful to consider these as a framework in the parts of the curriculum concerned with specific content areas e.g. dermatology, ophthalmology.

2.1  Clinical tasks

2.1.1        the ability to manage the broad field of complaints, problems and diseases as they are presented

2.1.2        to master long-term management and follow-up

2.1.3        to balance evidence and experience in an effective way.

2.2 Communication with patients

2.2.1        the ability to structure the consultation

2.2.2        to provide information that is easily understood and to explain procedures and findings

2.2.3        to understand and deal adequately with different emotions

2.3 Practice management

2.3.1        to provide appropriate accessibility and availability to the patients

2.3.2        to effectively organise, equip and financially manage the practice, and collaborate with the practice team

2.3.3        to cooperate with other primary care staff and with other specialists.

Background features of the discipline

Three features are essential for a person-centred scientific discipline: context, attitude and science.[30] [31] [32] [33] [34]

Contextual aspects

3.1.1           Use contextual aspects of the patient, his history, his situation and social background in diagnosis, decision making and management planning.

3.1.2           Show personal interest in the patient and his environment and be aware of the possible consequences of disease for family members and the wider environment (including working environment) of the patient.

Attitudinal aspects

3.2.1           Being aware of one's own capabilities and values

3.2.2           identifying ethical aspects of clinical practice (prevention/diagnostics/ therapy/ factors influencing lifestyles)

3.2.3           justifying and clarifying personal ethics

3.2.4           being aware of the mutual interaction of work and private life and striving for a good balance between them.

Scientific aspects

3.3.1           being familiar with the general principles, methods, concepts of scientific research, and the fundamentals of statistics (incidence, prevalence, predicted value etc.)

3.3.2           having a thorough knowledge of the scientific backgrounds of pathology, symptoms and diagnosis, therapy and prognosis, epidemiology, decision theory, theories of the forming of hypotheses and problem-solving, preventive health care

3.3.3           being able to access, read and assess medical literature critically

3.3.4           develop and maintain continuing learning and quality improvement

Teaching and learning resources

References

References have been shown as footnotes throughout and have been reproduced here, together with some further reading suggestions.

Introduction

1         The European Definition of General Practice/Family Medicine, WONCA Europe, London, 2002

2         Oxford Regional Group Priority Objectives for general practice vocational training  RCGP Occasional Paper 30, London, 1985

RACGP reference

3         The Educational Agenda of General Practice/Family Medicine (ed. Heyrman J) EURACT, Leuven (work in progress)

4         General Practitioners Committee of the BMA and the Royal College of General Practitioners. Good Medical Practice for General Practitioners. London: RCGP; 2002.

5         Framework for Professional and Administrative Development of General Practice / Family Medicine in Europe,

6         Starfield B. Primary care: balancing health needs, services and technology. Oxford: Oxford University press, 1998.

7         H.M. Government.  The National Health Service (Vocational Training) Regulations.  The Stationery Office.  1979.                                                                 

Learning outcomes

8         Dreyfus H, Dreyfus S. Mind over Machine: The Power of Human Intuition and Expertise in the Era of the Computer. Oxford: Basil Blackwell; 1986.

9         Glaser R. Toward new models for assessment. International Journal of Educational Research 1990;14(5):477

10     McWhinney IR , A textbook of  Family Medicine, 2^nd edition, Oxford University Press 1997

11     Stewart M, ea. Patient-Centered Medicine: transforming the Clinical Method , Sage publ.1995

12     Haggerty JL, Continuity of Care, BMJ 2003; 1219-1221

13      Rosser WW. Approach to diagnosis by primary care clinicians and specialists: Is there a difference? The Journal of Family Practice 1996; 42: 139-44.

14     Horder J et al The Future General Practitioner: London, RCGP, 1972

15      Pendleton D et al The Consultation; an approach to learning and teaching: Oxford, Oxford Medical Press, 1984

16      Stott NCH and Davis RH The exceptional potential in each primary care consultation: Journal of the RCGP 1979:29:201-209

17      Neighbour R The Inner Consultation, Lancaster, MTP Press, 1987

18      Schmidt HG, Norman Gr, Boshuizen HPA. A cognitive perspective of medical expertise: Theory and implications. Acad Med 1990; 65:611-621

19     Sheldon M, Brooke J. Rector A (eds). Decision-making in general practice. London: MacMillan Press, 1985.

20     Kemper K.J. Holistic pediatrics = Good Medicine. Pediatrics, 2000. Part 3 of 3, Vol 105, issue

21     Pietroni P. Holistic medicine: new lessons to be learned. The Practitioner, 1987. 231 (1437):1386-1390.

22     Edlin G. & Golanty E. Health & wellness: A Holistic Approach 4th edn. Jones & Boston. 1992.

23     Butler C.C, Evans M, Greaves D, Sompson S. Medically unexplained symptoms: the biopsychosocial model found wanting, Journal of the Royal Society of Medicine, 2004. 97:219-222.

24     Engel GL, The need for a new medical model: a challenge for biomedicine. Science, 1977.  196 (4286), pp. 129-36;

25    Engel GL, The clinical application of the biopsychosocial model. Am J Psychiatry, 1980.137 (5): 535-44

26     Ram P, van der Vleuten CPM, Rethans JJ, Grol R, Aretz K. Assessment of practicing family physicians in a multiple-station examination using standardised patients with observation of consultation in daily practice. Acad Med 1999;74:62-9.

27     Ram P. Comprehensive assessment of general practitioners. A study on validity, reliability and feasibility. Thesis 1998, Maastricht University.  Van den Hombergh P, Grol R, van den Hoogen HJM, van den Bosch WJHM. Assessment of management in general practices: validation of a practice visit method. Br J Gen Pract 1998;48:1743-50.

28    Heath I, Evans P, van Weel C. The specialist of the discipline of general practice. Br Med J 2000;320:326-7.

29     Van Weel C. Examination of context of medicine. Lancet 2001;357:733-4.

30     Stephenson A, Higgs R, Sugarman J. Teaching professional development in medical schools. Lancet 2001;357:867-70.

31    Metz JCM, Stoelinga GBA et al. Blueprint 1994: training of doctors in the Netherlands. Objectives of undergraduate medical education. Nijmegen University, 1994.

32     Sackett DL, Richardson WS, Rosenberg W, Gray JA, Haynes RB. Evidence based medicine: how to practice and teach EBM. Edinburgh: Churchill Livingstone, 1997.

Further reading

Primary care management

1. Jones R ed. Oxford Textbook of Primary Medical Care, 2004.Oxford University Press.
2. Rakel RE. Textbook of Family Practice, 2001. W B Saunders; 6th edition.

Person-centred care

1. Balint M, The doctor, his patient and the illness. Pitman Medical Publishing, London 1964
2. Emanuel E.J;  Four models of the physician-patient relationship, JAMA 1992; 267:2221-6
3. Fehrsen GS, Henbest RJ. In search of excellence. Expanding the Patient-centred Clinical Method: a Three-stage asessment. Family Practice 1993 vol 10, no 1, page 49-54.
4. Freeman & Olesen : keynote lecture at the WONCA conference in Vienna 2000
5. Henbest RJ, Stewart M. Patient-Centredness in the consultation. 2: Does itreally make a difference? Family Practice 1990, vol 7, no 1, p28-33
6. Leopold, N , Sustained partnership in Primary Care, J.Fam.Pract 1996; 42: 129-7
7. Levenstein JH, ea. The patient-centered clinical method. I. A model for the doctor-patient interaction in family medicine. Family Practice 1986; 3:24
8. Mead N, Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Social Science & Medicine 2000;51:1087-1110.
9. Mold JW, Goal-Oriented Medical Care,  Family Medicine 1991 23,1:46-51

Specific problem solving skills

1. Allen T, Bordage G, Page G. Key features: An effective guide for assessment of patient management skills. In: International Conference Proceedings: Approaches to the assessment of clinical competence: Part II. Ninewells Hospital and Medical School. Dundee 1992:478-483.
2. Bordage G, Zacks R. The structure of medical knowledge in the memories of medical students and general practitioners: categories and prototypes. Med Educ 1984;18:406-416.
3. Bordage G. Elaborated knowledge: A key to successful diagnostic thinking. Acad Med 1994;69:883-885.
4. Case MS, Swanson DB, Wooliscroft JO. Assessment of diagnostic pattern recognition skills in medical clerkship ussing writen tests. In: International Conference Proceedings: Approaches to the assessment of clinical competence: Part II. Ninewells Hospital and Medical School. Dundee 1992:452-458.
5. Dowie J, Elstein AS (eds). Professional judgement: a reader in clinical decision making. Cambridge University Press, 1991.
6. Kassirer JP. Kopelman RI. Learning clinical reasoning. Baltimore: Williams and Wilkins, 1991.
7. Knotnerus JA. Medical decision-making by general practitioners and specialists. Fam Pract 1991;8:305-307.
8. Norcini JJ, Shell JA. The effect of level of expertise on answer key development. Acad Med 1995;65:515.516. 
9. Thistlethwaite JE. Making and sharing decisions about management with patients: the views and experiences of pre-registration house officers in general practice and hospital. Med Educ 2002; 36: 49-55.

Comprehensive approach

1. Kaufman DM. ABC of learning and teaching in medicine: Applying educational theory in practice. Br Med J 2003;326:213-6.
2. Van der Vleuten CPM. The assessment of professional competence: developments, research and practical implications. Advances in Health Sciences Education 1996;1:41-67.

Community orientation

1.       Feachem RGA. Poverty and inequity: a proper focus for the new century , Bulletin of the World Health Organization, 2000, 78 (1)

2.       Gulbrandsen P, Fugelli P, Hjortdahl P. General practitioners' knowledge of their patients' psychosocial problems: multipractice questionnaire survey. BMJ 1997; 314: 1014-1018.

3.       Gulbrandsen P, Fugelli P, Sandvik L, Hjortdahl P. Influence of social problems on management in general practice: multipractice questionnaire survey. BMJ 1998; 317: 28-32

4.       Longlett SK, Kruse JE, Wesley RM. Community-oriented primary care: critical assessment and implications for resident education. J Am Board Fam Pract 2001;14:141-7.

5.       Marmot M. Improvement of social environment to improve health. Lancet 1998; 352: 57-60.

6.       Oandasan IF, Ghosh I, Byrne PN, Shafir MS. Measuring community-oriented attitudes towards medical practice. Fam Pract 2000;17:243-7.

7.       Pearce N, Foliaki S,Sporle A, Cunningham C. Genetics, race, ethnicity, and health, BMJ. 2004; 328: 1070-1072

8.       Pollock AM,.Majeed FA. Community oriented primary care. BMJ 1995;310:481-2.

9.       Smeeth L, Heath I. Tackling health inequalities in primary care, BMJ. 1999; 318 (7190): 1020-1.

Holistic care

1. Kolcaba R. The primary holisms in nursing. Journal of advanced nursing, 1997. 25: 290 -296.
2. McWhinney IR. Beyond diagnosis: an approach to an integration of behavioral science and clinical medicine. N Engl J Med 1972; 287:384-387.
3. Patterson E. The philosophy and physics of holistic health care: spiritual healing as a workable interpretation. Journal of Advanced nursing, 1998. 27(2): 287-293.
4. Pietroni P. Holistic medicine: new lessons to be learned. The Practitioner, 1987. 231 (1437):1386-1390.
5. Wharton M. Clinical training in the community - a holistic approach. British Medical Journal, 1995. 310 (6976): 407.

Date: October 04

Credits: Prepared by Justin Allen

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