Dr Nicola Moerdyk provides 10 top tips on developing tomorrow’s GPs, taking into account the impact of the COVID-19 pandemic on teaching and assessment

Moerdyk Nicola

Dr Nicola Moerdyk

Read this article to learn more about:

  • how to support trainee GPs to get the maximum benefit from their training
  • changes to training and assessment necessitated by the COVID-19 pandemic
  • additional career options to working full time in general practice, such as portfolio careers.

Read this article online at: GinP.co.uk/456370.article

The purpose of the GP specialty training scheme is to develop and nurture our colleagues of tomorrow. We need to inspire, instil values in, and shape our doctors to become well-rounded GPs who we would want to work with and, perhaps more importantly, have care of us and our families in the future.

GP training is a significant investment, both in terms of the time committed by the trainer, training practice, and trainee, and in terms of the cost to the taxpayer, currently £220,000 for the 5-year degree.1 There is also a considerable emotional and personal investment for the trainee, and for their trainer, who is usually part of their journey from the very beginning. The hope is that the trainee will complete their training as a well-informed, competent GP, who will make a significant contribution to patient care—and general practice as a whole—in the short and long term.

Typically, a GP trainee will have many years of studying behind them at the point of starting their GP training. A recognised primary medical qualification, either as an undergraduate or postgraduate, and successful completion of foundation years is the bare minimum. Doctors entering GP training may also have undergone training and completed some exams in another area of expertise, or have a Master’s degree or PhD. They need to be registered with the General Medical Council and eligible to work in the UK. Although the selection process has changed for 2021 (see Box 1),2,3 trainers and trainees are well versed in the content and structure of the GP curriculum (see Figure 1 and Table 1).4 However, given the disruption caused by COVID-19, how can we maximise learning opportunities for our trainees?

Box 1: Assessment and selection process for GP applicants in 20213

‘The assessment and selection process will involve the Multi-Specialty Recruitment Assessment (MSRA) which is a computer-based assessment delivered in physical test centres. A subsequent face-to-face or virtual assessment at a selection centre will not occur in 2021.

‘In the event of significant disruptions to testing during the scheduled window due to the COVID-19 pandemic, the MSRA will be delivered remotely to applicants.

‘Successful applicants will be considered for appointment across the whole of the UK, based on their performance in the MSRA. This method is known as Single Transferable Score (STS), as applicants are not restricted to being considered for appointment in a single specific region. The STS system is designed to maximise opportunities for successful appointment.’

General Practice National Recruitment Office website. Applicant guidance—general practice ST1: recruitment 2021–22. London: NHS Health Education England, 2021. Available at: gprecruitment.hee.nhs.uk/Recruitment/Applicant-Guidance/GPST1  

Contains public sector information licensed under the Open Government Licence v3.0.

Figure 1: The five areas of capability in the RCGP curriculum for general practice4

RCGP=Royal College of General Practitioners

© Royal College of General Practitioners. Reproduced with permission.

1. Make the most of face-to-face appointments

Once upon a time, our waiting rooms were full; our mornings and afternoons consisted of looking into the whites of our patients’ eyes, with a few telephone appointments bolted on. Today, a large proportion of our contacts are conducted over the telephone, with face-to-face consultations taking place by invitation only. Although this is probably the right approach in the middle of a pandemic, the impact of these changes cannot be underestimated.

The shift to remote consultations may affect not only the way patients are managed, but also how trainees develop their clinical skills and acumen. From a trainee’s point of view, it has impacted their ability to gain valuable experience by seeing and examining patients. We gain so much from seeing our patients in person and assessing them holistically in a way that cannot be done over the phone. Therefore, we must prioritise trainees’ face-to-face exposure—while being mindful of their own risk profile—to try to mitigate some of the disadvantages of the current situation.

2. Maximise learning opportunities

GP trainees have a very generous allowance for study leave (30 days a year for full-time trainees, 15 of which are for Vocational Training Scheme [VTS] work);5 therefore, every week, time should be set aside for a tutorial. By drawing on the skills of the wider clinical team in these tutorials, trainees will get the best possible experience and insight into a particular condition or area of practice. For instance, our diabetes specialist nurse knows more about diabetes than I do; therefore, she is clearly best placed to conduct that particular tutorial.

3. Allocate a supervisor for each session

All GP trainees must be supervised and supported while working clinically, so a supervisor should be appointed for each session.6 The supervisor does not necessarily need to be a trainer; it can be any GP in the practice with adequate experience and an interest in teaching.6 The level of supervision must be appropriate to the trainee’s confidence, competence, and experience, and must be agreed between trainee and supervisor.6

The supervisor is the trainee’s first port of call for urgent questions or queries—for example, when a rash needs to be looked at straight away. Initially, it may help to block out a few slots throughout the session to ensure that the supervising doctor isn’t overly rushed, but that may be more difficult to achieve. At the end of the session, it is also worth catching up and reviewing any issues or concerns that may have arisen—10 minutes after every session is often more helpful than 1 hour once a week, as questions can be answered there and then, while they are fresh in the trainee’s mind. It is also useful to expose a trainee to different consulting styles and different ways of doing things, as we all do things slightly differently.

Table 1: The five areas of capability and 13 specific capabilities for general practice4
Area of capabilitySpecific capabilities for general practice. To be a GP, you must be capable of:

A. Knowing yourself

and relating to

others

Fitness to practise

  • Demonstrating the attitudes and behaviours expected of a good doctor
  • Managing the factors that influence your performance

Maintaining an ethical approach

  • Treating others fairly and with respect and acting without discrimination
  • Providing care with compassion and kindness

Communication and consultation

  • Establishing an effective partnership with patients
  • Maintaining a continuing relationship with patients, carers, and families

B. Applying clinical

knowledge and skill

Data gathering and interpretation

  • Applying a structured approach to data gathering and investigation
  • Interpreting findings accurately to reach a diagnosis

Clinical examination and procedural skills

  • Demonstrating a proficient approach to clinical examination
  • Demonstrating a proficient approach to the performance of procedures

Making decisions

  • Adopting appropriate decision-making principles
  • Applying a scientific and evidence-based approach

Clinical management

  • Providing general clinical care to patients of all ages and backgrounds
  • Adopting a structured approach to clinical management
  • Making appropriate use of other professionals and services
  • Providing urgent care when needed

C. Managing complex

and long-term care

Managing medical complexity

  • Enabling people living with long-term conditions to improve their health
  • Managing concurrent health problems within an individual patient
  • Adopting safe and effective approaches for patients with complex needs

Working with colleagues and in teams

  • Working as an effective team member
  • Coordinating a team-based approach to the care of patients

D. Working well in

organisations and

in systems of care

Improving performance, learning, and teaching

  • Continuously evaluating and improving the care you provide
  • Adopting a safe and scientific approach to improve quality of care
  • Supporting the education and development of colleagues

Organisational management and leadership

  • Applying leadership skills to improve your organisation’s performance
  • Making effective use of information and communication systems
  • Developing the financial and business skills required for your role

E. Caring for the whole

person and the wider

community

Practising holistically, promoting health and safeguarding

  • Demonstrating the holistic mindset of a generalist medical practitioner
  • Supporting people through experiences of health, illness, and recovery
  • Safeguarding individuals, families, and local populations

Community orientation

  • Understanding the health service and your role within it
  • Building relationships with the communities in which you work

 © Royal College of General Practitioners. Reproduced with permission.

4. Support your trainee to develop interests

The essence of GP training is to turn out well-rounded, proficient GPs. The curriculum covers everything necessary to meet this aim over the course of the training (see Figure 1 and Table 1),4 and tutorials and teaching are tailored to take into account the trainees’ previous experience and knowledge. However, there are some trainees who, having completed their assessments and exams in good time, wish to start developing a particular interest or skill set—gaining letters of competence in intrauterine techniques and subdermal contraceptive implant techniques7,8 or learning to perform joint injections or minor surgeries are good examples of this. Various deaneries and GP teaching organisations run 1- or 2-day theory courses offering, for example, practice on tissue specimens to learn techniques, but often an enthusiastic GP in the practice can supervise and mentor the trainee to acquire skills such as joint injections or minor surgeries. It is good practice to keep a log of procedures and to audit outcomes.

5. Adapt to the differing needs of trainees

There are many different routes to becoming a GP trainee. Some trainees have extensive backgrounds in other specialties; others have had to sit their exams and assessments several times, and have spent time in multiple training practices. The result is that every trainee has different needs. Flexibility—in terms of day-to-day appointment structure and being able to book appointments and bring patients back in for follow up—is really useful to trainees because it allows them to prioritise the types of appointment (whether face to face or telephone/video) needed for the Recorded Consultation Assessment (RCA)9 and other assessments. Flexibility in planning teaching is also vital. There seems little point in offering 2 days of intensive paediatric teaching to someone who has Membership of the Royal College of Paediatrics and Child Health, for example—that time would be better spent doing something else.

6. Embrace the changes in assessment

COVID-19 has necessitated considerable changes to the way GPs operate on a daily basis. Likewise, assessment for Membership of the Royal College of General Practitioners (MRCGP) has also changed—for the time being at least. Although the Applied Knowledge Test (AKT)10 has remained largely unchanged—the same core syllabus tested in the same way at large computer centres across the country, albeit with social distancing—the Clinical Skills Assessment (CSA)11 has been temporarily replaced by the RCA.9 Instead of engaging actors to play the role of standard patients and asking examiners to observe the consultation, face-to-face or telephone consultations are now being recorded, edited, and assessed.9 Trainees who have gone through this assessment tell me that having plenty of time to edit and refine their videos—in particular, to ensure that they have a broad range of cases to display and meet all the necessary criteria—makes all the difference.

The RCA is assessed under the Workplace Based Assessment (WPBA),9,12 which is the non-exam based aspect of the MRCGP exam. The WPBA is designed to look at ‘the trainee’s performance in their day-to-day practice’.13 The WPBA also serves to provide constructive feedback on areas of strength and developmental needs, and evaluates aspects of professional behaviour that are difficult to assess in the AKT and CSA/RCA.13 FourteenFish Ltd (www.fourteenfish.com), a UK-based company specialising in medical appraisals, has recently taken over management of the trainee portfolio, in conjunction with the Royal College of General Practitioners (RCGP).14

There are a variety of other assessments to be completed as part of the WPBA, all assessing different skills (see Box 2).12 Together, these assessments build a picture of the trainee, their professional conduct, their strengths and weaknesses, and how they will function as a GP in the real world.

Box 2: Assessments and reports to be completed as part of the WPBA12

  • Case-Based Discussion—a structured oral interview designed to assess a trainee’s professional judgement in a clinical case (to be replaced by the Care Assessment Tool)
  • Mini Consultation Evaluation Exercise—an observed, real-life interaction between the trainee and a patient
  • Consultation Observation Tool—an expanded version of the Mini Consultation Evaluation Exercise that considers a trainee’s consultations with real patients in real time during their primary care placements
  • Audio Consultation Observation Tool—an assessment of a trainee’s telephone consultation skills
  • Clinical Examination and Procedural Skills—an assessment of competence in general and systemic examinations for the clinical curriculum areas
  • Multisource Feedback—a tool used to collect feedback from a trainee’s colleagues about their clinical performance and professional behaviour
  • Patient Satisfaction Questionnaire—a tool that provides patient feedback on a trainee’s empathy and relationship-building skills during consultations
  • Leadership Workplace Based Assessments—reflective activities and multisource feedback on mandatory leadership activities
  • Quality Improvement Projects—assessments of areas of practice that may have an impact on patient safety
  • Quality Improvement Activities—reflective learning log entries that typically feature an evaluation, a quality improvement action, and an outcome
  • Prescribing Assessment—a self-assessment prescribing review.

WPBA=Workplace Based Assessment

7. Have a wide-ranging and inclusive induction period

GP training is a commitment made by the entire practice, from the trainer right through to the receptionists and administrative staff. For trainees starting their first GP placement, it is worth spending time with everyone in the practice to gain insight into their roles and how things work. Time spent in the ‘back office’ is useful, as is time spent with health visitors and other teams that interact with GPs regularly.

8. Make your trainee feel part of the team

Most practices have a daily meeting, whether it takes the form of a mid-morning coffee break to allocate home visits, sign prescriptions, and review deaths, or a team catch up just before lunch to discuss anything urgent, and it may be managerial or clinical. It’s important and useful to include trainees in these meetings—after all, there is more to being a GP than just seeing patients. It also gives them (and us) an opportunity to discuss challenging cases, and seek opinions from the wider group on how best to proceed.

9. Manage your trainee’s workload

A trainee drowning in paperwork, blood test results, and tasks is unlikely to get the maximum benefit from their learning. In time, they will need to take responsibility for ordering and interpreting blood and imaging tests, and read letters from their patients’ consultants, but they also need space to be able to reflect on their learning and build on it. Although we need to prepare them for the real world, administrative work and everything that comes with it can wait until after they have passed their assessments.

10. Look beyond the clinical

General practice is so much more than just the medicine. It’s worth exploring partnerships and how to find a good fit, extended roles, and the world of portfolio careers.

There is no longer such a thing as a typical GP career. One of the great joys of a career in general practice is that it can adapt to the different stages of one’s life and interests, both clinically and nonclinically. The days when training was followed by locuming or a salaried role and then a partnership until retirement have long gone. It is now not uncommon to add a specialist interest, a day or two of management, or a clinical lead role into the mix to keep things fresh. Appraising, training, and chief medical officer roles are just some of the options; although it isn’t the function of a trainer to train and prepare a trainee for a specific role, it is worth discussing options and looking at tools to consider what is important to the trainee, to allow them to gain insight into their current priorites (accepting that these may change with time) and to equip them to assess and reassess these going forward.

Signposting trainees to post-Certificate of Completion of Training fellowships and programmes may also be helpful—there are many, including the RCGP’s First5 programme15 and NHS England’s New to Practice fellowships and programmes.16 It may also be beneficial to direct trainees to mentor schemes, practitioner health programmes, and local learning groups. Towards the end of training, a trainer’s time may be well spent acting as a mentor—helping a trainee to start distilling personality traits, and working out how they think, how they would fit into a team, and how they see the bigger picture. There is a stable for every horse—help trainees to find theirs.

Box 3 provides some useful sources of support and advice for GP trainers.

Box 3: Sources of support for GP trainers

  • NHS HEE (West Midlands). Information for GP trainers: bit.ly/2XRwwfm
  • NHS HEE (East of England). GP training in the east of England: bit.ly/3omoQNc
  • Bradford VTS. Bradford VTS online resources: bit.ly/2YaLM7s
  • Cambridgeshire & Peterborough Training Hub. GP trainers & educators: bit.ly/3EYEp3L

HEE=Health Education England; VTS=Vocational Training Scheme

Summary

Life in a training practice is exciting—I would argue that we learn as much from our trainees as they do from us. Get everyone at the practice involved, from the administrative team to the senior partner. Trainers within each VTS usually meet monthly to discuss trainees, teaching, and progress. These meetings offer an ideal space to support each other, untangle concerns about individual trainees, and generally move things forward. 

Life, medicine, and general practice has changed significantly over the past 18 months. Day-to-day clinical practice is not the same as it was before the pandemic. In terms of assessment, the biggest change has been the almost overnight shift from using the CSA to using the RCA because of the need for social distancing. How things will progress as we move out of the pandemic is being explored. Rumour has it that some sort of a hybrid model is being considered for the CSA/RCA. However, I wonder whether this simply adds another layer to an already complex assessment process. If we think back to all the work that was done on the CSA originally, reverting to a modified CSA may simplify things for our trainees and ourselves.

Despite all the changes that we have been forced to make—and despite the significant disruption to the fabric of our lives, both personally and professionally—with careful planning and some tweaking, we can still shape the education of our trainees positively, to ensure that they become great GPs of tomorrow.

Dr Nicola Moerdyk

Portfolio GP, South Warwickshire

References

  1. Triggle N. Student doctor numbers to rise by 25%.www.bbc.co.uk/news/health-37546360 (accessed 30 September 2021).
  2. General Practice National Recruitment Office website. General practice recruitment. gprecruitment.hee.nhs.uk/Recruitment (accessed 30 September 2021).
  3. General Practice National Recruitment Office website. Applicant guidance—general practice ST1: recruitment 2021–22. London: NHS Health Education England, 2021. Available at: gprecruitment.hee.nhs.uk/Recruitment/Applicant-Guidance/GPST1
  4. Royal College of General Practitioners. The RCGP curriculum: being a general practitioner. London: RCGP, 2020. Available at: www.rcgp.org.uk/training-exams/training/gp-curriculum-overview/document-version.aspx
  5. NHS Health Education England East of England website. General practice study leaveheeoe.hee.nhs.uk/general_practice/gp-study-leave  (accessed 30 September 2021). 
  6. Royal College of General Practitioners, Committee of GP Education Directors. Promoting excellence for general practice: application of GMC standards to GP specialty training. London: RCGP, 2021. Available at: www.rcgp.org.uk/-/media/Files/GP-training-and-exams/Information-for-deaneries-trainers-supervisors/Promoting-Excellence-for-General-Practice—2021.ashx?la=en
  7. Faculty of Sexual & Reproductive Healthcare website. Letter of competence intrauterine techniques (LoC IUT).www.fsrh.org/education-and-training/letter-of-competence-intrauterine-techniques-loc-iut/ (accessed 30 September 2021).
  8. Faculty of Sexual & Reproductive Healthcare website. Letter of competence subdermal contraceptive implants techniques insertion and removal (LoC SDI-IR). www.fsrh.org/education-and-training/letter-of-competence-subdermal-implants-loc-sdi/ (accessed 30 September 2021).
  9. Royal College of General Practitioners website. MRCGP: recorded consultation assessment (RCA).www.rcgp.org.uk/gp-training-and-exams/mrcgp-exam/mrcgp-recorded-consultation-assessment.aspx (accessed 30 September 2021).
  10. Royal College of General Practitioners website. MRCGP Applied Knowledge Test (AKT). www.rcgp.org.uk/gp-training-and-exams/mrcgp-exam/mrcgp-applied-knowledge-test-akt.aspx (accessed 30 September 2021).
  11. Royal College of General Practitioners website. MRCGP Clinical Skills Assessment (CSA). www.rcgp.org.uk/gp-training-and-exams/mrcgp-exam/mrcgp-clinical-skills-assessment-csa.aspx (accessed 30 September 2021).
  12. Royal College of General Practitioners website. WPBA assessments. www.rcgp.org.uk/training-exams/training/workplace-based-assessment-wpba/assessments.aspx (accessed 30 September 2021).
  13. Royal College of General Practitioners website. Workplace based assessment WPBA. www.rcgp.org.uk/gp-training-and-exams/training/workplace-based-assessment-wpba.aspx (accessed 30 September 2021).
  14. Royal College of General Practitioners website. Introducing the new training portfolio.www.rcgp.org.uk/about-us/news/2019/september/introducing-the-new-training-portfolio.aspx (accessed 30 September 2021).
  15. Royal College of General Practitioners website. Supporting you as a First5. www.rcgp.org.uk/first5 (accessed 30 September 2021). 
  16. NHS England. General practice fellowships for GPs and nurses new to practice programme: operational guidance 2021/22. Available at: www.england.nhs.uk/publication/general-practice-fellowships-for-gps-and-nurses-new-to-practice-programme-operational-guidance/

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Lead image: Andrey Popov/stock.adobe.com