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New approaches to training general practitioners
  1. J H C Morgan
  1. Correspondence to:
 Dr Morgan; 

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Educating for capability is essential

Vocational training for general practice has been one of the most successful and creative developments in medical education in recent years. The systematic selection, training, support, and monitoring of teachers in local postgraduate deaneries has developed to a high degree. This includes experiential learning workshops to train and provide continuing professional development for general practitioner (GP) trainers that are part of a modular programme accredited for university qualifications in higher education. Also involved are quality assurance of teaching and clinical standards in training practices by regular peer inspection, and whole or part day release programmes organised by experienced educational facilitators that have successfully enhanced the learning of successive cohorts of GP registrars. The expertise gained by doctors working in GP training in the UK has been sought by organisers of technical assistance programmes to many developing countries, particularly the republics of the former Soviet bloc, and many of the creative ideas developed in the UK are now also being used in Russia and the Central Asian republics as they seek to reform their health care services and develop British style general practice.1


The key new approaches that have contributed to the success of GP training can all be described under the heading of education for capability. Traditionally, medical education at both postgraduate and undergraduate levels has focused on competence—that is, what the doctor knows or is able to do in terms of knowledge, skills, and attitudes. However, as Fraser and Greenhalgh pointed out in their series on complexity science in the BMJ,2 today’s health services need doctors who are capable—that is, able to adapt to change, generate new knowledge, and continue to improve their performance.

GP training in recent years has developed many educational methods that focus on process (supporting learners to construct their own learning goals, receive feedback, reflect, and consolidate) and avoid goals with rigid and prescriptive content, which is necessary for the development of capability in the learner. Capability is enhanced through feedback on performance, the challenge of unfamiliar contexts, and the use of non-linear methods such as story telling and small group, problem based learning. At the heart of developing capability lies the need for the learners to develop attitudinal self awareness, so that they can consciously remain open to the challenge of new concepts and approaches and be aware of their own responses that encourage or inhibit educational growth.

The year long relationship between registrar and trainer in the training practice, which is unique in medicine, enables the conducting of combined surgeries throughout the year, reflective diary use, individually tailored personal learning plans, and daily mentoring contact that all enhance capability development.

A number of different methods are also now regularly used by GP training schemes all around the UK to provide complimentary activities on the day release scheme that further encourage the necessary type of learning processes. I describe these below.


Many GP schemes now begin with a two or three day residential course in a suitable adult learning centre at some distance from the GP registrars’ places of work. These enable the registrars to get to know each other and their educational facilitators quickly in a non-working environment and establish supportive professional relationships in a pleasant social setting. The atmosphere of warmth and acceptance modelled by the facilitators defuses anxiety and allows the rapid forming of new small groups where the registrars can begin to share their previous experiences in medicine and explore together their learning needs for general practice. The relative lack of didactic input from the organisers sometimes initially confuses those used to a pedagogic teaching style, but most leave the introductory course feeling that, perhaps for the first time in their professional lives, their own ideas, concerns, and expectations have been listened to and valued by seniors and peers. This provides a necessary basis for the rest of their educational journey as GP registrars.

Specific tools such as the Honey and Mumford Learning Styles Questionnaire, the Myers Briggs Type Indicator, and the Belbin Team Inventory may be used during or soon after the course to give particular focus to self awareness development. Other residential courses focusing on specific issues may occur later in the registrar year. These events also provide a good opportunity for those still in the senior house officer years of GP training to meet their colleagues who are a bit further on, and keep them in touch with what they are ultimately aiming for.


All GP vocational training schemes are based around small groups where eight to 10 registrars meet regularly for up to 90 minutes with an experienced GP acting as facilitator and resource. The groups enable the registrars to bring the problems from their training practices to a safe place where they can be shared with peers; where they can “try out” different problem solving approaches to patient care and management, and where different approaches to consulting can be practised and feedback given. Information exchange can also take place, although the focus of the groups is normally on process (the interactions between the group members) as a learning resource, rather than on content. In the groups they begin to learn the significance and importance of being aware of their own reactions to patients’ problems and emotions, and how these may help or hinder their professional role.


Both the summative assessment process that doctors have to pass before being accredited to be independent practitioners in general practice, and the Membership of the Royal College of General Practitioner’s examination which many registrars take, require the submission of a videotape of the doctor consulting patients. This means that in both the training practice and the day release scheme, considerable time is given to looking at videotapes of the registrars consulting. If handled appropriately (and there are a number of well developed methods of doing this in a structured way to enhance learning),3,4 this can be a powerful educational experience not just for the registrar who is the subject of the tape but also for the others actively watching and commenting. Using videos in this way enhances communication skills, clinical knowledge, and problem solving ability. The small groups described above provide a safe context for this to occur, as also does the supportive one-to-one relationship that usually develops between trainer and registrar in the training practice.


A number of schemes have started using actors to help with communication skills training of registrars.5 A small group of actors who have been well briefed about the aims of the session can be given a number of carefully constructed scenarios and any necessary basic clinical information, matching other information (a fictitious medical record) given to the doctor who will be consulting. Again in the safe setting of a known and supportive small group, the actors “consult” the registrars in turn with the different scenarios, with feedback being given by the actor both in and out of role at the end of each consultation. This needs to be carefully structured so as the actors do not unintentionally offend the professional sensibilities of the registrars, but generally leads to a very powerful learning experience for those involved. Their consultation skills are challenged and stretched in a safe setting, with the opportunity for feedback and reflection.


The very term role play tends to strike terror into the hearts of most doctors, but constructing imaginative scenarios that enable the registrars to explore new concepts and practise new skills can help them learn creatively about a number of areas that might not otherwise seem very interesting. Partnership disputes, selecting and interviewing candidates for a partnership, and managing staff are all examples of topics that can be given to registrars with some guidance to construct their own scenarios, conduct the role play with their colleagues, and then debrief on it afterwards. Planning, negotiating, CV preparation, interviewing, and employment law are just some of the learning activities involved in these examples. Many schemes incorporate sessions like this now, and a complex scenario with several stages to it is a good subject for a short residential course.6


Doctors need to be able to listen to their patients’ stories with humanity and compassion in order to be able to treat them with competence. This is particularly true in general practice where many patients are anxious or concerned rather than ill. To this end, some GP training schemes have now made “medical humanities” a formal part of their curriculum. This may take the form of some of the small group sessions being a place where each registrar brings a book that has influenced or moved them, reads a section to the others, and explains what it is that has particularly impressed them. Sometimes one of the facilitators may suggest that the whole group reads sections of a book out loud in turn, and then asks participants to comment on what feelings and thoughts the passage provoked in them. A great deal of learning about what it is to be human can occur in sessions like this, helping develop sensitivity and concern for each unique individual and their story when the doctor is confronted with it in the consulting room. An author like Tolstoy, for example, can tell us more about what it really is to be human and have feelings than any number of textbooks of psychology.7


In the last 10 years GP training has fully embraced the concept of educating for capability. It has developed university accredited experiential training and continuing professional development for trainers, and quality assurance of teaching practices and training schemes. Residential introductory courses, regular small group work, the use of video consultations, the use of actors in communication skills training, the use of complex structured role play scenarios, and the use of good literature are all used to provide problem based learning, feedback on performance, unfamiliar contexts, and non-linearity. These enhance the development of adaptability to change, new knowledge generation, and continuing improvement of performance that are required of all doctors in today’s world.

Educating for capability is essential