Improvements in primary care skills and knowledge with a vocational training program: a medical student's perspective.

Dear editor

We read with great interest, the article by Djalali et al evaluating the impact of a training program during residency, targeted toward primary care.1 This resonated with us from a medical student’s perspective as we are fortunate enough to have a similar program at medical school. Although the article states that future career choices are more likely to be determined during residency, we believe that this can be nurtured earlier through knowledge and early exposure.

Within the UK, we too face the same challenges associated with primary care. In 2015, along with core psychiatry, general practice had the lowest number of applications per training post than any other speciality.2 Additionally, in 2016, a review by the King’s Fund showed that the majority of current trainees do not intend to continue full-time work after completing 5 years post-certification.3 We agree that increasing exposure to primary care is imperative, and we have explored some of the possible ways to do so.

The Integrated Clinical Apprenticeship (ICA) was piloted at Imperial College London last year. Its aims were to incorporate continuity of care and patient-centered care as core learning objectives, using primary care practices as the base. Year 5 students are assigned to specific general practices and patients. Every Thursday, students clerk and examine different presenting complaints, emulating the GP’s role. There are further opportunities to explore patient cases and receive feedback regarding their own performance. Overall, students have stated that they have gained confidence with their interpersonal skills, which supports the findings in the article.

The article postulates that a career in primary care correlates with prior exposure to this field. Currently, within the UK, the majority of graduates will undergo a 4-month GP placement during their foundation years. However, there has been no improvement in the number of applications. The North West of England Foundation School has recently begun a trial program called Longitudinal Integrated Foundation Training, not dissimilar to the ICA in terms of its structure and aims.4 Trainees attend a general practice for 1 week every month throughout their training, which improves their GP exposure.

Perhaps there is also scope for further change within the curriculum, notably in GP attitudes toward student teaching. GP placement feedback is purportedly linked with the enthusiasm and motivation for teaching given by the GP; a GP who solely consults the patient and does not involve the student will inevitably create a negative learning environment. The range of GP experiences is vast, with large geographical variations. Furthermore, the practical skills assimilated during GP placements are highly divergent: some students have the opportunity to shadow a variety of clinics and partake in practical procedures, including minor surgery, compared to a single clinic opportunity for other students. This is unarguably going to influence student satisfaction and will render decreased student interest in primary care. The implementation of GP standardization throughout UK medical schools along with longitudinal programs will allow for greater awareness and enthusiasm for primary care medicine.

Dear editor

We appreciate Ghosh et al’s feedback and agree with them.

Time spent in primary care during residency (average period of time/timing at the beginning or toward the end of education) is an easy-to-measure and easy-to-compare variable. That is why many studies rely on this variable.1–4

In contrast, content quality of training programs − including GP attitude toward student teaching − is much more difficult to define and to measure, though it might be the key to evoke awareness and enthusiasm for primary care medicine.

The implementation of GP standardization throughout medical schools (not only in the UK) along with longitudinal programs would make it a lot easier to develop quality indicators allowing to measure and compare content quality of training programs.

Unfortunately, in Switzerland, we have not reached this point yet. The evaluation of our vocational training program in Zurich was only a first step.