At WONCA Seoul, I had the opportunity to meet Dr Jo Buchanan, who is the President of WONCA EURACT.
“We [WONCA EURACT] are an organisation of teachers of GP from across Europe and our mission is to improve family medicine through learning and teaching. We are a community and we have representation from about 37 different European countries. We’re there to help countries develop their GP training schemes both at undergraduate to specialty training level and continued professional development.’
WONCA has several Working Parties and Special Interest Groups so that like-minded GPs can meet and share ideas. Attending one of the courses made available by each group or attend their workshop at a WONCA Conference is usually a good way to get involved or at least to meet and greet.
I thought Jo would be a great person to pin down for an interview for this blog as she will know about GP training across Europe more than anyone else. I also opened out the questions to the JIC – what did they want to know about education across countries? In this blog post, I hope to have answered some of these and whet the appetite of some of you GP educators out there!
Jo has been a GP in Sheffield for around 30 years and has been both a trainer and an appraiser. This would invariably have given her an opportunity to see how the landscape of GP education has changed over the years. “I think it’s changed for the better. Certainly, in the UK, there is a very welcome increased emphasis on training good clinicians. I think – and it’s partly to do with where medicine was at that time – we spent a lot of time thinking about communication when I was a trainee and in our early years and I think we didn’t focus so much on clinical skills. The focus on clinical skills which has come in the last 15 years has been really good for patient care and I don’t think that communication skills has been lost.”
Communication skills are the corner stone of GP – skills to create rapport, to seek the hidden agenda, to maintain long-term doctor-patient relationships. Coupled with being generalists and evidence-based, as a trainee, general practice can seem like a vast abyss of unsurmountable knowledge. The move towards more primary care-based research and publications of guidelines has really helped push general practice forward. The professionalisation of the specialty with the MRCGP, in its current format of AKT and CSA, becoming a compulsory integrated exam only in 2007.
I’m not sure if you feel the same as me but when I started my ST2 GP placement, I felt overwhelmed by the idea of being a generalist. Little did I know that it was about being safe and less about knowing every NICE guideline under the sun. And then there was the complexity of communication skills. Having initially started in core surgical training and being considered a good communicator amongst my then colleagues (so much so that I was always the one sent to tell patients that their operations were cancelled), I had a huge shock when starting in GP and realising I was really bad at it. I started using lines in parrot fashion which had felt very unnatural to me – leading to a stilted consultation and a rather flustered trainee. Jo was very reassuring about this.
“When we learn new skills, we are not immediately fluent in them so we are a bit clunky. Trying to incorporate a person’s ideas, concerns and expectations is not necessarily very easy and you actually have to practice it and you may not be very fluent with it. Some trainees are absolutely fabulous and they turn up to training and they can do it. For others it is harder and it is particularly hard for people who are not naturally empathic. We are all somewhere on the spectrum of empathy and we can all learn to be more empathic by being curious and asking the right kind of questions. But it is clunky to start with; it’s learning a new skill.”
This is really reassuring and I like the comparison to fluency in a language. I remember my time before CSA practice where I would try out different lines on patients and cross out the ones that didn’t work for me and settling on the ones that suited my personality. I also remember one of the AiT JIC members, when I smugly made a grand reveal of one of my killer I.C.E lines, responded rather flatly with “I can imagine you saying that, Sonia, but it’s not really for me…”. Bar leaving me a little deflated, this hammered it home that these ‘lines’ can be highly individual.
“When you are trying to learn something, you learn most from those who are just ahead of you. So when you’re an ST1, sometimes the ST3 can be so helpful in helping you understand something. You need people with lots of experience but in combination with people who have just been doing it. Just because we [the more experienced GPs] think we’ve developed a really sophisticated system doesn’t mean that we are best placed to provide all the support that those at the beginning need.”
A nice way that I’ve heard GP training explained was that it was like learning to drive. You don’t pass being the best driver ever but a safe driver and that experience continues to improve you. But what about after training? I asked Jo what she thought about mentorship and training after qualification.
“Everyone says that GP training is too short and there is some logic in that. The Dutch only have three years too though and they seem to be reasonably happy with that. Just as an aside there is a training scheme in Canada which is only two years training – that involves very intense training.”
“But I’ve always felt that three years will get you to a certain point but it would be really nice to get some proper mentoring after the three years to really help you as a clinician. It doesn’t fit this idea that you get to a certain point, you’re given a certificate and off you go – that’s really what the health service wants – a stamp to say that you’re ok and, you can do the job now – but in fact it’s an artificial transition.”
“I would hope that the model that we have will be adapted and at the end of the three years when you have passed all your exams there is then a final year to develop the broader skills and the time to integrate the things that you have learnt and become more fluent in practice.”
“I think [we need] just more time to integrate the skills. In fact, we’ve got to work in these three years but actually also work to support doctors in that transition and there is so much more available. The College is doing a good job of trying to adapt and there are more programmes about leadership for first5 groups. We have a very good first5 leadership programme here in Yorkshire that gets really fantastic reviews from young doctors; that’s been run by the Faculty with HEE [Health Education England] funding and that’s helping doctors in transition. Also appraisals – If you get someone who is really interested in you as a person it can be really helpful to have, particularly in those first few years.
So what about the rest of Europe? How is the UK measuring up for training?
“I think there are positives and negatives in all systems. I think that when it comes to where do you see good quality general practice and I think it would be Denmark. It has a very strong system of general practice training and also it is a country that has a high level of trust and high level of trust in professionals. They haven’t had the same problems that we have had with various scandals. They have five years of training and they don’t have an exit exam.”
This is the country where the capital has no ticket barriers on their metro system since there is an implicit understanding that everyone pays for their fares. This level of trust is probably inherent in their culture. I did a VdGM conference exchange in Copenhagen three years ago. One of the things I love about the Danish system is the ability to take six-month trials in certain specialties before committing to training. Not sure you want to do neurosurgery? No problem – trial it for six months. This could potentially save years of indecision for certain trainees and also means that specialties will retain the ones who are best suited to them. “They take you into training and then they expect you to be able to complete. And so that is so different from the UK. One of the things that I realise about the UK is that our trainees are highly assessed – we’re at one end of the assessment spectrum. I think that has improved the quality of the trainees as they come into practice and certainly, I am impressed by the young doctors that I see as a patient in the UK, but I think there is a balance somewhere to be had.”
“I have little problem with the other assessments but all the repetitive work that goes into the e-portfolio – I think that trainees could be using their time more effectively. I think this is something that we need to think about in the UK which is are there better ways of using a trainee’s time.”
I agree with this wholeheartedly. Now that I have witnessed several training systems across the world, I realise that our portfolio is pretty epic. However, many other countries don’t have the level of supervision or support that we do in the U.K. With all things being equal, I would always choose the more onerous portfolio with my quality of training and not the other way around. However, there were always those moments that I couldn’t help thinking that our portfolios could just be that little more user-friendly.
What else would you import?
“So, in Belgium, you have to complete a Master’s degree as part of your specialist training. It means that you have to do something more rigorous – more academic. You have to be able to look at the literature – to do something that stretches your brain a bit more than how the e-portfolio stretches your brain. Various countries including Slovenia and Turkey have to produce dissertations as part of your training. The Dutch system have their teachers of general practice post-graduate training based in universities and they have more of an academic base – more academic support and they tend to be more academic in their approach which I think is a good thing. It’s not ivory tower academia but practical. How can we use our critical thinking to improve our systems and services?”
“I think in the UK, I really think we have great systems and I’m a real advocate of GP in the UK but traveling and seeing other systems makes you question your own system and I think we lost a bit through the emphasis on service delivery in our training because the management of training is based within the health service.” To be fair, I heard this when I was doing surgical training. In other countries, trainees would be cutting or doing ward rounds in a shorter training period but, in the UK, due to the nature of the NHS, our training was diluted by service provision.
Our conversation turns somewhat and we start talking about leadership. I don’t know about you but I hear so much about how we should be encouraging everyone to become leaders – will we end up with “a too many chief, not enough Indians” scenario? Should everyone get involved with leadership as well?
“I’ve been an appraiser for about 20 years now so I’ve probably appraised something like 200 doctors so I have seen a huge spectrum of GPs and there are some GPs who are very happy to be clinicians. Accepting that for some people it [leadership training] is not the right thing, but it’s about offering the menu to young doctors and saying, ‘look at the people around you. Who do you want to be in 10-15 years-time?’ It’s all fine and we need all kinds of doctors and doctors who are solely clinicians will be being leaders in their own practice. But if you think you need more, look around and see what other doctors are doing -there are many more choices now, many more options of leadership roles – you can go into Faculty, you can go into CCG, education or the College nationally.”
“Why do it? Because it makes life more interesting and you develop new skills and a sense of perspective. It’s harder to get completely weighed down by the patients in the practice when times are tough. It’s more like an insurance against burnout. It’s about getting out there and looking at other ways of working that makes you realise that there are many ways of doing things. So even being an appraiser – going to different practices and doctors describe different ways of doing things – is really helpful for my own practice. To be a good doctor, you need to be curious and curiosity is the key, isn’t it? Just because we’re curious about our patients doesn’t mean that we shouldn’t be curious about the world.”
Our conversation wanders off into the million-dollar question of the GP retention and recruitment crisis and how to get doctors into under-served areas, both in the UK and globally. I’ve heard of golden handshakes in certain parts of the UK to improve recruitment in underfilled VTS placements; and in Fukushima in Japan, medical students get a significant bursary if they commit to seven years working in the prefecture after qualification.
“If I had an answer for this I would have a lot of money because it is a universal problem!!! There’s been many things that have been tried like recruiting and training medical students in those areas and creating good working condition. Norway has had some success recruiting in the very northern areas where the distances and isolation could be a deterrent.
“You have to start by having enough doctors in the country. When we were coming into practice in the late seventies/early eighties, people were struggling to get jobs in general practice. So places like Scunthorpe and Grimsby, who have huge difficulties recruiting, people went there because you couldn’t’ get a job anywhere else and developed worthwhile careers and very impressive practices.. But we have never trained enough medical students in the UK and they are trying to address that now. So those countries that have an oversupply of doctors will not have so much trouble recruiting.
What about the Government drive to recruit doctors from Europe? “The answer is not to recruit from elsewhere. Doctors should have the freedom to move if they choose but I find it difficult as a UK doctor – knowing how well served our NHS is – visiting countries like Poland, Ukraine, Romania and Bulgaria and hearing how difficult medical migration has been for those countries.” The brain drain.
“The NHS has tried repeatedly to recruit from elsewhere and it works to a degree … When I was involved in training, people would go to Spain to recruit doctors from Spain, doctors came and worked for a bit but it was too cold!! And they would go back!
However, for medical students to become GPs, we need to have exposure to general practice at undergrad level, surely? “The more traditional medical schools probably have less exposure than the newer medical schools. So, for example, at East Anglia you’re in there from week one into general practice and you have a lot of your teaching in general practice. It is set up with that model in mind. You go to another more traditional medical school you don’t see much general practice until you have blocks later in the teaching. This is not to criticise them, but it is harder in the medical schools that have been established for longer since there’s an inbuilt rigidity in the organisation that makes it harder to change. It’s a wonderful thing to be a young new organisation as you can make new rules!”
“And we need medical students to be exposed to charismatic GP role models early on. If I was running an undergraduate course. I would pick out two or three GPs who are really good at lecturing and throw them into year one so that people see these figures and so that they can see that GP can have these skills – it’s about role-modelling.” This is a really interesting point as I learnt first-hand when I met four very bright medical students from King’s College at WONCA Seoul last year. They only came to WONCA to present a poster mainly because it fitted with their final-year timetable and they were surprised with the enthusiasm and the motivation for good general practice shown by all these family medicine physicians from across the world. It wounds me a little when I remember one of them saying to me (with good intentions) that he had always thought that general practice was a graveyard of ambition and he had never considered it as a future career since he knew that he was a very driven person. WONCA had been, for him, a realisation of what general practice could be. This has changed my thinking a little bit about how we deliver JIC events with a strong belief that they should be opened up to everyone that is interested. Therefore, we plan to set aside a certain number of discounted tickets for Foundation Year doctors and medical students for both the symposium this year and the VdGM forum in two years-time.
We talk more about WONCA. I think we all know, if you read my blog regularly, that I love WONCA and it’s because I meet new friends every time but reconnect with all the people I have met before. What attracts Jo to WONCA?
“I think the sense of being part of a wider community of family medicine and that there are so many people who really want to improve patient care by improving family medicine and that’s such a great joy and it’s such great fun. You walk into a room in Krakow, Prague or Vienna and you see all these people and there’s warmth all round and we all rapidly connect. I’m sure you have that with VdGM [definitely!! I love my VdGM family!]”.
“It really challenges your assumptions and it really forces you to address issues of diversity and difference. I can be sitting in a meeting and I can be managing it in a particular way and someone from southern Europe will say ‘you’re managing it in such a ‘North-West European’ way’ i.e. ‘you are not giving me time to talk and to think about the issue. You’re being too quick. You’re being too to the point’. It is an opportunity to challenge the way we work and recognise that there are many other ways to work and that’s just within Europe. I find that one of the most exciting things which is recognising that I am being very ‘North-Western Europe’!!” These words echoed in my mind the other day when I was writing an email to my VdGM colleagues and I had to stop myself as I was writing in bullet points under summary headlines. Oh my gosh, maybe I was fulfilling my own stereotype as well.
“One of the big aspects of EURACT is that we are a community and the thing about being part of a community is that we help each other out. People come to council meetings with problems that they are having and everyone helps to problem-solve. We have just had a doctor from Russia trying to develop communication skills teaching and she’s looking for expert help. A colleague from Estonia who speaks Russian and her colleagues will go to Russia to help her develop her communication skills teaching. Slovenia has been very successful at developing family medicine since the separation of those countries that used to make up Yugoslavia and its been very successful at developing its own systems and it works really hard with the other former countries of Yugoslavia to develop family medicine. It’s that community that EURACT helps to facilitate.”
HOW DO WE SIGN UP?! “Well, you can join EURACT [http://euract.woncaeurope.org]. One of the things to consider is that we have a course for GP teachers which takes people at all levels including the occasional medical student. This is in Slovenia in September and attending this course is one of the ways to get involved.. This is a course where you will learn something for yourself but you will also meet teachers from across Europe and you will learn about other systems. It is run on a model of ‘come to the course, take the materials home with you, translate them into your language and cascade them’. So some countries use them [the resources] repeatedly.”
“There is something about becoming aware of what’s happening elsewhere and developing networks. We also have conferences every two years and we’ve just had one in Leuven where there was a huge amount of networking going such as ‘we can take your students’ and doing some cross-border working which is so rewarding for people who do it.”.
Jo also really encourages the younger generations to get involved. “We have a representative from VdGM, Chloe Delacour, on our council and she’s invaluable because it’s easy for us to get carried away and forget the trainee experience”
So as our interview draws to a close, Jo stops me and says,
“General practice is very fortunate because there is a cohort coming out after First5 who are saying ‘what can I do now?’. I am very excited about the future of general practice. I have to say, as an appraiser and as a patient, I am heartened, reassured and impressed by the quality of the young doctors that are coming through. You are very impressive as a generation of young doctors so there is great potential for the future.”