Every year, hundreds of GPs and medical undergraduates encounter each other during undergraduate attachments in general practice, arranged through GP university departments. One of the main benefits for students learning in general practices is that it provides good first-hand exposure to the one true generalist specialty. Prior to GP rotations, students have almost exclusively been attached to specialist teams in large acute hospitals.

GP rotations provide an opportunity for students to see a large number of common presentations that do not reach the hospital setting. Medical students can become focused on the 40-minute history and examination featuring in final exams, but in real practice, such time is rarely available. General practice, in that sense, is a necessary reality check.

The length of time spent in general practices during undergraduate education varies from one medical school to another. At a recent workshop on this topic at the College winter meeting, there was considerable debate among students, tutors and GPs over the optimal length of a rotation in general practice. Opinions on this varied, with some feeling two weeks in one practice was perhaps too short, whereas 18 weeks in one practice could be too long, for both students and GPs alike. 

General practice rotations help students become more efficient at recognising relevant areas of history and examination, deciding on the key investigations, formulating credible differential diagnoses, and making appropriate patient management plans, all within a tight timeframe. Students gain first-hand insights into key issues such as unequal access to healthcare, and difficulties in the flow of information between GP and hospital services. These are problems that students will not only encounter once they graduate, but for which they will also have a responsibility to advocate as future clinicians.

GP rotations remain the only rotation where students have exclusive one-to-one teaching with a senior physician. The focus of the recent workshop was on identifying how to make student rotations in GP practices more effective and enjoyable for both GPs and students. Some key points emerged during the discussion.

What makes for a good attachment?

The most significant take-home message under this heading was that constructive engagement from both students and GPs alike is an essential ingredient for a good attachment.

A well organised, structured placement should form the foundation of a student’s GP experience, ensuring they get the most out of a (usually) brief secondment in general practice. 

One-to-one learning with a GP tutor is ideal for both students and GPs. Having one student assigned to a practice at a time is less taxing on practice resources and the doctor’s time, and allows for the focus to be solely on that student, to optimise their experience in general practice. 

It helps if the rotation can be tailored to suit the student’s learning goals. Students come to practices with varying skill-sets and knowledge bases, so a brief assessment of students’ abilities at the outset is a really useful starting point. 

Variety and structure are important factors when organising an attachment. Arranging the week into blocks such as, for example, mornings sitting in on consultations, afternoons with the practice nurse, a few hours with the receptionist, gives a more complete impression and experience of general practice. 

It is important that students have access to a room in the practice and this should be a requirement for practices prior to accepting students. In this way, students can practise clinical skills, conduct consultations and carry out other learning activities. 

Focusing on both task-based and reflective learning delivers greatest benefit for students, allowing development and fine-tuning of clinical skills, along with broadening medical knowledge. Admittedly, space constraints in practices and inadequate resourcing of rotations makes this difficult to deliver on. The University of Limerick (UL) process (an 18-week attachment, with good resourcing and real participation of the student in team activities) was felt to be particularly positive in this regard. Students and GPs both agreed that the longer the placement, the more valuable the learning experience is for the student. The initial period involves settling in and climbing a steep learning curve, but as time passes, the student becomes an effective staff member.

Not all students, of course, will go on to train as GPs, so the undergraduate placement with a GP is the only time many prospective doctors will experience general practice. In view of this, and in terms of giving students a good insight into general practice, adopting a ‘warts and all’ philosophy to their learning is important. 

It is unnecessary and perhaps unhelpful to try to idealise GP life, and if difficult situations arise, practices should not be shy about exposing the student to them! If the student placement is in a GP training practice, regular interaction with the GP registrar can be very helpful, in both a general learning sense and in terms of getting an insight into the challenges of everyday practice experience.

Creating a good experience in general practice

At the workshop, both GPs and students identified lack of engagement as a factor making for less than satisfactory attachments. For the GP, this can mean little effort by the student to engage in answering questions, engaging minimally with patients, and poor attendance. For the student, it can mean absence of a schedule or teaching programme, no time devoted to questions following consultations, and not providing opportunities to practise skills, such as taking bloods, giving the occasional IM injection, or assisting with procedures. 

It helps if the practice is well-organised for student attachments – providing an extra chair in the consultation room, to give a simple example. It is also beneficial for staff to be receptive to having students in the practice. The absence of a room for student consultations can make for a less fruitful attachment as students miss out on opportunities to practice interpersonal and consultation skills. 

Difficulties around medical school exam times can provide challenges for student attachments; co-ordination between the GP and college regarding timetabling may be able to help here. Heavy practice workloads can provide challenges for student attachments. It is important to co-ordinate to cover for GP holidays, so that someone is responsible for the student during that time.

Issues around gender can also make for a less than satisfactory attachment. For example, male students missing out on learning opportunities during consultations with female patients was an issue raised at the workshop. GPs have addressed this in some practices by introducing the student as a colleague in training, or ‘student doctor’, asking if the student can observe for their learning. Ignoring cultural differences and the needs of non-national students can also make for less than satisfactory attachment. It is helpful for the colleges to provide appropriate supports to GPs, particularly when students have specific needs to be addressed, be they cultural, mental health, or otherwise. 

Students’ own costs can also be an issue, as the substantial costs of accommodation and transport, and the accompanying stresses, can be a barrier to access, dampen enthusiasm, and interfere with engagement during the attachment. 

In conclusion, medical student attachments with enthusiastic GPs are a greatly valued, if a somewhat challenging part of undergraduate medical education. The exposure of medical students to general practice has increased considerably during the past decade. There clearly are pitfalls and obstacles, but it is hoped the points emerging from the workshop discussion may be useful in informing and assisting students and GPs.

If they are well organised, student attachments provide unique and crucial educational insights into holistic and personalised medical care, and they can energise and challenge GPs who are good enough to allow their practices assist in this key part of the undergraduate curriculum. 

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