The wind of change: After the European definition—orienting undergraduate medical education towards general practice/family medicine

Abstract

Traditionally, medical students are trained in an algorithmic manner, to focus on excluding serious but rare diseases by conceptualizing diagnoses through a process of exclusion based on systematic and technological investigation of an extensive list of potential diagnoses applicable to the patient's presenting symptoms and signs. Students are not often exposed to common diseases, and trivialize all that which cannot be addressed within a strictly medical model. This paper reflects on the recommendations of the EURACT Educational Agenda document, and proposes a return to empiricism in basic medical training by introducing students to primary healthcare, disease, and decision-making processes early in their training. The authors recommend the teaching of communication skills within primary care doctor–patient encounters, the exploration of new ways of teaching the doctor–patient relationship, and that students and young doctors be encouraged to prioritize quality over quantity. Will this stem the current trends towards increasing workload and burnout?

• Family practice
• education
• medical
• undergraduate
• primary health care
• Europe

Introduction

Family medicine continues to grow as an independent academic discipline [1], even though research, teaching, and training in the domain lags behind other disciplines [2–4], especially in the south and east of Europe from where these authors hail [5]. Traditionally, colleges of family doctors have played the leading role in the academic development of the discipline and its emergence as a defined speciality [6], [7]. Examples of such leadership and seminal development include college-led vocational and specialist training courses [8], facilitating the setup of university departments of family medicine [9], and catalysing the development of international family medicine organizations [10]. However, the influence on undergraduate education seems to have been more difficult and therefore less successful, but has started recently in the United States [11].

At the European level, colleges network and work through the World Organization of Family Doctors (Wonca Europe), much of which work is output through the network organizations that predated and facilitated its birth. These network organizations support the academic growth of the discipline [12–14], and include the European Academy of Teachers of General Practice and Family Medicine (EURACT), traditionally the group that fosters teachers and teaching in family medicine and general practice. EURACT has a history of updating the European definition of general practice and family medicine (referred to as family medicine [FM] in this paper), and was in fact commissioned by Wonca Europe to draft a new definition that was published at the Wonca Europe Congress in London in 2002 [15]. This process revisited previous definitions [16], [17], and its final document is of central importance for FM, defining it as an academic speciality with specific characteristics and competencies. Early on in this project, it was recognized that an innovative approach was required, in that the essential elements of the discipline would first have to be defined and subsequently the role description of the family doctor would be derived. The definition contains 11 characteristics fundamental to the discipline and that are, or should be, generalizable to all healthcare systems regardless of contextual differences. These characteristics are combined into a role description of the family doctor, with six core competencies [15]. This project naturally developed into an Educational Agenda for General Practice and Family Medicine [18] that describes the educational consequences of these six defined core competencies. Thus, six core competencies lead to 25 first-level and 80 second-level educational objectives, and the educational and research implications of this work are profound and far reaching.

However, it seems to the authors that the focus of this transformational change is mainly on vocational training, postgraduate teaching, and postgraduate educational research, and it appears that this initiative would have little impact on the undergraduate teaching of medicine and the preparation of medical students for their role as future family doctors. The authors’ experience is in fact that undergraduate medical education is out of synchrony with accelerating developments in postgraduate teaching and training of FM, and this in turn represents a barrier for academic growth in the discipline of FM. For example, clinical clerkship in FM is today a challenging subject: a recent Medline search using the terms “clinical clerkship” [MAJP] and “Family Medicine” [MESH] returned just 275 publications, and that number fell to just 25 when the search terms included “Europe” [19].

This paper poses the question of whether more could and should be done to orient undergraduate medical training to community and primary care practice, and whether this could and would facilitate the academic development of FM.

Undergraduate education—problems with the current model

The daily practice of FM deals with patients’ symptoms and physical signs at the early stages of common diseases, often with symptom diagnoses that respond to symptomatic treatment, the management of uncertainty and the use of time as a diagnostic tool, and the awareness of changing diagnostic probability. Thus, family doctors become experts in a heuristic approach to managing common symptoms and complaints, applying a specific disease label to legitimate patients’ symptoms only where appropriate or useful [20], [21]. Increasingly, complexity theory is used to model the practise of FM [22], where the interaction of the patient and the doctor involves scientific evidence but also levels of agreement between them, and consensual—emerging—decisions are often made that make a lot of sense in the context of the encounter, but have little support in “evidence-based medicine”. Thus, one should not transplant secondary care decision processes unmodified to the environs of primary care. The corollary is that the two different perspectives should be taught independently during basic medical training.

Traditionally, medical students are taught to think of rare and serious diseases, and must identify all possible differential diagnoses for the patient's presenting complaints, history, and findings, no matter how rare. This approach is linear, and presents the working diagnosis through an algorithmic process of step-wise exclusion from a long list of remote possibilities, through a process of clinical and technological intervention. The rare and serious is prioritized, and the sensitivities and specificities of secondary care tests are too often inappropriate for common community morbidities. In fact, students are often not exposed to common ailments at all. The heuristic approach to diagnosis, based on probabilities changing in response to presenting symptoms, as seen in family medicine and as emphasized by EURACT [18], is not part of the standard undergraduate curriculum, is often trivialized, and is even sometimes viewed as unsound.

Another consequence of the secondary care specialist-centred approach to medical care is to dismiss that which cannot be easily explained by the disease model of care and subjected to medical interventions [23], [24]. However, young doctors working in FM will be faced with symptoms and complaints that do not fit a disease label but still beg legitimization and effective treatment. One cannot dismiss that which is felt by patients and yet does not have a defined medical explanation. Thus, the style of undergraduate education tends to instil in medical students an approach to the practice of medicine that is in conflict with the attitudes and special skills they will need in their future careers as family doctors. The facts are well known, but are the solutions high on the medical political agenda? More often than not, family doctor trainers must help trainees to unlearn the traditional medical model and approach, and learn the new skills and attitudes required. The authors strongly challenge this approach.

Besides being educated in traditional disease-centred models, medical students and young doctors are taught, and expected, to push themselves beyond their physical and mental limits in both education and training. They may feel guilty if they are not working full tilt most of the time. Such negative behavioural patterns are not surprisingly the norm when the same individuals graduate to secondary care and FM, and become directly responsible for dealing effectively with patients’ problems including social, emotional, and psychological problems that are not amenable to quick solutions. Young doctors’ reactions during intensive interactions with patients may be to revert to learned behavioural patterns, and thus result in them pushing themselves harder to counteract feelings of inadequacy. Increasing workload and inadequate coping skills may lead to burnout, and this has been found to be highly prevalent in family medicine [25]. This is another strong argument for including family medicine consultations in undergraduate medical curricula, to facilitate transfer of skills at an early stage in the education of doctors.

Impact on practice

There is general agreement that undergraduate training in FM has a positive impact on the infrastructure of FM, although there is some uncertainty of its impact on practice resources [26]. The inclusion of undergraduate medical education in FM implies necessary changes in medical curricula, and medical schools in the United States have responded to this challenge by developing interdisciplinary curricula that teach common problems in primary care. Such endeavours require expansion of curriculum content and methods, as well as enhancement of collegial support and resources to community-based and academic faculties [27]. Departments of FM have been considered as “uniquely responsible for teaching medical students”, as underlined in a recent report by the Association of Departments of Family Medicine [28].

Proposals

This paper proposes that the principles in the EURACT Educational Agenda document [18] be endorsed in national contexts by colleges, universities, and governments alike. The document should be accepted as a guide for under- and postgraduate medical teaching and education, and thus a reflective process should be initiated with regard to the content and delivery of medical education. Students and young doctors should be encouraged to prioritize quality rather than quantity, if the trends towards increasing workload and burnout are to be reversed. Crucially, we propose a return to empiricism in the training of students, to foster appropriate perspectives in the study of disease, illness, and health in general, in a variety of settings including community-based primary care.

The authors propose that basic medical education should become more FM oriented, unless we want to continue to subject students to the negative experience of unlearning disease-centred linear models before they can fully benefit from vocational training for family medicine. There is often a gap between the aspirations of a holistic and interprofessional approach to care, such as that developed in educational environments, and the reality experienced by students in work placements. FM has a contribution to make to the education of all doctors at all stages in their training: all students should be able to learn primary care management of patients not only through student clerkships in general practice during their later years of medical school, but also by integrating specific training in primary care management, community orientation, specific problem-solving skills, a comprehensive approach to patient-centred care, and a “holistic approach” throughout their training [18].

The patient and the doctor–patient relationship are central to this approach, and family doctors are experts in this field. To this aim, we should empower family doctors within academic medical institutions with chairs and departments of FM in every university in every country [29]. This development is becoming pressing, and it is nothing less than a pity to see how much effort students expend studying that which will often never be the basis of their actual daily practice. We must not forget that years have passed since the promised WHO Framework, and we are still so far away from achieving those desirable goals [30].

Undergraduate and postgraduate medicine need to become more closely aligned, as Jones and Oswald stressed in their discussion paper: “General practice at the centre of the undergraduate curriculum is an ideal area for undergraduate–postgraduate co-operation” [31].

It is time for the wind of change in basic medical education.

Dr Soler has recently been honoured with the award of a Visiting Professorship to the University of Ulster. He is the first Maltese GP to enjoy the title of Professor and is also the first Maltese doctor to have a visiting professorship outside Malta. Our congratulations to Dr Soler.