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EURACT Statement on Hospital Posts used for General Practice Training This statement is intended to provide guidance which can be applied throughout Europe to the education experience that general practitioners in training receive in hospital settings and from specialists. It is not intended to be a detailed description of the content of training as this will be of necessity context specific, and will depend very much on the tasks that family doctors are expected to undertake in different countries. There are however some key principles of such training, and its organisation, which are applicable universally.
Introduction The tradition in medical education in the past was that after gaining a medical degree a graduate doctor would enter hospital as a junior doctor before starting either specialist training or entering general practice. Such posts provided an important service support for the hospitals and the health care systems concerned. The education content of such posts was minimal, and was based on the apprenticeship system of learning by doing. This system did not seem to be effective or efficient in the absence of explicitly formulated aims or learning strategies. When general practice training became established such hospital based training was continued, not for educational reasons, but in order to meet the needs of the health care systems. The Doctors' Directive (93/16 of the EEC)1 sets out the minimum times that must be undertaken in general practice training in any member state, and has perpetuated this hospital based training, suggesting that only 6 months of a very short 2 year programme need be spent in a GP setting. However the minimum requirements of the Directive are exceeded by many member states, and also by many European states outside the EEA (see Appendix 1) The Directive is equally important and influential in non member states in Europe for two reasons. They often have ambitions to join the Union, and also because their developing health care systems are modeled on those of Western Europe. The directive was due for review in 1995, and in preparation for this UEMO organised a Consensus Conference on Vocational Training, and from this developed a series of recommendations. These statements gained wide support and were warmly welcomed by EURACT Council. They formed the basis of the 3rd report to the European Commission of the Advisory Committee on Medical Training (ACMT) in 1996.2 The recommendations which have a bearing on the hospital based component of general practice training were:-
These were accepted by most member states and, if fully implemented by the European Union, would have a major impact on training for general practice. The length of general practice based training would be increased in most countries, and that of hospital based training remaining the same The proportion of training in a general practice setting will increase. General practitioners would become involved in all aspects of the programme. At the same time there has been an increasing realization of the importance of a well developed, resourced and trained family doctor service in the provision of cost effective health care. This has been emphasised by the WHO in its statement on family health care in Europe3. In order to implement this strategy the training of doctors in this discipline must be given appropriate recognition and funding by governments and health care systems. It is therefore necessary to set down the principles that should ensure that training in the hospital setting is of the required quality for future general practioners.
Experience in hospital posts is an important part of postgraduate training for general practice and so should encourage the acquisition of the attributes of the future general practitioner. Education content In order to improve the quality and relevance of all hospital training to that of the best, general practitioners will need to focus attention both on what GP trainees are expected to learn during this component of training and on the learning opportunities offered. Increasingly high quality education programmes during hospital based training are expected and it is important to ensure that specialist teachers are adequately trained and supported. Time must be made available for consultant teachers not only to provide the teaching required, but also to acquire and maintain their own teaching skills. Where hospital posts are being used for general practice training, systems should be in place to ensure that the specialist teaching department has appropriate input and guidance from general practice teachers. A proper balance between the educational and service components of training must be maintained to protect GP trainees from developing a learning gap while training in hospital and to enable them to realize their educational aims. In all posts there should be sufficient formal and informal teaching in protected time and a named educational supervisor who will be responsible for ensuring that formative assessment occurs and that an appropriate, individual educational plan is drawn up and reviewed periodically throughout the post. Clinical audit, that is the systematic review of the quality of clinical care provided, is an important activity in modern health care systems. Ideally it should part of the education programmes in all hospital units selected for general practice training. The education provided should be orientated towards the needs of a future general practitioner, and throughout the hospital period of general practice training, contact should be maintained with general practice via a GP educational release programme and a training practice.
Clinical Content Suitable hospital posts should offer the opportunity to undertake more detailed investigation and more sophisticated management of many illnesses than is often possible in general practice. Such training should reinforce the clinical experience gained during internship*, and enable doctors in training to acquire increasing responsibility for the care of patients as they gather experience and gain confidence under supervision. Although GP trainees in hospital may be managing the investigation and treatment of patients with many illnesses at a stage not usually encountered in general practice, they should be able to refine their clinical skills of history taking and examination, acquire the ability to discriminate in the use of further investigations, and become familiar with the use of a wide variety of drugs and with their side effects. It is important to ensure that there is the appropriate amount of experience in both in-patient and ambulatory settings. As members of a hospital team they should gain an understanding of the roles and relationships of the professions involved in hospital care. This period of training should add to their knowledge of life-threatening diseases and their complications and consequences, and provide practical experience in a broad range of management decisions. It will also provide valuable insights into the interface between primary and secondary care. Suitable hospital posts should offer concentrated exposure to and experience of serious morbidity which is very important to clinical management within general practice but infrequently experienced. *"internship" refers to the period of supervised clinical work undertaken in many countries after the award of the medical degree, but before registration as an independent doctor.
Bearing in mind the advice of ACMT, supervising authorities in European states should ensure that training in hospitals for doctors intending to be general practitioners should be supervised by general practitioners. Posts should undergo a periodic selection and reselection process, along the lines suggested here, to ensure that the education experience provided is of appropriate quality.
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