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How to learn general practice

The majority of your learning for general practice will occur in the workplace, both in general practice itself and in your hospital placements. A key element of professional behaviour requires you to reflect actively on your experiences and incorporate your learning into your daily work with your patients [1]. There will also be opportunities for you to learn outside the workplace, through planned educational activities with other healthcare professionals and during formal teaching sessions. In each of the modules of the RCGP curriculum you will find a section which tells you some of the ways you can gain the necessary skills and experience to become an effective GP.

As a GP specialty trainee, your training programme will provide you with unique insights both into the ways in which your patients and their problems are managed in general practice and in the hospital, and into the interface between these care environments. It will also give you a deep understanding of the meaning of the patient pathway and your role in helping your patient to negotiate this. The curriculum modules suggest how you can maximise the benefit of each training placement, as well as the other learning opportunities that are available.

In every placement, patients and carers will teach you about how they manage their illnesses, and, with your encouragement, will help you to become a better GP. They are often experts in managing their illnesses and at handling doctors and the health care system.  You should also make the most of the opportunities to learn from the wide range of other colleagues you will work with in the multi-disciplinary team who are involved in caring for your patients, both in hospital and in the community.

As an adult learner [2] you will have your own distinct learning style and preferences. These will influence how you make use of the learning opportunities during your training programme and beyond, into your lifelong learning as a general practitioner.

Your key educational relationships will be with your educational supervisor (your GP trainer), the clinical supervisors in your placements and the Programme Directors of your training programme. These relationships will be embedded in active, professional practice where your experiences will not only allow the acquisition of skills but, by participation in professional practice, will enable you to acquire the language, behaviours and philosophy of the profession.

Ensuring a broad range of experience

To deliver the broad base of skills required for the NHS GP role, your training pathway should be configured to provide you with adequate, supervised exposure to the patients you will encounter in professional practice. For this reason, it is important your training in secondary care is grounded in the need to gain competences that apply to the GP's role and working environment.

Attachments in secondary care can provide you with a concentration of clinical experience which would take months or years to achieve in a general practice placement (such as confidence in recognising seriously ill children). You will have the opportunity to see and manage people with serious illness and study their pathway from presentation, admission to hospital and planned discharge, and participate in planning their rehabilitation.

As well as the differences in the clinical material, you will also find that the teams working in primary and secondary care are organised differently and you will be able to compare different approaches.

Training in the earlier stages of the pathway (i.e. ST1-2) should be sufficiently supervised to ensure you adopt a proficient, safe and appropriate approach to clinical assessment and management from the outset. This will enhance effectiveness and ensure patient safety during the latter stages of training, when the level of direct supervision is reduced and the clinical environment becomes more generalist in nature.

Ideally, all GP training programmes should be configured to provide you with adequate opportunities to gain skills in the assessment and management of the full range of the general UK population, as well as more targeted training in the care of patient groups that require a specific approach and skill-set. In addition to the general experience gained in GP placements, such targeted opportunities might include:

Patient group Examples of relevant training placements and posts in ST1-2
Infants, children and young people Infants, children and young people Hospital and community paediatrics services, Children's A&E, integrated services (e.g. 'Learning Together'), children's centres
People with mental health needs Psychiatry services, CMHT, CAMHS, IAPT, addiction services, student services, 'deep end' practices
Older people with dementia and multiple morbidity Acute and internal medicine services, geratology, care homes, dementia units, community hospitals, elderly care services, disability and rehabilitation services, end of life care
Acutely ill people requiring urgent assessment and intervention A&E, acute paeds/adult medicine, out-of-hours services, walk-in centres, minor injury units, intermediate care, hospital at home
Women requiring antenatal and postnatal care Antenatal and maternity services, obstetrics, early pregnancy assessment units, women's health clinics, family interventions

A secondary care training post may of course be configured to provide exposure to more than one patient group simultaneously – for example, a post based in a geratology service with an acute medical on-call commitment would provide relevant training experience in relation to both the elderly multi-morbid and the acutely ill patient groups.

Integrating specific approaches into generalist care

Throughout your training, it is essential to take the time to reflect on your practice. This includes developing a clear understanding of what has been learned and how it can be applied effectively to a general practice setting. Your Programme Directors will be able to assist you in accessing resources for learning during your hospital attachments, and can advise on ways of meeting leaning needs in specialties that are not included in your rotations.

In the latter stages of training, you will need to adjust your mindset to the different health needs, disease prevalence and range of clinical environments encountered in the general practice setting. This involves transferring the expertise gained from your earlier training experiences with 'filtered' secondary care populations to the 'unfiltered' population which presents to open-access community-based services, such as general practice.

Adequate workplace-based supervision and formative assessment is therefore essential in the context in which you will ultimately practice, if your clinical, risk management and decision-making skills are to be applied, honed and tested safely.

Work-based learning in primary care

Your training practice and the patient contacts that you make while working there will provide you with the foundation for your career-long development as a generalist medical practitioner.

Initially, you will work closely with your trainer when consulting with patients. As you gain in competence, you will work more independently with less direct supervision. Being observed, receiving structured feedback and reflecting on your work while providing care for patients, both in the surgery and in their own homes, are fundamental features of workplace-based learning.

In addition, you will have structured teaching sessions with your trainer, tailored to your learning needs. Your training practice is a complex organisation and you will be able to gain an understanding of how it functions as a community care provider and how it monitors the quality of the care provided. You should familiarise yourself with the tools used in quality management, such as significant event audit, critical incident reporting and patient satisfaction surveys, and use these tools with your supervisors  to recognise and meet your learning needs.

Self-directed learning

You are a self-directed adult learner and self-directed study is an important part of your development as a GP. Examples of this are reading around a topic, reflecting on your experiences, searching for evidence, or preparing for an assessment or teaching session. As well as the traditional methods of books, papers and journals, there are many online resources such as the RCGP e-learning courses, which cover the RCGP curriculum, providing you with feedback as you work through them. You will need to keep your e-portfolio up-to-date, which in itself will help you reflect on your training as a GP and help identify new learning needs.

In addition to the possibilities mentioned above, you will be able to participate in more formal learning sessions during your training. Workshops, lectures, seminars and case presentations may be arranged in departmental teaching sessions. Your GP training programme will include GP training seminars and other activities as part of a half-day release programme. In addition, there may be formal learning programmes from RCGP faculties or local University Departments of General Practice. Your LETB/Deanery will also offer updates and workshops for trainees and the local programme directors will assist in highlighting these. Your local medical education centre will be able to advise on funding arrangements for attending courses outside your locality.

Learning with other healthcare professionals

Your training programme will offer you many opportunities to learn with other healthcare workers. Much of the patient care in modern general practice is provided by nurses, health visitors, social workers and many others. Direct clinical contact with other healthcare professionals will provide rich learning opportunities. Examples include spending time with midwives in antenatal clinics, health visitors in child health clinics or with specialist nurses managing chronic diseases. Gaining an understanding of how the interfaces between these professionals and the GP work is another key task. Do not forget the receptionists and managers, who have to make key decisions on prioritising patient requests.

Finally there may be opportunities for you to join other healthcare professionals in joint educational events, learning together through in-house or locality-based programmes.

Lifelong learning

Becoming a qualified GP does not mean that your learning stops, of course. Rather, it is the beginning of a process of lifelong learning – not only to keep abreast of medical developments but also to improve in your application of the knowledge and skills that you learnt during your formal training.

Your learning needs will differ at different stages of your career and you need to be able to continuously review, identify and meet those needs. By linking explicitly with the General Medical Council's Good Medical Practice guidance [3], the RCGP curriculum can help you with this process, providing a framework in mastering the Areas of Capability within the fascinating and wonderful discipline of general practice.

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