Curriculum

Part A. Aims Of the day release course and theoretical basis for the curriculum
The overall aim of the 3 year scheme is to allow doctors to gain that which is needed to enable them to take up a role as an inner city GP. The day release will do what is best done in a group, and the trainers and consultants will do what is best done one to one in the clinical setting. The scheme is a 3 year whole with the option of people joining the day release for an independent registrar year. The scheme has an inner city focus and looks at Newham specific issues, with a view to encouraging people to want to stay in this type of area.

In order to become independent practitioners trainees will need to develop in all of the following areas:-

1. Knowledge base
2. Clinical skills
3. Application of skills e.g. consulting, ‘clinical nose’
4. Interpersonal skills
5. Personal development

Within these development areas, groups, and in particular small groups, provide an opportunity for:-

1. Group dynamics and peer support and therefore develop self confidence and self reliance – to trust own judgement and know limits. The group becomes a testing grown in which members can mature. Thus the quiet new ST1 will grow into a shaping ST3 as they grow in the group.
2. Develop insight and explore clinical attitudes – patients as people, how the doctor feels, complex transactions, personal boundaries/roles. Discussion with peers and exposure to ideas in an exploratory and non-judgemental environment allows values to be expressed, formulated, challenged and refined.
3. Access to wider resources. Look at different ways of doing GP. outside resource people and educational input. The group is able to access resources unavailable to individuals, eg site visits to community locations.
4. Develop interpersonal skills e.g. consultation skills, teamwork, mutual responsibility . The group is a safe place for interpersonal challenge as well as support, for laughter and tears.
5. By providing a stimulating peer orientated milieu, encourage the skills (e.g. critical reading, time management) and desire to learn and look at own development needs. The best environment in which to become excited about owns own education is a group of excited peers resulting in a learner centred group providing a supportive and safe environment..

With the exception of access to wider resources all of the above focus on application of skills, interpersonal skills and personal development. The bulk of the knowledge and clinical skill base and much of its application are best taught by one to one in the clinical setting.

It therefore follows that the group process is just as if not more important than the subjects covered by the day release course. The group part of our curriculum maps closely to the RCGP curriculum and GP capabilities, and we leave the topic area coverage more to the one to one settings. We clearly still teach in the medium of clinical general practice but the process is the focus. Thus a critical reading session will be around a clinical question, but the real emphasis will be on critical reading and analytical thinking skills.

We include learning styles that encourage people to own the group and to participate and try to avoid focusing on details of knowledge and ‘passive’ learning.. Thus we use interactive whole group teaching, divided group into 8-12 people for case discussion, smaller breakout groups 4-5 eg in SDL planning, and micro groups 2-3 for skills rehearsal for example. We discourage note taking and ‘didactic presentations’.

In setting our day programme we therefore look at what outside resourcing the group really needs and then plan other activities as participatory process focused learning so that there is a balance between educational input and work with the group.

Some formats have become regular slots because they fit the curriculum aims so well.

• Self directed learning
• Case discussion (post Balint, with relaxed rules of admissible material)
• Journal review, taking a topic, looking at important papers in a critical way then generalising out to a protocol
• A day in the hot topic, taking 2 ST3s cases and teaching in an interactive hot topic way to recreate something of the variety and excitement of a typical surgery
• Skins with Dr Sanjay Parmar (GPwSI in Dermatology)
• Consultation skills, telephone, micro groups of 3, half groups with more active PD facilitation and we run a CSA day with actors
• MSK with Dr Vicann During (GPwSI in MSK and sports medicine)
• Other slots have ad hoc developed sessions, but techniques such as case based discussion, interactive flip chart presentation, visits, show and tell remain as key learning tools based on the learning needs of the group

The RCGP curriculum has recently been updated and is now more overarching of General Practice topics. It is taught through  a series of themes, some frequent, some less so. As we plan each term the group are presented with the framework of themes for that term and then suggest clinical topics which will serve to deliver the themes.

B(I) Frequent Themes
Each term the programme will based around a core framework of these activities

1. Group led slots
We also include group led slots. The SDL format works well in encouraging self directed learning and group dynamic as well as case discussion.

2. Case discussion / reflective learning
Explore Dr\patient relationship. seeing patients, and doctors as people, multidimensional assessment, explore attitudes, and doctor emotions. Led using group counselling skills, we are happen to discuss any patient person or issue that has left a mark on the learner widening out to other group experiences as needed. The focus is on emotional insight and reflection on psychological responses.

3. Critical thought
Developing protocols, prescribing analysis, audit, project presentations. Group activities, partly process orientated, but encouraging sharper critical thinking, applied to practical problems. Critical digests of drug company presentations will encourage analytical thinking and give some clinical knowledge base input.

4. Critical reading
Journal club, critical reading techniques. Regular journal review encourages group process, but critical reading is an important skill for GPs. Journal club will be a regular termly fixture, and include skills in critical reading. Following a theme for the morning works well, working from papers through to abstracted principles and guideline development.

5. Consultation skills
Video, role play, telephone techniques. At least half a day of consultation skills will be included in each term. Role play and video have a strong group process feel, as well as being an important way to learn vital skills. Telephone consulting is an increasingly important part of general practice and is well explored by role play. We make use of the Silverman model for skills teaching and video feedback as well as adapting other models. We have developed our own Newham Window consultation analysis tool.

6. Clinical areas Knowledge and Personal development
All of these sections merge into one another but are listed separately to highlight different perspectives and approaches.
6.1 Clinical areas – GP Approach to . e.g. look at GP approach to diabetes, disability, asthma, hypertension, ischaemic heart disease, COPD, hyperlipidaemia, depression, eczema and psoriasis. Each term we take a common condition/group of conditions, and look at how general practice offers a unique approach because of continuity of care and individualisation of diagnosis and management plan. This encourages hospital based trainees to think in more of a generalist way, and encourage them to identify more with general practice ands its strengths. This is done in an interactive way often based around cases with opportunistic knowledge base input.. The sessions is therefore be as much process orientated as clinical.
6.2 clinical areas – knowledge base and attitudes These clinical topics are best done in the group so we can explore attitudes as well as difficult knowledge base. Examples are sexual health, child abuse, drugs, violence, terminal care, mental health act and sectioning and community care, chronic fatigue and other non specific disability. Looking at clinical areas which have controversial flavours, to explore attitudes and ethical sensitivities as well as thinking about how to approach problem areas. Some of these will need a whole afternoon to be dealt with properly.
6.3 Clinical areas needing group resources back pain, eyes, skins, screening in ‘the elderly, learning difficulties, dementia, breast screening, HIV disease, eating disorders. These clinical areas may benefit from being dealt with the help of an outside resource person who would be hard to get for one to one teaching. We listen to the group to help them identify learning agenda. Skins with Sanjay is a regular slot in this category.

7. Group process activities
Course planning, management and evaluation, team building ( including informal welcome for new people in the group and other social events, including a Christmas do, some jointly with the trainers ), informal discussion, trainee presentations.

We use a spread sheet framework to guide the planning process, but above all allow the group to identify their own learning agenda. Using this format we aim to cover all these areas at least once per year.
Different ways of doing GP police surgeon, dispensing, GP obstetrics, research in general practice, occupational medicine, single handed, large practices, collectives etc. There are lots of things GPs do that are worth exploring. Surgeries is only one aspect of our speciality. These sessions may well require external resourcing.. We might spend an afternoon in a local practice with the first half simply looking round at how the practice works, who is in the team, the practice population, and what makes this practice unique, and then spend the second half doing a task orientated activity.. As the day release is based in primary care we can use some of the resources of the host practices.
GP in a wider context of caring agencies, disabled living foundation, alternative practitioners, opticians, dentists, comm. OT, comm. physios, speech therapy, pharmacist, coroner, specialist nurses, pharmaceutical companies. Trainees need to aware of community resources and how to access them. The hospital years will give a good idea of hospital based resources, but external resource people to emphasise the wealth of organisations we work with encourages inter-professional working.
Non clinical skills and interpersonal skills computing, negotiating, assertiveness, dealing with violence and threats of violence, accounting, time management, how to run a business meeting, business management problems. Of course most interpersonal skill will come from working in the group being open to discuss the group needs and stresses within the group.
Newham specific and inner-city issues travel and tropical illness, poverty, culture, high birth rates and a high levels of multiple chronic disease and ethnicity, interesting projects and opportunities in Newham. A course run in Newham must take account of issues that are characteristic to Newham,
Health service framework and its role, CCGs, the coming STPs, primary care networks and deputising, BMA and LMC, Forum, RCGP. Trainees need to know the political landscape and where they fit in to the service framework and have some skills in dealing with it as well as exploring management skills and thinking.
Career planning finding locum work and managing the transition to a post VTS life and surviving partnerships and salaried posts. We will explore the non-clinical side of GP through experiential group work.
Forward planning and strategic management needs assessment of the practice population, emergency planning e.g. what emergencies are likely to arise and what will I need to deal with them?. Being able to look at practice population needs and plan a service to meet those needs will become an increasingly important skill in the future “primary care lead NHS”. W e need to cover areas such as practice development plans, health improvement plans and clinical governance.
Ethics debate and exploration of moral positions to look at underlying principles on which our everyday ethical decisions are based.
Medico-legal, in-house complaints, confidentiality and data protection. The law in terms of battery consent, competence, civil and criminal law need to be looked at.
Understanding peoples lives occupational visits, domestic violence, housing, prison, family relationships, transitions -adolescence, parenthood and post natal psyche, bereavement..
Inter-professional working Joint sessions with UEL postgrad. social workers or CMHTs on issues such as child abuse and mental health to help understanding of different disciplines.
Recognising own needs burnout, educational needs and personal goals, own limits and personality. These could easily be based around group task work. This is partly addressed in case discussion / reflective learning but special topics will need separate slots.
Basic needs. CPR cert, e-portfollio MRCGP  preparation etc The group needs to be fully aware of the basic hurdles they need to pass on their way, and the course may be a way of facilitating these. Some of this is covered in the after school activities and some by house keeping or spare slots, but some may need timetabled slots.

We run a yearly 1 day away day at the start of the academic year to help to build the group and to spend extended time doing more in depth experiential role play work, particularly on less familiar areas such as the practical aspects of being a GP and part of the community team, dealing with conflict, building a business plan for an innovative health care idea, lifestyle medicine, recruitment,  and future planning, primary care finance or team work which require a lot of getting into.

We also run a 2 day summer non-residential for ST3s about to exit the VTS programme, setting the agenda according to their needs. Often this looks at business side of GP, but consultation skills, CV skills, interview skills and finance is also a key theme.