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GP Training Report

The Report of the Training and Education in Dermatology for
General Practice Task Force

Authors:

Dr Susan Burge, Royal College of Physicians
Dr Sean Coughlin, UK Conference of Regional Advisers and Committee of General Practice Education Directors
Mr Peter Lapsley, The Skin Care Campaign
Dr David McKinlay, UK Conference of Regional Advisers and Committee of General Practice Education Directors
Dr Tim Mitchell, Primary Care Dermatology Society
Dr Margaret Price, British Association of Dermatologists

Dermatology Training for General Practitioners

*These recommendations were made by a task force of representatives from the UK Conference of Regional Advisors and the Committee of General Practice Education Directors (CoGPED), the Primary Care Dermatology Society, the Royal College of Physicians, the British Association of Dermatologists, nursing and patient representatives. They follow the publication of a core curriculum booklet on dermatology training for GP SHO's and registrars, produced by the Royal College of General Practitioners, the Royal College of Physicians and British Association of Dermatologists1 , they also take account of the All Party Parliamentary Group enquiry into the training of healthcare professionals who come into contact with skin diseases2.

This activity is taking place because:

• Consultations for skin disease in general practice have risen and up to 15% of GP consultations now relate to problems with the skin.
• The dermatology training of most General Practitioners has been inadequate and, therefore, some referrals to secondary care are inappropriate.
• There is a shortage of dermatologists.

A core curriculum ought to be the basis for current general practitioner training, but as many general practitioners have not had sufficient dermatology training, it must extend beyond the traditional training grades. *Provision will also have to be made for the many General Practitioners who wish to develop a special interest in dermatology.

* Several groups exist that require training:

• Undergraduates
• GP trainees (hospital and practice training)
• Higher professional trainees in General Practice
• Doctors seeking continuing medical education GP trainers
• Primary healthcare teams including nurses with a special interest in dermatology
• General Practitioners with a special interest in dermatology

Undergraduates

Undergraduate training is outside the remit of this group, but medical students should be exposed to dermatology so that they will understand common dermatological problems. A two week full time attachment to a dermatology unit, with a realistic assessment at the end of the course, is the minimum requirement. Dermatology should also be taught when undergraduates are working with general practitioners in the community. In addition, undergraduates are increasingly involved in Problem Based Learning: chronic skin problems, rich in physical, psychological and social issues are highly suitable for this.

General practitioner trainees

* Special emphasis should be given to the introduction of dermatology into the hospital component of training. Several methods of providing experience can be considered:

• Incorporating SHO posts in dermatology into vocational training schemes.
• Reconstituting SHO posts by bringing dermatology experience into existing medical SHO posts.
• Creating innovative hospital posts based on need e.g. composite dermatology/ophthalmology posts.
• Releasing GP SHOs from their normal hospital duties to attend dermatology clinics.

A six month post in dermatology alone or in a combined post (such as dermatology/general medicine or a combined minor specialty rotation) will help General Practitioners to take a special interest in dermatology.

There are, of course competing demands from other specialties during the two years of hospital training. There is nevertheless a need to be more imaginative here as the NHS is changing and traditional training may no longer be relevant. For instance the traditional six months experience in obstetrics and gynaecology could probably be reduced as obstetrics is becoming a midwife-led service and most General Practitioners are no longer involved routinely in intrapartum care.

Currently, about 75 doctors per year submit experience of dermatology as part of their application for a certificate of prescribed or equivalent experience from the Joint Committee on Postgraduate Training for General Practice. This is about 5% of the yearly output of GP registrars. It is not clear how many dermatology SHO posts are available or the number of posts combined with other branches of medicine. It is probable that the number of SHO posts in dermatology is inadequate to train all entrants into general practice even if they were all incorporated into vocational training schemes, which is unlikely as many are taken up by doctors prior to specialist registrar posts in dermatology.

Protected time for doctors to attend dermatology clinics while they are working in other specialties remains the most likely way of providing dermatology experience for the majority of doctors training for general practice. Study leave could be used to supplement this. Release to clinics during the general practice component of training will inevitably be difficult as it still takes only 12 months for most registrars and there are the added pressures of Summative Assessment, the MRCGP examination, and seeking a career post. It will be helpful however if trainees have some experience of general practice before attending dermatology clinics so that they can appreciate the purpose of this training and place dermatological problems in the context of general practice. The introductory period in practice employed by most schemes should provide this.

Arrangements for an adequate provision of dermatology training should be organised at local level, between VTS scheme organisers, consultants and the hospital personnel departments. The wider and more imaginative the training the more they will attract recruits. In this context combined minor specialty posts will be particularly relevant.

It is difficult to determine how many dermatology clinics will provide adequate experience for doctors on a training scheme for general practice. The minimum requirement would seem to be twelve clinics and more if minor surgical training is to be included. However attendance at clinics by itself does not suffice. An overall package of dermatology training and assessment should ideally include experience in general practice. This will involve co-operation at a local level between dermatologists, scheme organisers and trainers. Planned teaching, on a one to one basis or in small group seminars, should supplement the practical experience. Teaching sessions can be programmed as a hospital teaching activity or form part of the half-day / day release programmes which all doctors training for general practice have. Competence in dermatology should be required for the issue of vocational training regulation form 2 (VTR2) certificates and a satisfactory trainer's report.

If adequate dermatology training has not been provided in hospital the onus will fall on the GP trainer using the core curriculum as a guide. This is assuming of course that the trainer is competent to provide this and raises questions about the training needs of GP trainers.

It is important that adequate training is provided in minor surgery of which skin surgery is a big part. In North West England the Royal College of General Practitioners organises a two day course with "hands on" experience using dummy tissues, supplemented by practical experience under supervision in the training practices. This course could serve as a model for other regions. Skills can be further enhanced by the RCGP minor surgery CD-ROM ( Minor Surgery and Skin Lesions, Diagnosis and Management on CD-ROM, by Roger Kneebone and Julia Schofield). It might also be useful to link GP minor surgery training with that received by dermatology specialist registrars.

Higher professional development in general practice

It was never intended by educationalists that training for general practice would take only three years. The Royal Commission on Medical Education (Todd Report 1967) recommended 5 years, as is the case with most other specialties. However attempts to introduce the extra training have been inconsistent as the twelve months in general practice is limited by statute unless summative assessment (an end-point test of minimal competence) is failed. Recently, there has been a renewal of interest, with some more robust schemes addressing the needs of young principals which centre around personal and professional development and the organisation and management of general practice. This could also be a time to tackle some of the important clinical topics long neglected in medical training. Dermatology is prominent amongst these.

A training module designed in North West England is described below. This could act as a model for other schemes, but there are also other ways of delivering dermatology training at this level.

The course on dermatology in clinical practice

This course is organised by the North West England Faculty of the Royal College of General Practitioners, in association with the University of Central Lancashire. Advice and co-operation was also provided by the region's academic department of dermatology and most of the teachers on the course are local dermatology consultants. The teaching consists of two blocks, each of two days, and attendance at a minimum of 3 out patient clinics. More practical experience may be needed to complete the course assignments. The course also requires self directed learning and will focus on cases within the student's own practice as well as dealing with the evidence base and ethical principles that underpin management.

The course will cover important core topics in depth. Participants will learn to describe dermatoses and to recognise anything unusual. Teaching will concentrate on Eczema, infections, acne, psoriasis, urticaria and skin tumours because these constitute most GP skin consultations. The role of the practice nurse will also be covered in depth. This is a foundation course and only provides what should have been provided earlier in training, GP registrars and established principles could also benefit from it.

The course is university accredited, and, can be combined with other modules towards a higher degree. It is also an integral part of the North West Higher Professional Development Programme for young principals. The assignments consist of a portfolio of long and short case studies and reflective learning statements.

*Continuing Medical Education for General Practitioners

For the reasons stated many established General Practitioners still have much to learn about dermatology. The traditional CME lecture is no longer adequate. For many doctors the whole core curriculum has to be covered. Courses like the one described above could meet these needs. Short clinical attachments to dermatology units, with attendance at teaching clinics would also help. The recently published Core Curriculum in Dermatology for vocational trainees in general practice1 defines learning needs for all levels of dermatology in primary care and should inform both the personal learning plans and practice development plans outlined in the Calman Review of Continuing Professional Development in General Practice 4.

Many general practitioners are already competent in basic dermatology and want to take this interest further through more advanced courses. Dermatologists and GP academic networks should work together to produce programs that will cater for them. A good example already exists in the Diploma in Practical Dermatology organised by the University of Wales College of Medicine. Academic training should complement clinical experience; and the wealth of clinical experience within general practice can be greatly enhanced by a local dermatologist acting as a mentor or just exchanging ideas.

GP trainers

The All Party Parliamentary group recognises the importance of the GP trainer when it states that GP registrars should be provided with a copy of the core curriculum and be expected to implement it in discussion with their trainer. However, competence in dermatology training will vary. Questions relating to this should be included at trainer appointment interviews and at practice reinspection visits. Where necessary trainers should seek further training of a type that is recognised as appropriate. Trainers with special expertise could support the development of teaching programmes in trainers workshops.

Primary Healthcare Teams

The Chief Medical Officer's report on Continuing Professional Development4 places an emphasis on practice based and multidisciplinary learning to meet local needs. Within dermatology this must mean using nursing expertise to improve the care of patients. Nurses also have a role in health education and health promotion, areas which are often inadequately dealt with by doctors. Most teams run asthma management clinics often overlapping with the care of eczema and allergy. Similar programmes could be developed for other chronic skin diseases. (e.g. leg ulcers and psoriasis). Teams can learn through audit and protocol development. They can also learn from periodic visits by experts e.g. dermatology nurse practitioners and consultants. In particular the role of the dermatology liaison nurse is likely to expand.

Doctors with a Special interest in dermatology Many general practitioners with a special interest in dermatology may wish to develop this role within a large practice or primary care group. With an appropriate higher qualification, and a formal link with the local dermatology department to ensure CME this role could be extended but would not take the place of the full diagnostic service provided by a specialist department. It would cover specific procedures (e.g. cryotherapy) and areas of management, for example, the treatment of patients with chronic inflammatory skin disease such as psoriasis or eczema. Such General Practitioners would help in the training of GP registrars.

Key Documents

1. Dermatology for General Practice Trainees The Royal College of General Practitioners and The British Association of Dermatologists and The Royal College of Physicians 1998
2. Enquiry into the Training of Healthcare Professionals Who Come Into Contact With Skin Diseases A Report of the All Party Parliamentary Group on Skin: July 1998
3. Hospital Doctors: Training for the Future: A Supplementary Report by the Working Group Commissioned to Consider the Implications for General Medical Practice Arising from the Principal Report The Report of the Working Group on Specialist Medical Training March 1995
4. A Review of Continuing Professional Development in General Practice A Report by the Chief Medical Officer 1998
5. An Investigation into the Adequacy of Service Provision and Treatments for Patients with Skin Diseases in the UK  A Report on the All Party Parliamentary Group on Skin: March 1997
6. The Quality of Hospital-Based Education for General Practice The Royal College of General Practitioners 1997
7. Recommendations on the Selection and Re-Selection of Hospital Posts for General Practice Training The Joint Committee on Postgraduate Training for General Practice 1998
8. Recommendations on the Selection and Re-Selection of General Practice Trainers The Joint Committee on Postgraduate Training for General Practice 1998
9. The Diploma in Practical Dermatology Department of Dermatology, University of Wales College of Medicine