GP training is both the success story and core activity of the ICGP since its foundation 28 years ago. GP trainees are proud members of College. This is reflected by 68% of trainees being either satisfied or very satisfied with their respective GP training programme.¹ Trainees appreciate the protection of ‘day release’, the structured career pathway and also their future employability in Ireland, especially when compared to hospital-based training colleagues.

Nevertheless, some difficulties with GP training have been identified at successive National Association of GP Trainees (NAGPT) meetings, through the ICGP online discussion forum and also in a survey of GP trainees.¹ Examples of such issues include out-of-hours working by trainees, volunteering at sporting events and accreditation of prior hospital training experiences. It is fair to say most trainees greatly appreciate the efforts of the Postgraduate Training Committee (PGTC) to progress the first two issues. 

Many trainees have accrued significant postgraduate experience, of varying degrees, after internship before commencing their GP training. The failure to accredit prior hospital-based experience is frequently raised as a major cause of dissatisfaction. 

Accreditation of prior training experience

The steady, consistent supply of over 300 GP training SHOs annually has in a large part alleviated the perennial manpower crises affecting Irish hospitals. There are 317 hospital-based GP trainees, 623 GP trainees overall and approximately 4,650 NCHDs in Ireland as of October 2012. This system has benefited both local hospital services and training sites by allowing predictable human resourcing for hospitals and guaranteed SHO placements for GP training schemes. However, many GP trainees wish to work in a specialty or grade they have never worked in before, to attain new skills, experiences and knowledge. For example, a doctor with two years of paediatric experience may not want to work in paediatrics for a further six months, but rather in dermatology or palliative care, if possible. It is also true that some GP trainees may be content to work in a hospital rotation in which they have already gained experience. 

The Criteria for Postgraduate Training Programmes in Irish General Practice 2010 stipulates: “Where a trainee has previous experience in a specialty, alternative rotations may be provided at the discretion of the Steering Committee. For prior experience to be recognised, it should have been undertaken in a post approved by that specialty for training in that specialty or a general practice training programme. This does not allow for the duration of training to be shortened.”² A system is clearly in place to allow trainees to work in an ‘alternative rotation’ but anecdotal evidence suggests this system is not operational. There is a consensus that little has been done to help GP trainees in this regard specifically. It has to be asked whether this system represents a positive training experience for that individual trainee. 

Fast track training

A second issue pertains to the shortening of training, if suitable prior experience is present. A recent study has shown that 76% of trainees felt that GP training should be shortened for applicants who have suitable prior experience.¹ In April 2010, the lead article in Forum celebrated the expansion of GP training from 120 to 157 places a year. The challenge of training satisfactory numbers of GP trainees to meet manpower requirements in the future also raised the issues of ‘fast-track training’ for those with prior hospital experience, and allowing alternative routes to membership for many GPs already working in the community.³ In the interim, ‘MICGP-alternative routes’ has been developed through the PGTC to deal with the latter issue, but what of the former? 

The then director of postgraduate training believed that: “Phase two training needs to come into play. This is a new model of fast-track training which the College has supported for a number of years but for which we have not been able to get financial support from the HSE to date. Phase two training is for doctors who have recently qualified and have completed a number of hospital posts at SHO level…relevant to general practice”.³

To the knowledge of the authors little has been done since to progress this issue.

Comparisons with other countries and colleges

The ICGP fought hard to extend training from three years to four years. Many European countries, including the UK, have endeavoured to follow this example. The RCGP is embarking on ‘extension’ of training. Applicants in the UK who wish to use their earlier training from hospital once they have been accepted for a three-year programme need to apply directly to the GMC for a Certificate of Eligibility for GP Registration (CEGPR); the Deanery may then agree to alter the length of training. The RCGP is as yet unaware of the rules relating to new ST4 training programmes.⁴

The Australian General Practice Training programme is three years in duration and applicants can apply for ‘Recognition of Prior Learning’ for assessment of prior learning/ experience, which may potentially reduce the time it takes to complete training.⁵ In Canada there are 17 family medicine residency training programmes. While they do not accredit prior experience, they are two years in length, with a recent debate calling for training to be extended to three years.⁶ In New Zealand, the RNZCGP GP Education Programme comprises three registrar years, so comparisons cannot be easily made.⁷ As for Irish postgraduate training bodies, most accredit prior experience at basic specialist training (BST) level for their trainees (eg. medicine and paediatrics).⁸

Aims

• The main aims of our study were to:
• Quantify the extent of postgraduate experience among GP trainees before commencing GP training
• Explore their desire for having their prior experience accredited
• Assess the impact on the overall training experience of GP trainees who work in the same specialty or grade again
• Discover if trainees think prior experience should influence the overall length of GP training.

Methods

We performed a quantitative, cross-sectional survey over three weeks in September 2012. We invited all GP trainees in Ireland to participate in a www.surveymonkey.com survey by email, contacted through each of the 14 training schemes. A further reminder was placed on the ICGP discussion forum. Quantitative data was extracted directly from the surveymonkey.com website. Text boxes were available to respondents for certain questions and the qualitative responses were processed by each of the four authors independently and underwent thematic analysis. The demographics of GP trainees were obtained from the ICGP.

Results

There was a 37% response rate (232/623). The demographics of respondents were representative of the overall population of GP trainees in the country. Respondents were equally distributed across the years of GP training: year one – 23%, year two – 23%, year three – 24% and year four – 29%. The male/female ratio of respondents was 30:70 (n = 70:162) compared to the overall population ratio of 27:73 (n = 168:455). All 14 training schemes were well represented.

Previous experience

Some 23% (n=53) of respondents entered GP training directly from internship, while 77% (n=180) accrued experience in other areas before commencing GP training. As regards the amount of experience (in years) of each of the four GP training years, the four years are positively skewed, with some trainees having accrued significant prior experience before commencing GP training. The median length of time from graduation to commencing GP training was three years (median 3.6 years, first quartile two years, third quartile five years).

The 180 (77%) respondents who gained hospital experience prior to commencing GP training were asked to outline this experience in detail. Some 55% of this group (n=96) had completed basic specialist training (BST) in a particular specialty and 44% (n=77) had completed their respective membership examinations in this specialty. Some 8% (n=14) were on a higher specialist training (HST) programme prior to commencing GP training. Table 1 documents their exact experience both by specialty and length of time. 

Accreditation of prior experience

Over 90% (n=158) of the 180 who had accrued experience before commencing GP training wished to have their experience recognised and to work in a different job (either a different specialty, or different grade within a specialty, in which they had already worked). 

Of these 158, only 32% (n=51) asked their respective programme director if their prior training could be accredited, thereby allowing them to work in a different job for this period of time. Only 10% (n=16) were successful and reassigned to another specialty or grade, as they wished. The job durations varied from three to six months. Five of the 16 swapped from SHO to registrar grade in a specialty in which they had already worked and four of the 16 worked in palliative care. Other job swaps included ENT SHO instead of ED SHO, ENT SHO instead of obstetric SHO and swapping into ophthalmology and general practice.

Effect of working in the same hospital specialty again

Some 90% (142/158) of GP trainees wanted, but were unable, to modify their hospital jobs based on their prior experience. When asked whether “working in the same specialty in which one has already accrued experience represents a positive training experience?”, 79% (n=112) answered ‘no’, while 21% (n=29) answered ‘yes’.

When asked: “How do you think your training was affected by being prevented from working in a different specialty or grade?”, 46% (n=65) said ‘negatively’, 6% (n= 9) said ‘very negatively’ and 45% said ‘neutral’ (n= 63), while 1% of respondents said ‘positively’ or ‘very positively’.

Length of GP training

GP trainees were asked: “Do you think GP training should be shortened if significant prior hospital experience was present before starting the scheme?”, some 81% (n=185) answered ‘yes’. However if “significant prior experience” was not present, GP trainees felt differently. In this situation, a majority 61% (n=141) thought GP training should be four years, 1% (n= 1) two years, 28% (n= 66) three years, 8% (n= 19) five years and 2% (n=5) six years.

Discussion

This research has highlighted that Irish GP trainees are both highly experienced before commencing their four-year GP training programme and frustrated that this experience is not recognised by their training scheme.

Some 77% of GP trainees have already gained hospital experience (beyond working for one year as an intern) before starting their GP scheme. Some of this experience is extremely comprehensive. The majority (90%) of those who have prior hospital experience wanted their training accredited and to work in another specialty or grade during their two-year hospital placement. Yet only 10% of this group (7% of the overall group) were successfully reassigned to another specialty or grade. We know that other countries and other training colleges in Ireland manage to both accredit prior experiences and in some cases shorten basic training accordingly. We believe it is time we did the same.

Implications

Accreditation of prior experience

The authors feel the service requirements of local hospitals trump the training needs of individual trainees who have prior experience. The predictable, guaranteed service provision by GP trainees is clearly important for hospitals that have become used to experienced trainees passing through their wards. Manpower clearly matters and GP trainees, having worked for many years in our country’s many hospitals, are very much aware of this. 

There is an inherent irony with experienced GP trainees working in hospital specialties, given the fact that these same specialties accredit prior training for their own trainees through their respective colleges. In effect, GP training in Ireland is helping other colleges and specialties permit retrospective accreditation of prior posts for their own basic specialist trainees, at the expense of our GP trainees. 

What about the 7% (n=16) of overall trainees who were fortunate to be allowed to work in other areas by their steering committees? Though a small number, it is fair to make three comments. Firstly, the majority of these job swaps were serendipitous in nature, eg. when a trainee either returned from maternity leave to a filled SHO position and had to swap jobs, or because of an unexpected NCHD shortfall in another specialty. Secondly, these trainees did not represent those with the ‘most experience’, ie. the extent of training did not lead to the decision to swap jobs. Thirdly, these job swaps were reactive, the move being led entirely by the GP trainee, and were not planned on the basis of that trainee’s specific training needs.

Respondents offered potential solutions through their qualitative responses. A concerted effort by steering committees to focus on individual trainee needs, to progressively foresee future job allocations many months in advance and to be flexible in weighing up both training and service requirements are admirable, achievable suggestions. Certainly this would help some trainees, yet it is unlikely this can deal with this issue comprehensively. It is clear that trainees lack confidence that anything can be done, as only 32% of trainees asked their programme director if a job swap was possible. Detailed individual training-needs-assessments before commencing GP training may help.

Shortening the duration of training 

In our study, 81% of GP trainees think that GP training should be shortened if ‘significant’ prior hospital experience is attained before starting GP training, comparable with other research.¹ Again it must be stated that the majority of respondents also think that training should be four years if no prior experience is present. 

For those with extensive prior experience, is there a role for devolving the allocation of hospital posts completely from local training sites and allocating hospital-based jobs centrally instead? There is no consensus on this issue, but all options should be explored. We need to learn from other colleges in Ireland and must look to training structures in other countries. Most of all, we need to listen to our trainees who want action on this issue.

Limitations

There was a 37% response rate to this survey. However, respondents were well matched to the overall population. Another limitation may relate to the phrasing of questions pertaining to implications for training and the results of this question must be interpreted accordingly. 

Learning opportunities

Many aspects of current GP training are functional and should not change. We acknowledge that a complex problem exists, with no easy solution. Yet the solution should emerge if we focus on what is best for current trainees and patients. Does repetition of prior experience constitute a lost learning opportunity? Should training always be four years duration? There are failings in the current system and learning experiences are not as useful as they could be. The related, but separate issues of accrediting prior training to allow work in other hospital specialties, and the possibility of shortening training, need to be addressed, from a governance, training and quality of care perspective. 

Acknowledgements: The authors would like to thank the ICGP, RCGP, RNZGP, RACGP and CFCP for their help in accessing information. The authors would also like to thank all respondents and the Sligo Specialist Training Programme in General Practice for their support. The results of this research will be provided to the PGTC

References

1. O’Kelly et al. A national survey of GP trainees 2012. November 2012. ICGP.
2. Criteria for postgraduate training programmes in Irish general practice 2010, Chapter 4.4, IGGP Publications, page 12
3. GP training- at last a ‘good news story’. Forum. April 2012.
4. www.rcgp.org.uk/policy/rcgp-policy-areas/enhanced-and-extended-speciality-training-in-general-practice.aspx (last accessed 16th November 2012)
5. www.agpt.com.au/AGPTtheProgram/AGPTFlowchart/ (last accessed 16th November 2012)
6. www.dfcm.utoronto.ca/prospectivelearners/prosres.htm (last accessed 16th November 2012)
7. www.nzrda.org.nz/wp-content/uploads/2011/07/The-Future-Direction-for-Training-in-General-Practice-in-NZ-final.pdf (last accessed 16th November 2012)
8. www.rcpi.ie/EducationAndTraining/Pages/GeneralProfesionalTraining.aspx (last accessed 16th November 2012)