Category Archives: Undergraduate

Brexit and statins: a tale of scepticism

christien-fortune-headshotChristien Fortune is a final year medical student at The University of Manchester and has interests in cardiology and medical education.

In the fabled land of post-June 23rd Britain and Northern Ireland, politics in the UK has been understandably dominated by the UK’s decision to exit the European Union. Vote Leave’s successful campaign, in part, utilised the public’s deep seated suspicion of the juggernaut that is the multinational political union of the European Union; one that in the eyes of the “Brexiteers” yielded little benefit despite its large cost to the UK. What was remarkable was the resonation of Leave’s message with the older population; according to YouGov poll over 64% of over-65s voted to leave the EU.1 The merits of EU membership can be debated until the end of time, but something which is unequivocally clear is that the older generation, in general, did not want to be part of the EU.1

As a casual observer of the UK political scene and avid viewer of the BBC programme, Question Time, I couldn’t help seeing striking parallels between the public attitude towards the EU and another juggernaut, this time of the pharmacological variety. To understand the aspersions surrounding statins is bewildering; at the time of writing, a Cochrane review of 19 studies assessing the value of statins in the primary prevention of cardiovascular disease revealed a marked reduction in all-cause mortality, major vascular events and revascularisation.2 Objectively, it seems unmistakably clear that statins have a major role to play in preventing our cardiovascular disease-baiting, overweight country. Unfortunately, the very nature of opinion does not lie in objectivity. In my admittedly limited experience, I have found a sizeable number of older patients sceptical about the benefits of statins. In broad agreement with my anecdotes, a study looking at adherence in secondary disease prevention for coronary artery disease in a US population revealed that consistent use of lipid-lowering therapy was 44%.3 The US does have other financial factors which will play a role in adherence, however, I’m sure that for certain healthcare professionals, this message will sound familiar. It is interesting that in the case of both the European Union and statins, scepticism seems to be the default setting of the UK’s older generation. Why is it that for a demographic, we (either Remain or medical professionals, take your pick) fail to convince them of a benefit which may be inconspicuous?

Although the older generation’s relationship with statins doesn’t pose quite as bigger problem to the future of our economy as the Referendum result will, it does still have important ramifications to an individual’s cardiovascular-related mortality. A failure to address the unhealthy relationship in those who are wary about the effects of statins has the potential to detrimentally affect the very lives we seek to care for. In a Scottish population, those who were compliant with statin use were more likely to have had the consequences of hyperlipidaemia emphasised.4 Tolmie et al also highlighted the need to a regular addressing of any concerns patients may have in order to prevent patients discontinuing medication without letting their doctor know.4 At the same time, there has to be some serious PR to promote the undoubted benefits of statins in the appropriate cohorts.

Interestingly enough, as was the case in the referendum, a major stumbling block in convincing the public about the benefits of their respective causes is the work of the tabloids. In a 15-day period, the Daily Mail published articles on their website with the following titles, “Statins ‘may be waste of time’…”,5 “Millions of people may be needlessly taking statins every day…”6 and “Don’t give up your statins…”.7 This startling contradiction indicates the type of mixed messages that the public is being told; it is unreasonable to expect the general public to be able critically analyse the underlying research and human nature means that the take home message will be the title in bold above the text. Naturally, this type of journalism creates the perfect conditions to promote widespread reservations about statin use. Therefore, it is up to healthcare professionals to combat the seeds of doubt surrounding statin use and provide a clear and coherent message about the advantage of using statins.

Now, the ship may have sailed across the Channel with respect to the UK’s membership but its sister ship containing some positivity about statins is still in the docks, albeit with increasingly frayed moorings. As doctors, we need to make sure that we shore up the public’s trust in statins; it is, of course, in their interest and that is something that it is easy to overlook.

References

1. Moore P. How Britain Voted. YouGov 2016 [Available from: https://yougov.co.uk/news/2016/06/27/how-britain-voted/.
2. Taylor F, Huffman MD, Macedo AF, Moore TH, Burke M, Davey Smith G, et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2013(1):CD004816.
3. Newby LK, LaPointe NM, Chen AY, Kramer JM, Hammill BG, DeLong ER, et al. Long-term adherence to evidence-based secondary prevention therapies in coronary artery disease. Circulation. 2006;113(2):203-12.
4. Tolmie EP, Lindsay GM, Kerr SM, Brown MR, Ford I, Gaw A. Patients’ Perspectives on Statin Therapy for Treatment of Hypercholesterolaemia: A Qualitative Study. European Journal of Cardiovascular Nursing. 2003;2(2):141-9.
5. Spencer B. Statins ‘may be a waste of time’: Controversial report claims there’s NO link between ‘bad cholesterol’ and heart disease. Daily Mail. 13 June 2016.
6. Spencer B. Millions of people may be needlessly taking statins every day: Study claims lowering cholesterol may NOT slash heart attack risk. Daily Mail. 20 June 2016.
7. Spencer B. Don’t give up your statins: Experts say warnings that made patients stop taking vital drug have put lives at risk. Daily Mail. 28 June 2016.

Casting down the pseudo-religion of clinical examination

Des Spence

Des Spence

Des Spence is a GP in Maryhill, Glasgow.
Des Spence

file3371281797656The glass bounced off my back and smashed into the drinks gantry shattering a whisky bottle. All I remember is the glass, the blood and that terrible screaming. Glass fights are dangerous, especially as barman, and for $1.80 an hour I often wondered if it was worth it. But it had its compensations for it was the best practical module on communication skills I ever had and I have used my experiences everyday of my medical career. Teaching undergraduates for the last 10 years I have enjoyed regaling them with my ‘pub communication’ stories.

I am convinced of the value of teaching communication skills but what of the scared cow, clinical examination? I was taught by rote – rigid application of clinical skills – inspection, palpation, auscultation and percussion. I was humiliated for not hearing split heart sounds, ridiculed for missing bronchial breathing, scolded for not saying “ninety-ninety” instead of “one-one-one” and I was laughed at for missing a breech presentation.

My objection is not that many of my tutors had a charisma bypass nor their dissocial personality disorders, my issue is that most of what they taught me to be unquestionable ‘fact’ was in reality complete nonsense. I will go further, not only were most of the clinical signs utterly worthless but many are downright dangerous.

How many times have I heard creps at the lung bases and in good faith organized a chest x-ray only for this to be reported 16 weeks later as being normal? I wonder about the times clinical examination has falsely reassured me leading to a delay in diagnosis – to my shame I can think of a few. The real unquestionable fact is that clinical examination is neither sensitive nor specific and devoid of any quantifiable predictive value of disease. Let’s be honest, most of clinical examination is merely the pseudo-religious ceremony of medicine passed down from our distant pagan healer ancestors.

I am, however, forced to pass these dark arts onto the next generation of unsuspecting doctors (secretly I subvert the students but please don’t tell my university). Even the iconic stethoscope is in reality little more than a simple stage prop used by insecure junior doctors who lack the gravitas to convince patients that they are doctors.

It is time for the unbearable and unthinkable but we must cast down the false deity that is clinical examination. In the new dawn light we should take the few worthwhile glittering gems from clinical examination but ditch the rest. Instead, let us teach students about health seeking behaviour, dealing with uncertainty and how to rationally investigate and manage common presenting symptoms. This might end the modern tsunami approach to investigations whose huge yield of minor incidental findings then burst and flood out the NHS outpatients. This might actually help prevent the rampant health neurosis that we as a profession are thoughtlessly inflicting on our poor patients.

Please, put your tumblers down for one last moment as I have a final point of heresy. Ultrasound is cheap, quick and easy, so why don’t we teach students to use an ultrasound probe? This could be used in many different clinical situations but I guess it might be heavy to wear round the neck! All I remember is the glass, the blood and that terrible screaming.

Bristol and Exeter Student GP societies: working hard to promote general practice

Alice

Alice James is a 4th year medical student at Bristol University. She is passionate about promoting general practice to other students in her role as Chair of the University GP Society (Bristol GPSoc) and student representative for the Severn Faculty RCGP.

Nilakshini

Nilakshini is a 4th year medical student based in Exeter and is passionate about general practice. She believes it’s time to put the stigma associated with primary care behind us and start giving recognition for the challenging and exciting career that it really is.

The Bristol and Exeter Student GP societies aim to inspire members to consider a career in general practice through showcasing general practice as a versatile and fulfilling career and by challenging the stigmas associated with the profession by addressing controversial issues in the field. The societies provide CV-boosting advice, information about the GP training programme and hold events involving GPs with backgrounds ranging from conservation medicine and broadcast journalism to GPs with specialist interests.

Exeter student GP society, founded only in 2015, has initiated monthly practical teaching sessions for students in their pre-clinical years. This has been very popular so far and we are hoping to extend this mentoring scheme for students in their clinical years as well. This year the GP society are excited to introduce our inaugural debate under the auspices of Devon and Exeter Medical Society, ‘Are the increasing portion of female doctors, a key contributor for GP shortages?’. We hope that by addressing relevant and topical issues we can successfully challenge the negative stigmas associated with a career in general practice. Holding the event with the Devon and Exeter Medical society also provides students the opportunity meet and interact with general practitioners who are passionate about their career.

Bristol GPSoc, now in its 4th year, is planning to extend their annual conference to a full-day event to include student poster presentations and added workshops. The society is also planning a clinical skills workshop suitable for both pre-clinical and clinical years as an OSCE revision session. As well as stand-alone events, Bristol GPSoc has also joined forces with other University and Bristol-based societies. Last week the society held its first event of the year: ‘Mental Health: The Psychiatry-Primary Care Interface’ together with the Bristol University psychiatry society (PsychSoc). We heard from 2 local GPs, a consultant liaison psychiatrist and the founder of the mental health charity ‘Student Minds’. The 4 speakers addressed different ways of promoting better mental health by exemplifying methods used in their working environments. Approaches included peer support groups, self-care smart phone apps and services offered within GP services themselves including cognitive behavioural therapy (CBT) and self-hypnosis.

Both societies have benefited hugely from support given by local RCGP Faculties. Exeter GP society would like to thank Tamar Faculty for the funding and GP reading list which they have kindly provided. Furthermore, Tamar Faculty RCGP have recently co- opted the Chair of Exeter GPSoc onto their board as student representative. Following this, Bristol GPSoc enquired whether Severn Faculty RCGP had would be willing to open up a similar role on their board at the next AGM. As a result, the current Bristol GPSoc Chair was elected as the Severn Faculty student representative at the start of this month. Severn Faculty also allows other students to attend board meetings as observers and provides elective bursaries every year for Bristol students undertaking an elective within a primary care setting.

University backing is also essential to the development of student GP societies. Bristol GPSoc committee members have been invited to GP teacher training days and have been involved in the University-wide curriculum review by the Centre for Academic Primary Care. In addition, the University of Bristol medical student society (Galenicals) have given support by advertising events, providing funding and holding a medical student Freshers’ fair to promote student-led societies. Exeter Medical school also played a key role in setting up the GP society and are often good port of contact for the committee members.

At the most recent RCGP conference, one of the RCGP Associate in Training (AiT) committee representatives, Jodie Blackadder-Coward, organised a meeting for student GPSoc representatives from around the UK. This provided an opportunity to communicate ideas that we can then relay to a national body. Suggestions discussed by students and RCGP committee members included formal affiliation of GPSocs with the college, guidance on elective opportunities in primary care and deliberation of having a foundation year doctor on their GP committee.

Support from the RCGP and individual Universities will be fundamental to the continued growth and development of GP societies and to facilitate communication between them. We hope
both Severn and Tamar RCGP Faculties will continue to advertise the role of student representative to medical students in future years and that other RCGP Faculties will follow suit. Such opportunities have enabled both societies to voice our ideas and concerns with the hope of making an impact at both the undergraduate and specialty training level. The recently forged links between the GP Societies at the Universities of Exeter, Plymouth, Bristol and Cardiff have allowed us to share ideas and extend invitations to events. We have also discussed the prospect of a collaborative event to attract students and junior doctors from across the South West.

Going back to the start – influencing prospective medical students

JmespicforJames Pearson is an ST3 trainee in Bath and the education scholar for the year.

Suddenly you are sitting there alongside all these very intelligent people and the familiar world of sixth form seems so far away. I still remember my first day at medical school when the year group were told in our welcoming lecture that the majority of us would become GPs. I distinctly remember my reaction and that of all my peers was one of surprise and shock! How could they suggest something as absurd as that?

At that point, our exposure to medicine had mostly involved work experience in secondary care and for a few of us, some volunteering in the charity sector. Only a rare handful had managed to secure some experience in primary care. This was mainly by means of a relative or friend with suitable contacts as there are many barriers; issues with confidentiality and perceived maturity of students to name but two. Looking back, it seemed as though we were programmed from the start and had no aspiration for General Practice – we only had personal experience and tales from the media to inform us.

Consequently, I decided to set out on a quest in my role as the ST3 Bath patch Educational Scholar to try and change this locally. I also wanted to provide an excellent opportunity for GP trainees to lead and organise a placement as well as some experience in supervision. Working alongside my counterpart in the Bristol area (Dr Howse) we recruited 32 sixth formers from schools in the local area who were planning to apply to medicine in the current academic cycle. They were a shortlist of the best as determined by their application form, personal statement and teacher reference including predicted grades. We were overwhelmed by applicants and had to turn away those unless they had a realistic chance of a successful application to medical school.

By meeting them all at our carefully planned one-day preparation course, I observed their enthusiasm for medicine and it was rewarding to be able to enlighten them on topics such as ‘the role of the GP’ and ‘members of a practice team’. It was astounding to hear their views in small group work and as predicted from this and their pre-course questionnaires, their views on General Practice were misled and mistaken. It gave us the chance to set the record straight, promote our career, brief them on confidentiality and explain our expectations of prospective medical students. Overall the feedback we received at the end seemed to have a positive impact on their attitudes and all were keen to undertake the offered work experience in General Practice.

Using the demographic knowledge obtained from the application form, we were able to ensure that no student lived or went to school in the area their allocated practice was based. This had previously been one major barrier when pupils had contacted their local practice and were declined for fear of them knowing some of the patients. They were then allocated a GP trainee and left to liaise together about suitable dates as well as the format of their work experience. Further information from the pre-course questionnaires on three things the pupil wanted to get out of the experience helped trainees plan specific activities for the individual. For example, my allocated student was able to spend time with different members of the practice team and really enjoyed watching minor surgery done at the practice. She was amazed at the variety of things that were on offer and the array of opportunities available.

The first year of this project is now coming to a close and certainly each student now has a subsidiary mentor who could help them through the application process. I really hope that this has given realistic prospective medical students an insight in to primary care and we were able to overcome the barriers to gain the experience. I am not intending to suddenly convert all these students in to budding GPs but I really feel that at the moment as a profession we are not doing enough to promote our career to this group of young minded individuals where a lot of their early experiences can shape their ideas on the future.

Let’s hope that their reaction at their first day at medical school to the obligatory statement of “most people will be GPs” is different to my year group’s.

BJGP Student Writing Competition – the winner

head shotLydia Yarlott is in her final year at Oxford Medical School.

She is the winner of the 2015 BJGP Student Writing Competition themed ‘The GP in the Digital Age’ with her original article A Digital Ache.

Her tale of one GP versus the system will be horribly familiar to anyone who has done battle with the new digital bureaucracy of the NHS. It’s a rather wonderful reminder of the fundamental importance of maintaining relationships between doctors to benefit patients. The PDF version is embedded below – it needs the formatting to get the full benefit. Enjoy.

Download (DOCX, 19KB)

RATs: Quality not Quantity

image1Joe Anthony is a history graduate currently in his fourth year studying medicine at the University of Manchester. He was joint second in the BJGP Student Writing Competition which had the theme The GP in the Digital Age. Joe’s article took us straight into how technology has an impact on two key topics for any GP: quality and continuity.

Talk to any politician and they will tell you that the problem is one of access. ‘GPs should be working 7 days a week’, ‘more appointment-slots should be available’, ‘better access equals a better service’, they yell from their soapboxes. And with a growing population, which has ever-increasing expectations of what the NHS should do for them, you might be forgiven for thinking that the problem is simply one of quantity.

This attitude is evident in the government’s recent approach to improving general practice. Development of effective telehealth in the UK has been a priority, with CCGs rolling out these services thanks to heavy financial backing. Telephone consultations were once the purported solution; increasing ease of access and therefore the quantity of consultations available was the goal, however, the results were far from satisfactory as the increased access simply led to greater demand. The telephone slots were used but those same patients too often still required a traditional consultation, hence the ESTEEM trial’s conclusion that telephone consultations were not cost-effective.1

CCGs are therefore turning to the next step in telecommunications and video consultations using Skype are now widely available. These continued attempts to pursue telehealth seem to ignore the lessons learnt on the telephone. Telehealth provides consultations at the click of a button, day or night, decreasing overheads for premises, administration staff, and the like. The goal is an increased number of consultations at low cost but as these services are not proving economical and have not tackled the previous issue of patients requiring a repeated consultation, what purpose do they serve?2

The digital age is, however, supplying technologies that are resulting in palpable improvements to health services. While telehealth receives the headlines and funding, the comparatively humdrum integration of Risk Assessment Tools (RATs) is leading to faster and safer consultations. In broad terms, this utilisation of software to carry out important analysis of patient data can and does save GPs valuable time, which can be better spent elsewhere in the consultation.

The growing numbers of RATs available to GPs are small steps that can make a big difference to patients. ECLIPSE (Education & Cost-analysis Leading to Improved Prescribing Safety & Efficiency) is just one example of such a tool. The software analyses data on practice systems and uses algorithms to detect long-term trends in clinical entries, prescribing, and pathology results. ECLIPSE identifies patients who are overdue for monitoring tests or being put at risk by their medications and presents these findings via a traffic light system of alerts, with the aim being to prevent unnecessary hospitalisations. For example, a full blood count shows a haemoglobin of 13.5 g/dL, a rushed GP sees a normal result but ECLIPSE sees the bigger picture. This patient is on an NSAID and their haemoglobin was 16.0 g/dL 2 months ago, an ODG is ordered, a peptic ulcer is detected, and an outcome improved.

ECLIPSE has already been rolled out by several CCGs and more RATs are being added; for example, Nottingham’s QCancer® score and Professor Willie Hamilton’s cancer prediction tools which aim to tackle an identified weakness of the NHS — early cancer diagnosis.3,4 This is not the story of a digital panacea, rather of incremental improvements that have the potential to improve general practice, and thus patient outcomes.

Talk to any GP and they will tell you the problem is not one of access. They will tell you the focus should not be on quantity but on quality. They will emphasise the importance of continuity of care and a safe and efficient service. RATs are helping to provide that service.

REFERENCES

1. Campbell JL, Fletcher E, Britten N, et al. (2014) Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis. Lancet 384(9957):1859–1868.

2. Henderson C, Knapp M, Fernandez JL, et al. (2013) Cost effectiveness of telehealth for patients with long term conditions (Whole Systems Demonstrator telehealth questionnaire study): nested economic evaluation in a pragmatic, cluster randomised controlled trial. BMJ 346:f1035.

3. Rubin G, Vedsted P, Emery J (2011) Improving cancer outcomes: better access to diagnostics in primary care could be critical. Br J Gen Pract doi:10.3399/bjgp11X572283.

4. Hamilton W, Green T, Martins T, et al. (2013) Evaluation of risk assessment tools for suspected cancer in general practice: a cohort study. Br J Gen Pract doi:10.3399/bjgp13X660751.

The Technophobe’s Guide to the Digital Age

R.VarleyRebecca Varley trained at Lancaster Medical School and is on the brink of being an FY1 based at Manchester Royal Infirmary. She was joint second place in the BJGP Student Writing Competition which had the theme ‘The GP in the Digital Age’. We liked her warm, personal counter-perspective on how we approach technology.

Douglas Adams had it right. In his Hitchhiker’s Guide to the Galaxy series he perfectly encapsulates the way I feel about technology. I am one of those poor Earthlings who “still thinks digital watches are a pretty neat idea,” and wonders why no one has noticed that technology is only making life more complicated? Adams’ infamous Nutrimatic-Drinks-Dispenser “invariably delivers a liquid that is almost, but not quite, entirely unlike tea.”1 And isn’t it true? Machines can’t even get tea right.

When the best part of technology is the “sense of achievement you get from getting it to work at all,” something is wrong.2 Despite having been born slap-bang in the middle of the digital age, I am dismayed to find myself a ‘technophobe.’ But when I look around at my colleagues-to-be, I don’t believe I’m alone.

On every GP placement I have heard doctors bemoaning technology day in and day out. And why not, when all the patient notes spontaneously decide to reboot mid-surgery, when the electronic prescribing program takes itself out for a few hours, or when a glitch renames every patient in the system ‘George’ (alright that one didn’t happen, although I bet it could). It causes chaos.

But technology is a wonderful thing. We should be exalting it, not quivering at the byzantine complexity of decrypting our own passwords. For goodness sake, people are printing pelvises; it’s simply marvellous!

It’s true, hospitals see the most dramatic breakthroughs — whereas on some of my GP placements I’d have been lucky to see a pulse oximeter — but even without the flashiest gadgets, over time, technology has changed the job of the GP in a subtle yet profound way. And the more I think about it, the more I am won over.

Gone are the dark days of paternalism where patients unassumingly followed advice. More and more, patients are feeling empowered by knowledge from the web. ‘Cyberchondriacs,’ as some are affectionately nicknamed, are developing increasingly unusual diseases and I think it’s fun to be kept on our toes; having to explain why it’s unlikely to be an amoebic liver abscess and more likely to be gallstones to someone who is alarmingly well informed. But all joking aside, technology is helping people to take responsibility for their health, which is fantastic news for everyone.

The development of health applications and online symptom checkers is part of this new age of patient empowerment. Of course they are currently far from perfect but their potential is incredible. Apps are being designed to make long-term conditions, such as diabetes, easier to manage at home, and apps that aim to improve diet and fitness could play an enormous role in the fight against obesity, a costly and growing concern.

I have come to realise that ‘technology’ is so much more than erratic computer systems and so what if I can’t run HTML backwards while simultaneously lowering cholesterol? We all have our strengths and computers aren’t mine: that doesn’t mean I should condemn all technology and run from it terrified. Technology was never the problem, I was.

My GP placements have helped me to see technology for what it really is and for that I am incredibly grateful. Even though I may never know what ‘the cloud’ is, and I am still waiting for that perfect cup of tea, I am embracing technology at last and am happy I will be a doctor in a digital world. So for anyone out there who has ever felt like me, keep going, we’ll get through it.

REFERENCES

Improving GP recruitment: a medical student perspective

photoNabila Rehnnuma is a first year graduate-entry medical student at Cambridge University.

A funding crisis, increasing workload, falling real income and continuing negative media press, these are just a few of the reasons why general practice is decreasing in its level of popularity amongst medical students.1 This problem is further exacerbated by medical schools, which have cultivated a culture where general practice is seen as the “second-choice”. This is despite the fact that general practice can be one of the most challenging and equally rewarding professions. Headlines describing the rising patient expectations, reduced resources and poor staffing levels further dissuades potential general gractitioners, with more than 400 GP trainee posts left vacant in 2014.2 This diverges from governments’ current plans which have stipulated that Health Education England should ensure that, by 2015, half of all medical students are to become GPs.1 Therefore, the question remains, how do we meet this target? And more importantly, how do we make the role of a general practitioner more appealing to the current medical student?

One of the important determining factors behind medical students’ career preferences tend to be their attitudes towards the medical specialities.3 Experiences at medical school tend to dictate an individual’s attitude, with attitude being one of the most important driving forces. Positive previous experiences on placement stood as one of the greatest influences affecting medical students’ career choices, according to a study carried out on medical students, trainees and practicing physicians regarding the factors which influence career preferences.4 Therefore one of the potential strategies medical schools can employ is to increase exposure to primary care experiences during the early years of medical school and emphasise primary care experiences during training years. Medical schools should allocate more funding towards GP delivered in the community. Increasing exposure enables medical students to be exposed to positive role models, such as Dr Weatherburn5, an Academic Fellow in General Practice in the University of Dundee, whom is able to “lead by example”, and illustrate why a career in GP is so rewarding. By providing high quality career’s advice regarding the flexibility and variety of avenues that a GP career can take, it enables a re-focus on why such a career still remains a good career choice.

Another means to curb the current decline in primary care, is to improve satisfaction among family physicians.4 As previously mentioned, it is positive experiences on placement which to some extent dictate a medical student’s career preferences. However, in order for the experience to be positive, current physicians must be content with their career and current lifestyle. One means to achieve this is to enable a greater employer focus on retaining and investing in their current staff.6 This can be via commissioning education and training opportunities to train and develop current staff, and attract the future workforce. Financial incentives such as the ‘golden handshake’, where GPs are offered higher salaries for working in rural areas, as well as greater flexibility in working hours are other means to retain the current GP workforce. If the government is able to reduce the pressure on GPs and invest in the future of general practice2, particularly in their training and education, this can attract potential medical students into the profession.

The final means suggested to attract the future GP workforce, is the opportunity to be able to vary career direction or combine careers.7 Offering clinicians the opportunity to combine a specialism with generalism may be another mechanism to attract more general practitioners needed to cater for large scale shifts from secondary care. This is where general practitioners are able to gain experience and qualifications in a field of particular interest to them, such as psychiatry or dermatology. Given recruitment problems often reside in the fact that students seek to train in fields where employment opportunities align with career preference, as opposed to service needs, dual training opportunities provide an appropriate means to accommodate for this. Therefore if students are able to combine career and training opportunities, this might be attractive to some doctors whom may not primarily consider general practice.

These are just a few of the means to attract the next generation of General Practitioners. However, it appears that what matters most to current medical students is personal interests. Could they see themselves as a GPs and more importantly what is the greatest factor that can sway their vote?

Links

1. http://careers.bmj.com/careers/advice/view-article.html?id=20017562

2. http://www.pulsetoday.co.uk/home/finance-and-practice-life-news/gps-feel-undervalued-and-angry/20008701.article

3. http://www.academia.edu/4775633/Career_preferences_of_medical_students_influence_of_a_new_four-week_attachment_in_general_practice

4. http://www.bcmj.org/article/factors-influencing-career-choices-made-medical-students-residents-and-practising-physicians

5. http://www.bmj.com/content/349/bmj.g6245/rr/786933

6. http://hee.nhs.uk/wp-content/blogs.dir/321/files/2014/12/HEE-investing-in-people-20151.pdf

7. http://careers.bmj.com/careers/advice/view-article.html?id=20018623

Seismic changes in GP teaching – where will the new GPs come from?

photo-2Alex Harding is a GP and academic based in Exeter.

UK General Practitioners are the largest part of the medical workforce, deliver the most care and deliver this care highly effectively. Most people who have ventured abroad and talked about health are surprised at the envious comments from patients and practitioners alike about the UK health system under the NHS.

However the UK GP workforce has not kept pace with the increases in healthcare need, increases in similar workforces abroad or increases in other health professionals in the UK.

In order to address this and an impending GP workforce crisis the English Department of Health has mandated HEE to ensure that by next year 50% of graduates will opt for GP training. At present however, 19% of final year students want to be GPs and many GP training schemes are struggling to recruit enough graduates. In some parts of the country there are now 40% vacancy rates.

There is some good research that shows that exposure to general practice as a medical student has a strong positive effect on future career choice and so appropriate general practice experience as a medical student is an important part of workforce planning.

With this in mind, we surveyed the UK medical schools regarding undergraduate and postgraduate teaching provision and how this was supported in financial and academic terms. We used standard methods to develop a questionnaire and then piloted and modified it.

We were pleased to get a 94% response rate, with 29 out of the 31 medical schools in existence at the time taking part.

The results came as a surprise. We found that the percentage of the curriculum taught in general practice was 13% and that this has remained static since 2002. We also found that when we measured teaching provision in another way (the total number of GP teaching sessions delivered over the entirety of the course) it had actually fallen – from 122 total sessions in 2007 to 102 sessions. This represents a 2 week loss of GP teaching overall.

We were interested to find out why this might be and looked at how teaching was supported. Here we found an apparent disparity between the teaching delivered and payment for teaching received. In addition, many respondents commented that the process of reimbursement for GP teaching seemed unnecessarily complex.

We then looked at teaching support from departments of general practice. We found that departments offering both educational and research capability had dropped by 50%.

Perhaps the most surprising finding however, has been the rapid expansion of postgraduate teaching. Prior to the year 2000 there were no foundation doctors, fewer postgraduate trainees and these trainees spent only 12 months in practice. Calculated in months of experience the total increase is over 80,000 months in little more than a decade. This compares with a total reduction of 15,000 months of undergraduate provision over the same time (2 week reduction for the 30,000 medical students currently being taught).

A number of things are apparent. Firstly, seismic changes have been occurring in general practice teaching – especially in the postgraduate sphere and in the fate of integrated departments of general practice. In contrast, undergraduate teaching seems to have risen slowly – having taken almost 50 years to reach its current level of 13%, but may now be falling.

It is tempting to propose some explanations. Dramatic increases in patient demand and government regulation may play a part in squeezing out medical students who are unable to make meaningful contributions to service delivery – unlike postgraduate trainees.

The rate of reimbursement for undergraduate teaching may also be relevant and is currently being reviewed. This may provide an opportunity to address the disparity between teaching provision and pay. A simpler mechanism of payment may also be beneficial where monies are paid direct to GPs rather than being routed through various other organisations. An important additional factor is reimbursement for space.   Lack of space was identified in our survey as the main factor preventing expansion of teaching. Finally, educational support from departments may also be helpful. These are not easy issues to resolve and central planning and guidance may be necessary. GPs and the NHS are part of the fabric of our society and a debate needs to happen regarding the role of general practice in undergraduate education. After the words concerning the value of general practice and education must come actions.

The BJGP Student Writing Competition

A huge thanks to everyone that submitted entries to this year’s competition themed ‘The GP in the Digital Age’. We have received many wonderful entries and we are just in the final stages of judging. The people on the shortlist have now been notified by email and we will be announcing the winners next Monday.