Contents... What is General Practice? Qualities and skills required The 21st Century GP GPs with Special Interests What the research says about General Practice The GP Training Programme Induction and Refresher Training  Communication skills, empathy and sensitivity is the essence of being a GP. Variety, challenge and uncertainty is the essence of General Practice.

What is General Practice?

Do you enjoy challenges? Do you thrive off variety and uncertainty? - This is the essence of General Practice! Can you be empathetic and sensitive whilst maintaining professionalism and communication skills? - This is the essence of being a GP!

General Practice is about caring for the whole person as well as their illnesses, the promotion of healthy life styles, and providing the first point of contact and out of hospital care for patients. Doctors working in General Practice enjoy problem-solving with their patients, combining evidence-based medicine, wide ranging clinical skills and compassion to care for the individual. They provide a holistic approach aimed at managing risk, and dealing with (rather than resolving) uncertainty and complexity. The added value is delivered by allowing a story to evolve and develop rather than applying a protocol to every presentation in an attempt to resolve it.

A recent (and typical) morning surgery consisted of:

	A potential case of malignant melanoma
	A possible diagnosis of Weil’s disease
	A lady who needed her hypertension monitored who always asks about my family
	Someone who had become dysfunctional which a recurrence of their panic attacks and paranoia
	A person that turned out to have acute renal failure
	And a few coughs and colds for good measure!

Now THAT is variety! The patients above all presented with great uncertainty in their history and were dealt with using no resources other than being able to take a history and conduct an examination.

Qualities and Skills required

The personal qualities required to be a good GP include:

	Ability to care about patients and their relatives
	A commitment to providing high quality care
	An awareness of one's own limitations
	An ability to seek help when appropriate
	Commitment to keeping up to date and improving quality of one's own performance
	Appreciation of the value of team work
	Clinical competence
	Organisational ability
	Ability to manage oneself
	Good interpersonal and communication skills
	Ability to work with others
	Maintaining good practice
	Relating to the public
	Ability to deal with uncertainty

General Practice needs doctors who are ready to undertake this challenge. Applications for GP Specialty Training are welcomed from all levels including:

	Doctors who are just completing F2 training
	Doctors already qualified in another specialty but looking for a change of career
	Doctors already in Specialist Training in another specialty post but beginning to realise that they would prefer to deliver care closer to the patient

The 21st Century GP

A great service is provided by general practice, and GPs will remain the bedrock of the NHS whatever model of delivery is used (traditional GP, walk-in centres or Darzi practices or poly-clinics), and regardless of whether you choose to be a salaried doctor or a partner. If you enjoy intellectual challenge and the chance of continuity of care for patients and their families, GP is for you.

General practitioners will continue to have a critical role in the NHS, not only consulting with patients but also as providers and organisers of an increasing range of high quality services in the community, and as gatekeepers of hospital care. This pivotal position is dependent upon the clinical role of general practitioners with their patients and their ability to manage and provide leadership.

General practice has tremendous potential to remain at the centre of care. Most chronic care will be done by the primary care team, and increasingly diagnostics (near-patient testing) will be done in the surgery without requiring consent of the specialist. GPs within their individual organisations will be encouraged to develop special interests and skills

All GP’s of the future will need to be generalists, clinicians, team players, life-long learners and managers (at least of themselves). Some will need to provide leadership for the larger and more complex primary care organisations that will emerge, and more widely for the primary care led NHS. Good communication and the formation of professional doctor-patient relationships are crucial to General Practice.
 

In recent years there has been a trend for many general practitioners to develop special interests in certain areas. This might be in education, in the management arena, medical politics, or in clinical topics. The level at which general practitioners operate can vary too, with some working at a practice level, some taking referrals from local practices, some working for a primary care organisation, some working in a hospital setting, and some working at a regional or national level. Many general practitioners enjoy developing special skills and doing so fits in with changes in the National Health Service and improves services to patients.

In most practices, individual general practitioners take on more specialised roles. Most practices now will have at least one member specialising in diabetes care, and another will probably lead on gynaecology and contraception. For instance in my practice I take the lead on neurology care, acting as a source for internal referrals, I am part of the education team, and take responsibility for the Quality and Outcomes Framework and Clinical Governance.
The future for developing a special arm to your general practice career looks good. The coalition government wants to continue the trend to move services out of secondary care into the community, and wants general practitioners to take on the role of commissioning services. This seems likely to increase the need for general practitioners with special interests (GPwSI) at every level of the health service. The RCGP wants to see groups of practices federate together to provide internal referral pathways.

A 2006 survey by the Royal College of General Practitioners demonstrated how wide the range of clinical topics covered by GPwSIs is; http://www.rcgp.org.uk/pdf/ISS_INFO_11_JAN06.pdf. Dermatology and cardiology were the commonest topics covered outside the practice, with minor surgery, A&E, ENT, sexual health and rheumatology following on. Extensive evaluation of GPwSIs working in ENT has shown how the service can be improved economically, which makes taking on GPwSIs attractive to health service planners.

So, how do you become a GPwSI?

One of the great things about working in general practice is the career flexibility, and there are many possible routes. If you have a burning ambition to be involved in one particular clinical topic then you may be able to plan for this by selecting appropriate foundation posts and general practice rotations during your training but for most people the training to be a GPwSI will come outside of the three year training program for general practice. Once you have got your Certificate of Completion of Training for general practice there are lots of opportunities both inside and outside practices. Your practice may perceive the need to develop skills in a clinical topic and encourage you to train in this area. Or a primary care organisation may want to move services into the community and be looking for general practices to take this on.

Bradford, for instance, has developed services in cardiology, neurology, gynaecology, urology and diabetes using GPwSIs. Another possibility is to take a career break between ST2 and ST3 years and use this sabbatical time to develop a special interest. This option does need a considerable amount of forward planning, but it is the route one of my trainees is taking as he plans to do an MSc in cardiology. Yet another way is to start off specialist training, develop your expertise in a clinical topic, then train as a general practitioner – which is how one of the partners in my practice learned his diabetology skills.

Of course, maintaining professional standards is important for patient safety and there has been a growth in training courses, appropriate qualifications and professional organisations to cater for GPwSIs. This has helped to ensure appropriate standards are maintained and that GPwSIs are not working in isolation and continue to be an asset for their patients.

I think the main message should be if you have a passion for a particular clinical topic then you should look to develop that somehow in your career in general practice – it is very likely that opportunities will crop up for you to develop your skills which is likely to result in better services for your patients and enhanced job satisfaction for you.

Dr. Bill Hall.

Find Out More

Royal College of General Practitioners www.rcgp.org.uk
The Royal College of General Practitioners (RCGP) produces some excellent booklets and information sheets for anyone considering a career in general practice.

NHS Careers www.nhscareers.nhs.uk and Medical Careers www.medicalcareers.nhs.uk
Find out what it is like working in the NHS plus GP careers advice and information.

Information about the training requirements for general practice can also be found on...
www.pmetb.org.uk and www.mmc.nhs.uk

Further Reading

	A Guide to General Practice Careers Edited by Baker M & Chambers R, London, Royal College of General Practitioners, 2000.
	So you want to be a general practitioner? Dr David Haslam, Royal College of General Practitioners 2000
	Opportunities and Options in Medical Careers Chambers R, Mohanna K, & Field, S. Radcliffe Medical Press, 2000.
	A Celebration of General Practice Mayur Lakhani, Radcliffe Medical Press, 2003
	Choosing General Practice – Your Career Guide Edited by Anne Hastie and Anne Stephenson. Blackwell Publishing 2008

What the research says about General Practice

Research articles have also played a role in highlighting the importance of the doctor-patient relationship. In 2007, Burkey, Black and Reeve found that “most patients talked positively about the quality of the relationship with their general practitioner. They felt their family doctor knew them as a person and cared about them.” This can be seen throughout a period of time with Kearley, Freeman and Heath (2001) maintaining that “within the context of general practice, the opportunity exists for a personal relationship to develop between the patient and doctor”. They also suggest that “seeing their ‘personal doctor’ increases patient satisfaction”. And more recently, Tarrant et al. (2003) state “Personal care in the context of a relationship was important if problems were complex or emotional”. It was also ascertained that “GP’s in particular emphasised the value of a continuing relationship in making care personal”.

References

Burkey, Y., Black, M., & Reeve, H. (2007) Patients' views on their discharge from follow up in outpatient clinics: qualitative study. BMJ (electronic) Vol 315, pp 1138-1141. Available: http://www.bmj.com/content/315/7116/1138.full. [Accessed, 28th October 2010].

Kearley, K.E., Freeman, G.K., & Heath, A. (2001) An exploration of the value of the personal doctor-patient relationship in general practice. British Journal of General Practice (electronic) Vol 51, pp 712-718. Available: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314098/pdf/11593831.pdf [Accessed, 26th October 2010].

Tarrant, C., Windridge, K., Boulton, M., Baker, R., Freeman, G. (2003) Research: Qualitative study of the meaning of personal care in general practice. BMJ (electronic) Vol 326, pp 1310-1317. Available: http://www.bmj.com/content/326/7402/1310.full [Accessed 28th October 2010].

GP Patient Survey

A recent GP patient survey completed by over 2 million patients nationally and published by the Department of Health, has shown highly positive levels of patient satisfaction during July 2009 - June 2010. Results in brief state that 90% of patients are satisfied with the level of care received at the surgery. In regards to the importance of the patient-doctor relationship, 94% of patients have complete confidence and trust in their doctor. With communication skills for a GP being pivotal in providing the best care possible, 88% of patients believe doctors listen to them, and 78% are happy with the explanation of tests and treatments.

Further results are available at: http://www.dh.gov.uk/en/Publicationsandstatistics/index.htm

The GP Training Programme

The Basics…
To become an independent general practitioner in the UK, you must undertake at least three years of GP Specialty Training (GPST), normally including 18 months in an approved training practice with a further 18 months in approved hospital posts.

To ensure that you become a competent, effective and confident GP of tomorrow as well as directly addressing the GP curriculum, Deaneries will tailor your training to your individual needs and your particular rate of progress. There is an increasing number of four year options available giving extra valuable experience. On joining a GP Specialty Training Programme you should register with the Royal College of General Practitioners.

Gaining Valuable Experience

GP posts...
All GP posts are undertaken in a wide variety of locations, and always in an approved training practice under the supervision of a GP trainer. Here you will receive personalised tuition from an experienced GP who has had further training as an educationalist, as well as other members of the Primary Health Care Team. The training will be targeted to your identified needs.

Hospital Posts...
The exact posts offered by Deaneries in their programmes vary, but you will be offered a complete programme that complies with the regulations set down by the GMC. All posts are accredited and approved for GP training. The specialties available include:

	General Medicine
	Elderly Care Medicine
	Paediatrics, Community Paediatrics
	Obstetrics and Gynaecology
	Psychiatry and old age Psychiatry
	ENT
	Accident and Emergency
	Dermatology
	Ophthalmology
	Palliative Care

Some Deaneries have innovative programmes that combine hospital and General Practice posts.

Assessing your Skills

Assessments and Examinations...
To become a General Practitioner you must possess a Certificate of Completion of Training (CCT). During all your placements you will complete workplace based assessments as well as preparing for the external MRCGP examinations – the Applied Knowledge Test (AKT) and the Clinical Skills Assessment (CSA). Your progress will be monitored at least yearly by an Annual Review of Competency Progress (ARCP) Panel. More details of the examination can be found on the RCGP website www.rcgp.org.uk

Educational Supervision...
You will be assigned to an educational supervisor based in General Practice throughout your time on the programme, who will help you through the MRCGP procedures, using an e-portfolio to do so.

Other Opportunities

Academic Clinical Fellowships...
Some deaneries may also offer a limited number of Academic Clinical Fellowship programmes where time is spent on additional academic projects or offer programmes where some time is spent abroad or working in a particular relevant area of interest. These are subject to availability and more information will be provided on individual deanery web sites.

The personal skills assessed
in the recruitment and selection process for entry to GP specialty training are:

	Clinical Knowledge & Expertise: Capacity to apply sound clinical knowledge & awareness to full investigation of problems
	Empathy & Sensitivity: Capacity & motivation to take in others’ perspectives & to treat others with understanding
	Communication Skills: Capacity to adjust behaviour & language as appropriate to needs of differing situations
	Conceptual Thinking & Problem Solving: Capacity to think beyond the obvious, with analytical and flexible mind
	Coping with Pressure: Capacity to recognise own limitations and develop appropriate coping mechanisms
	Organisation & Planning: Capacity to organise information/time effectively in a planned manner
	Managing Others & Team Involvement: Capacity to work effectively in partnership with others

The page above was last updated on Wednesday December 01, 2010

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