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EURACT Statement on Selection of Trainers and Teaching Practices for Specific Training in General Practice
Tartu 2002

EURACT is the education network organisation of the European Society of General Practice/Family Medicine, and this document has been produced by a working party of EURACT Council.

Specific Training for General Practice is now mandatory in most European countries and the scope of such training is broadening in line with the public's increasing expectations of the role of the general practitioner. There is a need to encourage those countries who do not have Specific Training in General Practice to commit to establishing and funding such training. There is an increasing need for additional numbers of high quality training practices and therefore there is a need to establish proper selection criteria for trainers and training practices.

Harmonisation of the European legislation, based on common ideas and values, allows for the free movement of doctors and the mutual recognition of diplomas and certificates across the European Union. There will therefore need to be harmonization of the preconditions of the training process across the region. The similarity of the process should act as the guarantee for the quality of education, and obviate the need for testing the outcome of these programs. It is therefore necessary to set down the principles that should ensure that training in GP settings is of the required quality for future GPs. For this purpose common standards in selection of trainers and teaching practices are needed.

The Doctors' Directive (93/16 of the EEC) sets out the minimum time that must be undertaken in general practice training in any member state: it states that 6 months of a 2 year program needs to be spent in a general practice setting. However these minimum requirements are exceeded by most European countries. In its Consensus document on Vocational Training UEMO recommended that at least 50% out of minimal 3-year training period should be spent in general practice. This minimal requirement has been strongly supported by EURACT as the educational branch within European Society of General Practice/ Family Medicine.

Within the last decade both the New Leeuwenhorst Group/EURACT and UEMO have been active in planning vocational training in general practice: the New Leeuwenhorst Group/ EURACT organized a conference on vocational training in 1987 and again in 1994, UEMO Plenum has adopted criteria for general practitioner trainers in 1992 and held a Consensus Conference in 1994. The Advisory Committee on Medical Training to the European Commission agreed with UEMO and advised the EC to revise the Directive in accordance. In recent discussions EURACT has been working to formulate a new definition of the discipline of General Practice and competencies needed for such a discipline. Along side this debate a working group has been working to define the common criteria for the selection of trainers in General Practice which is to be found in the following statement, approved by the EURACT Council in Barcelona 2001.

According to the UEMO consensus document on specific training for general practice, the task for general practitioners is to accept the responsibility for all training for general practice, focusing on the relevance of training. Further by defining the aims, content and methodology of training, to select appropriate locations for training in and outside general practice. Selection and education of trainers and teachers in general practice are crucial in order to raise the quality of training and to inspire innovation and motivation. Training of trainers and teachers must be continuous and an integrated part of the educational program. These programs must cover the three aspects of teaching: what to teach, how to teach, and how to evaluate, with both formative and summative assessment. A viable career structure for trainers and teachers is essential.

There are wide differences between different European countries as to which organizations are responsible for specific training in general practice. However, the body responsible for vocational training should be responsible for approval of training posts for general practice training. The responsible bodies should establish criteria on how the selection of trainers and training practices takes place.

Each country establishes their own criteria for the selection to reflect local circumstances and interest, but these must be congruent with the common ideas among the profession in Europe. The implementation of common guidelines will indicate to the profession, to health authorities and to the public that general practice training is of a proper and accepted standard in European countries. Trainers should be selected by judging the extent to which they, and their practices, provide the environment and opportunities for appropriate learning to take place. They should fulfil criteria which describe the necessary medical experience and educational and organizational standards required in a training practice. Some anxieties have been expressed that in setting and interpreting criteria approval procedures have concentrated on those features of practice which are most easily and objectively assessed.

Motivation of doctors to become trainers include financial, status/respectability, sharing of workload, time off/improved rota, employer may provide better conditions of work, a desire to teach, a desire to learn. All GPs should have the right to become trainers and should start that process from an equal baseline. Having definite criteria in the selection of doctors to become trainers does not as yet have proven validity i.e. no proof that criteria do in fact produce better trainers. A precondition for selecting trainers is that there are enough applicants, in some countries recruiting GPs who wish to become trainers is a problem. In countries where there is not enough trainers in general practice, there may be temptation to lower the criteria for the trainers. Although in short term this may lead to the numbers of trainers needed being recruited, in the long term as it is not to be recommended as it will affect the quality of training.

The criteria for trainers are described under two main titles: the trainer (as a doctor and as a teacher) and the training practice and its organization (Table 1).

Table 1. Summary list for criteria for selection of trainers and teaching practices

Trainer

Criteria	How to evaluate?
Professional values	performance should be measured
Clinical competence, quality of care	difficult to measure; comprehensiveness, continuity, personal care should be evaluated
Experience as a doctor	years in practice?
Active in CME, quality assurance	credits collected
Ability to communicate	doctor's verbal and written communication information to patients and to staff feed-back from trainees
Preparation for teaching, teaching skills	Certificates of trainers' courses; Evaluation of teaching skills by sitting in or video-taping; feed-back from trainees
Commitment to teaching	Application to be a trainer, feed-back from Trainees
Time for teaching	Evaluation of daily schedules
Availability and accessibility to patients	efficiency of the appointment system; waiting times for patients

Practice

Selection of trainers should include consideration of the trainer's curriculum vitae; an assessment of the availability of the doctor, both from the point of view of his medical care of patients and also his educational responsibilities as a trainer; personal interview of the trainer; evaluation of the training practice. Practice visits should pay attention to clinical care, practice culture and learning environment.

Current situation in Europe

Trying to identify the current situation of selection of trainers and training practices in Europe, the survey was performed in April 1999 by 22 council members of EURACT- representatives of the 22 countries.

The survey results revealed that most of the countries have clearly defined procedure of selection of trainers and training practices, except for Turkey, Lithuania and Poland.

A wide variety of criteria is used for selection of trainers in different countries. Some countries decide on selection based on 2-3 criteria (e.g. in Austria-time of GP in practice, and criteria of the practice itself). On the other hand, some countries present much more requirements for the future trainer (e.g. United Kingdom, Ireland, Italy) including professional qualification, clinical competence, teaching skills, commitment to teaching, activeness in continuous medical education (CME), quality assurance and others-as performing audit. Some countries also evaluate research activities (some regions of Spain). The rest of countries have a combination of different criteria mentioned above. Most widely used criteria are professional qualification, time in practice, commitment to teaching and specific criteria of training practice.

Effective training process can be ensured not only by use of careful selection but also by improving teaching skills of selected trainers. This is achieved by organizing specific education for trainers as well as CME activities. Initial training courses for GP trainers are organized in most of the countries, but, as it is in case of trainers selection, not everywhere they are obligatory condition to start the training activities. The duration of initial training is also different between the countries. The content of courses mostly depend on priorities established for a certain country. Educational importance of different teaching methods is generally accepted and special training on didactic skills is usually included.

Payment for the trainer for his teaching activities is also important. In countries where the trainer is paid directly, mostly the payment is defined as "symbolic (Spain, Croatia, Lithuania), other countries do not pay for the training activities at all (Austria, Germany, Hungary, Poland). In some cases financing is indirect- money is coming to the owner of the practice (community) and the owner decides how these finances have to be spent (e.g. Finland).

Accreditation of training practices for general practice vocational training is performed either separately (Croatia, Denmark, Spain, Germany, Greece, Israel, Ireland), or practice criteria are taken into consideration when selection of trainers is performed (Belgium, Italy).

Usually organizatoions responsible for the selection of trainers and those responsible for training are the same. Commonly universities are involved in selection (Bosnia I Herzegovina, Estonia, Finland, France, Hungary, Lithuania, Norway, Poland, Slovenia). In many cases obligatory professional organizations (Germany, the Netherlands, Italy, UK), voluntary professional organizations (Israel), Ministry of Health/Social Affairs (Austria, Croatia), county councils (Sweden) are involved.

EURACT council members prioritised the above-mentioned criteria as follows:

• A personal commitment to teaching
• Practical teaching skills
• A high standard of clinical competence
• The ability to communicate effectively
• A high professional qualification
• Activeness in CME
• A commitment to quality assurance
• Adequate time in practice
• Others (audit, research activities)

The criteria in selection of training practices were distributed according to the importance as follows:

• Good quality premises, equipment, library facilities and other teaching aids
• Well organised medical records
• Adequate number of patients and workload to ensure the gaining experience for trainee
• Good quality health care team
• Effective practice management
• Others (audit, research activities, continuity of care)

Recommendations

There should exist clearly defined mechanisms of selecting teachers and training practices for specific training in general practice.

All general practitioners should have an opportunity to apply to be a teacher for specific training in general practice.

Selection of teachers and training practices should be provided by the same organization responsible for organization of training.

Trainers' selection should be based on a list of clearly defined characteristics, providing information on the applicant as a teacher and as a doctor.

The most important trainer characteristics are teaching skills, commitment to teaching, clinical competence and professional qualifications.

In practice selection the most important criteria include premises and equipment, medical records, number of patients and health care team.

References

• UEMO (1992).Criteria for general practitioner trainers.
• UEMO (1994). UEMO consensus document on specific training for general practice.
• Joint Committee on Postgraduate training for general practice (1993). Recommendations to regions for the establishment of criteria for the approval and reapproval of trainers in general practice.
• Joint Committee on Postgraduate training for general practice (1998). Recommendations to deaneries on the selection and re-selection of general practice trainers.
• EURACT Confernce on Vocational training. Leuven 1994.
• Vocational training in general practice. NLG workshop 1987.
• Scottish council for postgraduate medical education (1991). Learning general practice. Appendix III. Characteristics of an approved teaching practice (p.41-43)
• Report and Recommendations on the Review of Specific Training in General Medical Practice: Advisory Committee on Medical Training to the European Commission, XV/E/8433/95-EN October 1995.

Written by:

Margus Lember (Estonia) and Egle Zebiene (Lithuania) with support of the EURACT Specific Training Task Force members Marten Kvist (Finland), Fergus O'Kelly (Ireland), Justin Allen (UK), Ivar Östergaard (Denmark), Dolores Fores (Spain), Athanasios Simeonidis (Greece), Igor Svab (Slovenia), Okay Basak (Turkey), Gertraud Rothe (Austria), Bernard Gay (France), Francesco Carelli (Italy), Owen Clarke (Ireland).

This document has been presented and discussed at the WONCA European Conferences at Palma de Mallorca 1999 and Tampere 2001.