Summary
- As a GP you should be able to understand, critically appraise and communicate the results of relevant research and evidence from a wide range of sources.
- You should be able to decide whether the findings are applicable to your own patients, considering individual variability in genes, environment and lifestyle, the patient’s values, priorities and circumstances, the community and the healthcare setting.
- While scientific rigour and use of the latest best evidence should inform your approach, you should also recognise the economic, social, and environmental benefits and costs of an intervention, as well as its personal value to the patient.
- It is essential to apply clinical judgement and to adopt a personalised, collaborative approach to care.
- Be aware of individual bias (including unconscious bias) in interpreting data and follow the General Medical Council (GMC) Good medical practice guidance in respecting culture, disability, religion, gender, sexuality and social and economic status.
- Every GP should have the skills to share knowledge with others (for example, through teaching and supervision) and be prepared for lifelong learning.
Knowledge and skills guide
Research and academic skills
As a GP you will need to acquire the research and academic skills that are necessary to keep up to date with progress in your field and to aid your decision-making. These skills may be used in many areas of practice, including:
- the clinical management of patients, including treatment, referral and acute care
- dealing with uncertainty (using best available evidence)
- challenging established practice and abandoning ineffective practices
- understanding the ‘value’ of an intervention
- practice-based research
- prescribing
- enabling safer working systems
- improving the quality of health promotion and preventative medicine in your practice
- audit and quality improvement within your practice or organisation
- addressing health inequalities
- lifelong learning
- improving population and planetary health
- primary care research, management, medical education or specialist roles.
A GP is expected to understand basic research methodology and how different types of research activity may contribute to patient care. This includes:
- qualitative and quantitative research:
- differences in forms of research
- levels of evidence and the most appropriate research design to examine a hypothesis
- how to articulate a research question to answer a real-world problem
- patient factors requiring both quantitative and qualitative analysis (such as adherence to treatment)
- study designs and their advantages and disadvantages, including:
- systematic reviews and meta-analysis
- experimental: randomised controlled double blind
- quasi-experimental: non-randomised control group
- observational: cohort (prospective, retrospective), case-control, cross-sectional
- qualitative studies
- techniques such as pilot studies, questionnaire design, focus groups and consensus methods such as Delphi
- surveys and local healthcare reviews
- strengths and limitations of research methodologies
- differences between research, clinical audit and quality improvement.
Epidemiology and statistics
(see also the Population and planetary health and Infectious diseases and travel health topic guides)
As a GP you share responsibility for the health of your local population and should understand fundamental concepts in epidemiology and statistics that are relevant to general practice. These include:
- association and causation
- basic probability, including sensitivity, specificity, positive and negative predictive value, p-values and confidence intervals
- bias and confounding including ways to adjust for these (such as regression)
- concepts and measures of risk, including absolute and relative risk, absolute and relative risk increase or reduction, hazard ratio, odds ratio, number needed to treat and number needed to harm
- differences between population and individual risk
- disease occurrence, including aetiology, frequency, surveillance, determinants, risk factors, prevention and control measures (including decisions or interventions made in the interests of a community or population of patients)
- measures of disease frequency (such as incidence and prevalence) and standardisation
- measures of health, morbidity and mortality (such as years of life lost, standardised mortality rates and ratios, and case fatality)
- principles of making inferences from a sample to a population, type 1 and type 2 errors
- risk of disease in population groups, including your own practice population
- reliability, validity and generalisability
- sampling, sample size and statistical power
- types of data, ways of presenting data (such as scatter diagrams, box plots and forest plots), distributions (normal and non-parametric), mean, median, mode, standard deviation and range.
Evidence in practice
As a GP you should understand the principles, strengths and limitations of the use of scientific evidence in practice. You should apply evidence to your own practice and set your own learning objectives based on your clinical experience.
Further knowledge and skills in this area include:
- applicability of population-level studies to individuals and certain groups (such as groups commonly excluded from clinical trials and disadvantaged groups)
- applicability of research results or conclusions to clinical practice
- approaches to clinical care when research evidence or guidelines are limited or absent
- approaches to complex tasks
- clinical decision-making tools
- critical appraisal of written or graphical information such as trial results or abstracts, clinical governance data (audit, benchmarking, performance indicators) and data presented in medical journals
- desk-based research: how to search for and retrieve valid information and evidence
- effective communication about the evidence underpinning interventions to help patients make decisions about their health, including methods of calculating and explaining risk to patients
- evaluation of guidelines to determine how suitable they are for clinical practice (including methodology, evidence base, validity, applicability, authorship and sponsorship) and of health economics studies on healthcare resource allocation and guidelines
- influence of individual and systemic bias and cultural and social factors on interpretation of research results. For example, a health outcome attributed to a certain characteristic (such as ethnicity) may be due to an underlying environment of disadvantage
- pharmaceutical marketing
- polygenic risk scoring to aid risk stratification
- precision medicine (including pharmacogenomics)
- reasons for lack of evidence about certain interventions (such as rare conditions, new diseases, conditions that have low morbidity or low pharmacological input, bias in research priorities)
- role of large GP records databases and how to contribute patient data to these
- role of genomic databases and the impact on clinical practice
- use of decision aids and information technology (IT) in clinical practice
- use of population-level data to improve the health of local populations.
Teaching and lifelong learning
As a GP you have a role in sharing knowledge with others. This may include formal or informal teaching, mentoring, supervising colleagues and peers, and education in the wider community. You are also a lifelong learner. Underpinning all this is the need for better patient care. Important principles include:
- understanding that teaching others involves more than imparting information
- the difference between clinical and educational supervision and the different skills required in the two roles
- approaches to effectively teaching and mentoring others within a team
- how to engage those you are teaching in a dialogue about their values and goals
- understanding your preferred learning style
- identifying the best methods and opportunities to address personal learning needs
- adjusting your learning style in response to challenges
- identifying methods to support the learning needs of others being taught, mentored or supervised, being aware that not every individual will learn in the same way
- techniques to adjust your teaching style to suit the individual, the topic and the circumstances
- understanding the health literacy of the people with whom you share knowledge
- using digital and online technologies appropriately to enhance learning
- giving and receiving effective feedback to and from individuals or groups, following the GMC’s Good medical practice guidance.
Skills in sharing knowledge with patients are also covered in the Population and planetary health and Consulting in general practice topic guides.
Ethics and governance in education, research and evidence-informed practice
As a GP you are likely to participate directly or indirectly in research and educational activity. For example, you may be an educational supervisor or academic GP, your practice may be part of a research network or you may be asked to assist in recruiting patients to clinical trials. Also, you may see patients who are involved in clinical trials or be asked for your professional or expert opinion on a piece of research. It is important to understand the ethical and governance principles that underpin such activities and have an awareness of your own attitudes, values, professional capabilities and ethics in this context.
Important knowledge in this area includes:
- autonomy and patient choice
- awareness that there are different types of knowledge and ways of thinking, learning and teaching, including critical reflection on why certain types of knowledge have come to be favoured over others and the implications of this for teaching, learning and practice
- co-production of knowledge with patients
- confidentiality (including relevant legislation)
- conflicts of interest (such as incentives for certain interventions)
- consent
- ethical approval and role of ethics committees
- impact of GP research on patients and staff
- inclusivity in research, including the need for diverse data sources
- information governance, intellectual property, legal, privacy and security issues when sharing knowledge (including via online and social media channels), particularly when this involves other people’s work or identifiable information about individuals
- patient safety
- research fraud.
Case discussion
You are in a busy morning clinic and unexpectedly find you have been tasked with supervising a medical student. The student will be observing you. The next patient you see, Marie Nowak, has repeatedly presented with persistent symptoms for which no underlying cause has been identified, and there is no confirmed diagnosis.
Marie tells you about a research study that is trialing a new drug for symptoms she thinks are similar to her own. The study is advertising online for participants. She also shows you a social media message, which her mother forwarded to her, about a promising new therapy that has emerged from another part of the world involving dietary change to combat inflammation. Marie’s mother firmly believes that ‘you are what you eat’ and Marie values her mother’s opinion very much. Marie feels that the NHS investigations and treatments she has received so far have not helped her and would like your opinion on the new avenues she has shared with you, including whether to participate in the trial.
Separately, you have recently become aware of emerging global case reports about a novel disease for which there is not yet an established scientific evidence base. Its symptoms seem similar to Marie’s.
The medical student seems enthusiastic and engaged and asks you whether there could be an underlying mechanism of inflammation in this case and, if so, what it could be.
Questions
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual GP’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | How might Marie’s health beliefs affect my behaviour towards her? What are the sources of potential stress in this situation? How might they be prevented? How do I feel when having to undertake multiple tasks or roles at the same time, and why? |
An ethical approach This is about practising ethically, with integrity and a respect for equality and diversity. | What types of bias may influence the consultation with Marie? What ways of thinking, learning, teaching and knowing are present here? Which ones have greater value or credibility? Why? What ethical considerations should be made when advising patients about participation in clinical research? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | What challenges might I face when communicating with Marie? In what ways might an observed consultation differ from an unobserved consultation? What communication methods and skills could enhance the learning experience for me, the student and the patient? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | What further contextual information would I want to explore with Marie to help me understand her presenting problem? How would I approach gathering and interpreting evidence about an emerging health problem? How would I approach interpreting the research article presented by Marie? What is the value of a case report both in the traditional hierarchy of evidence and in this context? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | What methods can be used to teach clinical skills? How might I learn or teach a multisystem approach to clinical examination with limited time? What resources can help? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | How would I approach making an individually tailored shared- management plan with Marie? In what ways could I manage the uncertainties in diagnosis and management? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | What do I need to consider when responding to Marie about participation in the clinical trial? How can I make clinical decisions in areas where scientific evidence is limited or absent? |
| Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | How would I respond to the medical student’s question? How could I have made best use of the medical student’s skill set? What is a GP’s role in teaching and learning within the practice team? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | What factors (for example individual, systemic and environmental) create a good learning experience? How could the medical student’s learning experience have been improved? What are my development needs as an educator? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | How can digital technology be used to enhance learning in practice? Why is it important to keep good records of a consultation? What systems does my GP practice have for collecting and sharing data for research? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | What factors (for example individual, systemic and environmental) create a good learning experience? How could the medical student’s learning experience have been improved? What are my development needs as an educator? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | What social, economic and cultural factors might influence Marie’s health beliefs? What do I know about Marie’s life and lifestyle? Why has Marie come to me for an opinion? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | What would I need to consider when interpreting clinical evidence from another country and how would I apply it to my patient? What are sustainable healthcare approaches to managing people with persistent unexplained physical symptoms? Are there alternative ways of approaching this case using examples of good practice from other areas or countries? |
How to learn this area of practice
To become an effective and efficient professional learner, it is important to develop the habit of embedding your learning and CPD into your daily practice (in all your roles), adapting your approaches to your personal development aims and the context in which you work.
The ePortfolio is a useful tool to enable your knowledge, reflections and learning to be recorded, reviewed and continually updated. Learning entries may arise from a wide range of activities. These include:
- compliments and complaints
- critical and significant event analyses
- discussions with peers, supervisors, mentors, appraisers and teams
- feedback from teaching sessions
- learning events, such as attendance at lectures, courses, study days and workshops
- online learning activities (such as eLearning, webinars and podcasts)
- patient feedback surveys and engagement meetings
- practice-based learning events (including journal clubs or learning with a group of peers)
- quality improvement projects (including audits)
- reading books, journal articles and electronic materials
- deflection on a patient’s unmet needs (PUNs) or the doctor’s educational needs (DENs)
- reflection on guidelines (such as those issued by the National Institute for Health and Care Excellence (NICE) or Scottish Intercollegiate Guidelines Network (SIGN))
- reflection and learning from any wider portfolio role you may have (for example academic)
- structured feedback from supervisors, colleagues and teams.
A good understanding of how you and your colleagues learn will not only help you in your own CPD but also enable you to help develop the whole team through group learning activities.
Multidisciplinary learning
You can obtain useful knowledge and skills from a wide range of different professionals. This could be through direct clinical contact with other professionals providing services to your patients, for example, in clinics with midwives, practice nurses and health visitors. You may have a supervisory role for other health professionals within your practice team.
Working with research networks or academic institutions allows you to get a sense of the principles of good research practice, and spending time with public health teams may help you better understand the principles of epidemiology and their application to populations.
Academic and educational roles in general practice
Many GPs develop academic careers in addition to their clinical work. This can be done in a variety of ways – for example, through specific academic training posts or by entering academic practice after completion of training. GPs are also often formal educators, such as undergraduate or postgraduate tutors or clinical and educational supervisors. You may have opportunities to obtain further qualifications in teaching or academia.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Common terminology used in risk communication, such as ARR, RRR, NNT and NNH, and simple calculations relevant to general practice
- Interpretation of clinically relevant graphical and tabular data from commonly available resources
- Principles and concepts in understanding research and statistical analyses
Simulated Consultation Assessment (SCA)
- Discussion with a patient who is unsure about whether they should start on a statin after they have been identified as having a borderline 10-year cardiovascular risk
- Phone call: a father wants to know why an antibiotic was not prescribed during an earlier consultation for his child, who now has acute otitis media
- An elderly woman with well-controlled hypertension has been identified through a practice audit as having atrial fibrillation – but she is not taking anticoagulation therapy
Workplace-Based Assessment (WPBA)
- Log entry reflecting on the visit of a pharmaceutical company representative promoting a specific drug
- Audit of your antibiotic prescribing against current national guidance and evidence
- Consultation Observation Tool (COT) discussion about the risks and benefits of hormone replacement therapy (HRT) for a perimenopausal woman.