Last week I took a brief look at the way OSCEs, as part of the examination process can cause significant stress and strain to and individual aiming to become a doctor.
This week I wanted to raise an issue that has set the doctor forums on fire for the past week.
At this point I will make it clear, this week’s post is more of a rant than a ramble. The following has made me very angry and I hope this post will help you to understand why.
An article published in a particular newspaper by a publicly known GP commented on the GP’s personal views that, current newly qualified GPs do not use clinical skills appropriately and are ‘investigation-happy’ with their patients after talking to them. Entitled : They’re very caring, but young GPs can’t diagnose for toffee, his post highlighted a few issues.
Firstly his clinical reasoning seems to be a little off:
If they had pneumonia, and therefore fluid on the lungs, the voice would sound high-pitched, and the vibrations would be reduced.
Now as a newly qualified that knows nothing about medical science, pathology and all that jazz, I may be mistaken, but wouldn’t the more dense substance of fluid or consolidation that may suggest a pneumonia increase the vibrations rather than decrease them?
The following few paragraphs make mention of checking a patients jugular venous pressure (JVP) as a mark of heart failure, and Weber’s and Rinne’s test for checking for hearing difficulties. While the JVP is correct in detecting heart failure at 70%, it has a sensitivity of only 37% (Morrison et al, 2002). However, the ability of the Weber’s and Rinne’s test for checking hearing difficulties is less well documented i.e.
The overall accuracy of the Rinne’s and Weber’s tuning fork tests in predicting conductive hearing loss associated with OME in children is poor (Behn et al, 2007).
So now that we have dealt with those issues, let’s move on.
Surprisingly I do agree with said doctor on one issue. GP training does need changing. From medical school to foundation training, we learn to talk to patients, AND how to understand the pathophysiology of disease, pharmacology of drugs, and even some genetics, anatomy and a lil epidemiology and aetiology, a veritable Kumar and Clark.
However, after foundation training, all doctors are now expected to have decided on their career, and as such sign up to specialist training in a chosen field. This in particular I feel is one of the contributing factors to the issues raised in the article. Previously a doctor could work in a variety of posts, training or not till s/he decided which speciality s/he wanted to follow. With this not being the case, you can now be a GP within five years of graduating. I do feel there are still some excellent GPs trained as a result of this, but will admit that the phase ‘competent not confident’ can be heard from the mouths of said GPs and their associates.
I do find it interesting, that as a speciality where we must know all areas of medicine, a ‘jack of all trades’ as some would say; but to accomplish this, trainees are not given the opportunity to experience all the specialities of paediatrics, A&E, psychiatry, obs & gobs (obstetrics and gynaecology), general medicine, geriatric medicine or other hospital based specialities that can help broaden the knowledge of the developing practitioner. In some cases, training schemes will even enforce trainees to rotate through placements that would be of limited educational benefit in the interest of logistics and supply/ demand. (How many people know of experienced practitioners that have had to repeat a rotation because the programme says they must, i.e. psychiatry reg having to rotate through a psychiatry rotation while aiming to become a GP).
Consider surgical training : a minimum of six years post foundation training, psychiatry would be four years, peadiatrics may be up to 8 years in some cases. And GP training is 3 years long. I pause to allow you to contemplate your emotions at this point.
I fully agree that training should change. I fully agree that an extension of GP training should occur, to teach not only the business of GP but also allow an individual trainee to develop their own individuality as a practitioner, and more importantly their confidence. Several interested bodies have made noises about extending training to five years, although even attempts to extend to four years is unlikely to get the blessing of the financial coffers of parliament, and all proposals are still being kept in the long green grass.
So yes, I agree that training should change and be extended. I however do not agree with this article in its delivery method. In this article, the GP insults his newly qualified colleagues. I personally feel part of this, was just a method of trying to sell more copies of his book, but I can not fault his attempts of self promotion. However the method he has chosen shows contempt, insurrection, and at least, poor taste.
His statement is also without clear evidence, more a generalist statement. It could similarly be argued that senior GPs do not practice evidence based medicine, and as such treat patients based off anecdotal impressions. It could be stated that senior GPs refuse to make way for younger GPs to allow them into partnerships, or commissioning boards, as they crave the power and money that they feel they can keep their miserly fingers on. It could be stated that established GPs will keep their private list of 500 odd patients, and dish their less favoured patients to the underling sessional GPs.
While individual cases of the above could no doubt be found, I do not feel this is true of all, in fact the GPs I work with (ranging from 3-25 years my senior) are learned colleagues, who do practice EBM, who have integrated me into their practice, and shared the practice responsibility and decision-making with me, despite me NOT being a partner. I respect my colleagues, and I know many others who feel the same. It is a shame our article GP does not seem to do the same.
So in summary, Mr Article GP, who as you can tell I refuse to name (especially as I did hold him in respect having read his book), has made one salient point, in a myriad of confused other ones. I openly invite comments, critiques and rebuttals, but as a newly qualified GP myself, I will defend my practices, and that of my colleagues. I also challenge any that agree with the above mentioned article, to answer the question of what have you done to change the situation if it is such an issue?
Morrison et al, Utility of a rapid B-natriuretic peptide assay in differentiating congestive heart failure from lung disease in patients presenting with dyspnea Journal of the American College of Cardiology
Volume 39, Issue 2, 2002, Pages 202-209.