Abstract
The approach to generalism is daunting for all trainees. How exactly do you start to gain confidence working in a discipline of such breadth? In a classical legend, Alexander the Great is faced with the challenge of the ‘Gordian knot’, which is seemingly impossible to untie because the ends are not visible: … most writers say that since the fastenings had their ends concealed, and were intertwined many times in crooked coils, Alexander was at a loss how to proceed, and finally loosened the knot by cutting it through with his sword, and that when it was thus smitten many ends were to be seen (Plutarch tr. Perrin, 1989)
Performing a formal learning needs assessment is a useful task when trying to work out how to approach the breadth of knowledge required for general practice. It does not, however, help with working out what areas you should prioritise in order to rapidly become proficient at working within your specific practice area.
During my first 6-month placement in general practice as a Specialty Trainee 1 (ST1), I recorded the themes of all the problems that occurred in my consultations. With this, I hoped that I would be able to ascertain the topics that I needed to concentrate on mastering, and better understand the needs of my practice population. An advantage of modern medicine is that we have technology constantly at our fingertips, with immediate access to information within the consultation. This is of particular importance when managing rare conditions, where even experienced practitioners would have to refer to written information. Over-reliance on technology, however, risks disruption of the doctor–patient relationship. With the additional constraints of short consultation times, it is critical that trainees are able to manage common conditions rapidly and proficiently.
Contacts by subject area.
Top-10 presentations.
What did I learn from this?
Watching the data emerge over 6 months allowed me to build a better idea of the common problems that I encountered. It permitted me to target learning and to ensure that I was prepared to efficiently manage the most common presentations. I also performed a separate learning needs assessment to highlight areas where I lacked confidence in my ability to appropriately manage conditions. Correlating these results with the consultation data, I was able to focus my personal development accordingly. I identified areas that were both commonly encountered in day-to-day practice and flagged as areas for development in the needs assessment. Thus, I particularly focused on the rapid assessment of the unwell child, mental state examination with provision of self-management resources for depression and anxiety, and explanation and advice for acute lower back pain without red flags. I addressed these learning needs by looking at local referral pathways and resources, seeking out the British Medical Journal clinical reviews and ‘10-minute consultation’ articles, and looking for relevant articles in back-issues of Innovait. Although genitourinary medicine was the second most common subject area that I encountered in practice, I rated my confidence in managing these problems highly, and therefore elected not to focus on this as an area for development.
It has been shown that registrars see a different mix of patients to established GPs, with greater emphasis on acute versus chronic problems (Eccles, Bamford, Steen, and Russell, 1994). De Jong et al. (2011) concluded that their data was valuable in highlighting clinical areas to which trainees have less exposure. Therefore, another use for the data was as a point of discussion with my educational supervisor, to help ensure that my case-mix was appropriate to my learning needs.
After 2 years of rotating through hospital specialities, returning to work in primary care as an ST3 is once again a daunting challenge. Looking back at the themes from my ST1 consultations has allowed me to quickly refresh my management of the most common presentations, helping me to feel more prepared.
How could it help you?
Have you considered a similar survey, perhaps over a shorter time frame? Populations served by practices vary, so although useful trends can be identified looking at the results I present here and the work of De Jong et al. (2011), data collected from a survey of your own consultations will be more relevant to your personal learning. You could also discuss the results with your clinical supervisor to ensure that you are seeing an appropriate mix of cases. Could you use your results as a point of discussion at a group study session on community orientation and diversity?
You could consider correlating your results with those of learning needs assessment tools (such as the ‘Personal Education Planning’ programme offered by the RCGP) to provide a personal learning plan for your first months in general practice: any area which occurs commonly and is an area flagged by the needs assessment should be a focus for further study. Analysing your results will not only allow you to discover areas of practice where you lack confidence, but will also target your learning to the needs of your practice population. It would be useful to repeat this if you change practice to highlight potential differences.
Footnotes
Acknowledgement
Thank you to Alex Imrie, PhD Student in Classics at the University of Edinburgh for noticing the parallel between my clinical dilemma and the story of Alexander’s approach to the Gordian knot and hence suggesting the title of this article.