PRINCIPLES OF SELECTION OF THESE OBJECTIVES

The first is to select those objectives which are crucial to the doctor's work, for example, the ability to deal effectively with life-threatening illness and the ability to communicate with patients.  Secondly, are those attitudes and skills that are commonly required in a large proportion of the doctor's work.  Thirdly, are attributes that are not only required but will continue to be required throughout a doctor's professional life-time and particularly the ability to review his/her own work and to adapt to and produce change.  Finally, there is understanding principles or developing skills that can be transferred from the condition or setting in which they are learned to other settings and conditions in the future.  This is educationally effective and more economical.

The list of priority objectives may look long, but they are as specific as possible which should make them easier for teachers to apply.  They are not intended as a list of tutorials to be worked through.  Vocational training extends over three years and takes place in hospital and general practice, supplemented by day release courses and other teaching.  Therefore, these objectives may be achieved in any of these places and it is up to the course organisers and trainers to decide when they introduce topics and how much time each individual trainee needs on each section.

 A.            PATIENT CARE

 One of the difficulties facing a general practitioner is the wide range of problems with which he/she has to deal, and this means it is virtually impossible to draw up a list of conditions that all trainees should be competent to manage by the end of their training. All trainees will see a wide, but not necessarily adequate, range of problems during their training programme and we believe the essential objectives are largely to do with general principles, which can be learned from some problems which have been seen and subsequently applied to others which have not.  There are separate detailed lists of conditions.

 1.    Problem Definition

The doctor should be able to demonstrate that he/she:

a)    can recognise common physical, psychological and social problems presenting in general practice and give equal consideration to them;

b)    can include in his/her assessment of the problem:

¨      the patient's beliefs, ideas and concerns about the problem

¨      its effect on daily living, family and friends

¨      its effect on the psychological state of the patient

¨      the patient's expectations of the doctor

c)       understands the principles of problem definition, including:

¨      the consideration of appropriate possibilities

¨      the use of probabilities

¨      the use of selective history taking, physical examination and investigations

d)    can cope with his/her own anxieties, particularly in relation to:

¨      the unstructured presentation

¨      the inability to reach a firm conclusion

¨      the lack of continual professional monitoring
 

2.     Management

The doctor should be able to demonstrate in his/her management of the patient's problem that he/she:

a)       can choose with the patient the appropriate management for each problem;

b)       understands the importance of making and reassessing a management plan which includes:

¨      the effective involvement of other members of the team

¨      the effective use of records

c)       in his/her prescribing of drugs, has a knowledge of their:

¨        pharmacological action

¨        side effects

¨        interactions

¨        dosage

¨        cost

¨        regulations, including that of scheduled drugs

¨        appropriate use
   and that he/she is aware of the sources of information concerning other drugs.

d)       has the knowledge and skills necessary for the management of life events and crises.  These   
   include, for example, death, alcoholism, domestic upheavals and psychiatric illness.

e)       can provide appropriate care and support for his/her patients and their families.

f)       has the knowledge of available agencies and resources, and skills to make appropriate referrals.

g)       understands the importance of appropriate involvement and education of the patient.

h)       is aware of the costs of his/her activities, especially in the field of prescribing and practises in
   the knowledge that the resources of health care are finite.

3.     Emergency Care

The doctor should be able to diagnose and initially manage in general practice all acute emergency situations and provide immediate follow-up care where appropriate. Important examples of these are acute asthma, pulmonary embolus, myocardial infarction, acute left ventricular failure, acute abdomen, acute haemorrhage, management of the unconscious patient, including diabetic coma and hypoglycaemic coma, status epilepicus, road traffic accident, obstructed airway, self-poisoning, acute depression and compulsory mental health admission.
 

4.     Prevention

The doctor should be able to demonstrate that he/she:

 a)    understands the principles involved in identifying preventable diseases in general practice, for example:

¨    case finding during routine consultations

¨    health education during routine consultations

¨    screening sub-groups of the population

¨    monitoring preventative activities, e.g. immunisation and cervical screening rates; level of family planning; attendance at child health development clinics; health education for groups of patients and the community at large.

b)    has a knowledge of systems used to identify individuals and sections of the practice population.

c)    is able to provide effective preventative services to individual patients and to his registered practice population.

 B.        COMMUNICATION

 1.    Patients

Communication with patients takes place largely in the consulting room but also at home, on the telephone, and in other situations.  Effective communication can be defined as the ability to establish or maintain a relationship with the patient and to use appropriate strategies and skills to achieve the aims of patient care.

The tasks that can be achieved in a consultation have been described by Pendleton et al (1984) and have been incorporated in our objectives for patient care.  The doctor should  be able to demonstrate that he/she can achieve these tasks in his consultations.

 2.     Partners, practice team and other professionals

The doctor should be able to demonstrate:

 a)    understanding and respect for the professional training and differing roles of members of the practice team and other disciplines who may be involved in the care of his/her patients.  This is particularly important in relation to:

¨  district nursing sisters

¨   treatment room sisters

¨   health visitors

¨   community midwives

¨   social workers

¨   practice managers, secretaries and receptionists

b)    his/her understanding of the importance of meetings and discussion with his/her partners,  family, practice team, and local colleagues in hospital and general practice.

c)    the skill to discover the strengths and weaknesses of the members of these  groups and their need for support.

d)    the use of his/her knowledge of the practice and his patients to their mutual benefit in various contacts, such as at practice meetings, team meetings, and within the family.
 

C.        ORGANISATION

We emphasise the need to be able to monitor and manage as being more important initially than being conversant with every paragraph in the Statement of Fees and Allowances (Red Book).  If the broad principles are grasped, it is likely much else will follow.

Some aspects of organisation are covered in the other sections.

 1.    The Practice

The doctor should be able to demonstrate:

a)    an understanding of the importance of the need to manage a practice effectively.

b)    an ability to monitor aspects of practice activity, including:

¨      accessibility and appointment systems

¨      information given to patients

¨      records and registers

¨      employment and attachment of staff

¨      use of time

 c)    the ability to take appropriate action when problems are identified in these fields.

d)     his/her knowledge of the most important sections of the NHS contract and regulations, including:

¨      his principal obligations

¨      sources of income

¨      superannuation

e)     his/her knowledge of the most important organisational aspects of practice and partnership, including:

¨    partnership agreements

¨    principles of book-keeping and accounts

¨    financing and premises

¨    income tax   

f)      his/her understanding of the application of new technology to general practice.

g)      his/her understanding of the principles of the successful introduction of change and innovation
 including:

¨      the nature of innovation

¨     the characteristics of the adopter

¨     the characteristics of the organisation

¨     the implications for his future practice.

2.     Personal

a)      the doctor should be able to demonstrate the ability to manage his/her time:

¨      in consultations

¨      in the balance between patient care, the practice, his/her family and other activities.

b)      the doctor should demonstrate an awareness of his/her own limitations, respect the skills of 
  others, and the ability to delegate appropriately.

 3.     Community

a)    the doctor should be able to determine and to respond to the health needs of the community.

b)    he/she must know how and where to intervene in the community on behalf of individuals or groups of patients and have the ability to deal with and relate to a wide range of people responsible for community affairs.

 D.            PROFESSIONAL VALUES

 In this section we have attempted to describe some personal attitudes and values which

we regard as fundamental attributes of the good general practitioner.

The doctor should be able to demonstrate:

 a)    awareness of his/her own values, beliefs and attitudes, the factors that influence them, and the way that they affect his/her work and relationships with patients and colleagues.

b)     his/her recognition of the social, cultural,, and organisational factors that define and affect his/her work as a doctor (e.g. social class, race, methods of payment).

c)     the possession and application of ethical principles in his work.  These include:

¨         respect for the value of human life

¨         respect for the dignity of patients and the promotion of their autonomy

¨         maintenance of confidentiality

¨         willingness broadly to place the needs of the patients above his/her own convenience

¨         justice and fairness in allocating resources

¨         personal and professional integrity.

d)        tolerance, respect and flexibility in this response to the ideas of others, including those of  
    his/her patients, peers and teachers.

e)        his/her willingness to submit his/her work to review by his/her peers and the ability to give and
    receive criticism.

f)        that he/she is able to maintain his/her own physical and mental health.  He/she should be aware
    of the stresses of his/her work and of his/her own responses and defence mechanisms.  He/she
    should be able to seek and obtain appropriate  support.

g)        his/her awareness of the factors that influence the relationship between his/her personal and
    professional life (e.g. financial and family commitments).

h)        a willingness to accept appropriate responsibility for his/her patients, partners and colleagues
    within the practice.  He/she should be prepared to provide      appropriate support for others in
    the practice.

 E.            PERSONAL AND PROFESSIONAL GROWTH

 The doctor should be able to demonstrate: 

a)        that he/she can identify strengths and weaknesses in his/her performance as a doctor and
    his/her educational needs.  This may be achieved by performance reviews, peer group review,
    and other assessment tools.

b)        that he/she can recognise, define and respond to changing needs in his/her patients, in his/her
    community, and in other professions with whom he/she works.

c)        that from his/her review of his/her own work and the changing pattern of needs, he/she can 
    define his/her own educational needs and appropriate methods of meeting these needs (e.g.
    critical reading of the medical literature and methods of continuing medical education).

d)        the ability to adapt to change and to produce positive change both in himself/herself and others.

e)        an awareness of the factors that limit his/her effectiveness, e.g. the management of time and
    resources, and demonstrate the ability to manage and overcome them.