General practitioner

In the medical profession, a general practitioner (GP) is a medical doctor who treats acute and chronic illnesses and provides preventive care and health education to patients.

A general practitioner manages types of illness that present in an undifferentiated way at an early stage of development, which may require urgent intervention.^[1] The holistic approach of general practice aims to take into consideration the biological, psychological and social factors relevant to the care of each patient's illness. Their duties are not confined to specific organs of the body, and they have particular skills in treating people with multiple health issues. They are trained to treat patients of any age and sex to levels of complexity that vary between countries.

The role of a GP can vary greatly between (or even within) countries. In urban areas of developed countries their roles tend to be narrower and focused on the care of chronic health problems; the treatment of acute non-life-threatening diseases; the early detection and referral to specialized care of patients with serious diseases; and preventative care including health education and immunization. Meanwhile, in rural areas of developed countries or in developing countries a GP may be routinely involved in pre-hospital emergency care, the delivery of babies, community hospital care and performing low-complexity surgical procedures.^[2][3][4] In some healthcare systems GPs work in primary care centers where they play a central role in the healthcare team, while in other models of care GPs can work as single-handed practitioners.

The term general practitioner or GP is common in the Republic of Ireland, the United Kingdom and several Commonwealth countries. In these countries the word physician is largely reserved for certain other types of medical specialists, notably in internal medicine. While in these countries, the term GP has a clearly defined meaning, in North America the term has become somewhat ambiguous, and is not necessarily synonymous with the term "family doctor" or primary care provider, as described below.

Edward Jenner

Historically, the role of a GP was once performed by any doctor qualified in a medical school working in the community. However, since the 1950s general practice has become a specialty in its own right, with specific training requirements tailored to each country.^[5][6][7] The Alma Ata Declaration in 1978 set the intellectual foundation of what primary care and general practice is nowadays.

Asia

India and Bangladesh

The basic medical degrees in India and Bangladesh are MBBS (Bachelor of Medicine, Bachelor of Surgery), BAMS (Bachelor of Ayurveda, Medicine and Surgery), BHMS (Bachelor of Homoeopathic Medicine and Surgery) and BUMS (Bachelor of Unani Medicine and Surgery). These generally consist of a four-and-a-half-year course followed by a year of compulsory rotatory internship in India. In Bangladesh it is five years course followed by a year of compulsory rotatory internship. The internship requires the candidate to work in all departments for a stipulated period of time, to undergo hands-on training in treating patients.

The registration of doctors is usually managed by state medical councils. A permanent registration as a Registered Medical Practitioner is granted only after satisfactory completion of the compulsory internship.

The Federation of Family Physicians' Associations of India (FFPAI) is an organization which has a connection with more than 8000 general practitioners through having affiliated membership.^[8]

Pakistan

In Pakistan, 5 years of MBBS is followed by one year of internship in different specialties. Pakistan Medical and Dental Council (PMDC) then confers permanent registration, after which the candidate may choose to practice as a GP or opt for specialty training.

The first Family Medicine Training programme was approved by the College of Physicians and Surgeons of Pakistan (CPSP) in 1992 and initiated in 1993 by the Family Medicine Division of the Department of Community Health Sciences, Aga Khan University, Pakistan.^[9]

Family Medicine residency training programme of Ziauddin University is approved for Fellowship in Family Medicine.^[10]

Europe

France

In France, the médecin généraliste (commonly called docteur) is responsible for the long term care in a population. This implies prevention, education, care of the diseases and traumas that do not require a specialist, and orientation towards a specialist when necessary. They also follow the severe diseases day-to-day (between the acute crises that require the intervention of a specialist).

They have a role in the survey of epidemics, a legal role (constatation of traumas that can bring compensation, certificates for the practice of a sport, death certificate, certificate for hospitalisation without consent in case of mental incapacity), and a role in the emergency care (they can be called by the samu, the French EMS). They often go to a patient's home when the patient cannot come to the consulting room (especially in case of children or old people), and have to contribute to a night and week-end duty (although this was contested in a strike in 2002).

The studies consist of six years in the university (common to all medical specialties), and three years as a junior practitioner (interne) :

• the first year (PACES, première année commune aux études de santé, often abbreviated to P1 by students) is common with the dentists, pharmacists and midwifery. The rank at the final competitive examination^[11] determines in which branch the student can choose to study.
• the following two years, called propédeutique, are dedicated to the fundamental sciences: anatomy, human physiology, biochemistry, bacteriology, statistics...
• the three following years are called externat and are dedicated to the study of clinical medicine; they end with a classifying examination, the rank determines in which specialty (general medicine is one of them) the student can make his internat;
• the internat is three years -or more depending on the specialty- of initial professional experience under the responsibility of a senior; the interne can prescribe, he can replace physicians,^[12] and usually works in a hospital.

This ends with a doctorate, a research work which usually consist of a statistical study of cases to propose a care strategy for a specific affliction (in an epidemiological, diagnostic, or therapeutic point of view).

Netherlands and Belgium

General practice in the Netherlands and Belgium is considered advanced. The huisarts (literally: "home doctor") administers first line, primary care 24 hours a day, 7 days a week. In the Netherlands, patients cannot consult a hospital specialist without a required referral. Most GPs work in private practice although more medical centers with employed GPs are seen. Many GPs have a specialist interest, e.g. in palliative care.

In Belgium, one year of lectures and two years of residency are required. In the Netherlands, training consists of three years (full-time) of specialization after completion of internships of 3 years.^[13] First and third year of training takes place at a GP practice. The second year of training consists of six months training at an emergency room, or internal medicine, paediatrics or gynaecology, or a combination of a general or academic hospital, three months of training at a psychiatric hospital or outpatient clinic and three months at a nursing home (verpleeghuis) or clinical geriatrics ward/policlinic. During all three years, residents get one day of training at university while working in practice the other days. The first year, a lot of emphasis is placed on communications skills with video training. Furthermore, all aspects of working as a GP gets addressed including working with the medical standards from the Dutch GP association NHG (Nederlands Huisartsen Genootschap).^[14] All residents must also take the national GP knowledge test (Landelijke Huisartsgeneeskundige Kennistoets (LHK-toets)) twice a year.^[15] In this test of 120 multiple choice questions, medical, ethical, scientific and legal matters of GP work are addressed.^[15][16]

Spain

Francisco Vallés (Divino Vallés)

In Spain GPs are officially especialistas en medicina familiar y comunitaria but are commonly called "médico de cabecera" or "médico de familia."^[17]

Most Spanish GPs work for the state funded health authority through the regional government (comunidad autónoma). They are in most cases salary-based healthcare workers.

For the provision of primary care, Spain is currently divided geographically in basic health care areas (áreas básicas de salud), each one containing a primary health care team (Equipo de atención primaria). Each team is multidisciplinary and typically includes GPs, community pediatricians, nurses, physiotherapists and social workers, together with ancillary staff. In urban areas all the services are concentrated in a single large building (Centro de salud) while in rural areas the main center is supported by smaller branches (consultorios), typically single-handled.^[18]

Becoming a GP in Spain involves studying medicine for 6 years, passing a competitive national exam called MIR (Medico Interno Residente) and undergoing a 4 years training program. The training program includes core specialties as general medicine and general practice (around 12 months each), pediatrics, gynecology, orthopedics and psychiatry. Shorter and optional placements in ENT, ophthalmology, ED, infectious diseases, rheumathology or others add up to the 4 years curriculum. The assessment is work based and involves completing a logbook that ensures all the expected skills, abilities and aptitudes have been acquired by the end of the training period.^[19][20]

United Kingdom

In the United Kingdom, physicians wishing to become GPs take at least 5 years training after medical school, which is usually an undergraduate course of five to six years (or a graduate course of four to six years) leading to the degrees of Bachelor of Medicine and Bachelor of Surgery (MB,ChB/BS).

According to Julian Tudor Hart, before the mid-1960s poor conditions and low expectations existed as GPs were taught entirely by specialists in hospitals; back then GPs were men who had failed to become specialists and were unable to work in a hospital.^[21] Or as Lord Moran wrote in 1966: "I was dean of St. Mary’s Hospital [medical school] for 25 years.. . all the people of outstanding merit, with few exceptions, aimed to get on the staff. There was no other aim, and it was a ladder off which some of them fell. How can you say that the people who get to the top of the ladder are the same as the people who fall off it? It seems to me so ludicrous."^[22]

Up until the year 2005, those wanting to become a General Practitioner of medicine had to do a minimum of the following postgraduate training:

• one year as a pre-registration house officer (PRHO) (formerly called a house officer), in which the trainee would usually spend 6 months on a general surgical ward and 6 months on a general medical ward in a hospital;
• two years as a senior house officer (SHO) - often on a General Practice Vocational Training Scheme (GP-VTS) in which the trainee would normally complete four 6-month jobs in hospital specialties such as obstetrics and gynaecology, paediatrics, geriatric medicine, accident and emergency or psychiatry;
• one year as a general practice registrar on a GP-VTS.

This process has changed under the programme Modernising Medical Careers. Medical practitioners graduating from 2005 onward have to do a minimum of 5 years postgraduate training:

• two years of Foundation Training, in which the trainee will do a rotation around either six 4-month jobs or eight 3-month jobs - these include at least 3-months in general medicine and 3-months in general surgery, but will also include jobs in other areas;

• A three-year "run-through" GP Specialty Training Program containing (GPSTP): 18 months as a Specialty Registrar in which time the trainee completes a mixture of jobs in hospital specialties such as obstetrics and gynaecology, paediatrics, geriatric medicine, accident and emergency or psychiatry; 18 months as a GP Specialty Registrar in General Practice.

The postgraduate qualification Membership of the Royal College of General Practitioners (MRCGP) was previously optional. In 2008 a requirement was introduced for doctors to succeed in the MRCGP assessments in order to be issued with a certificate of completion of their specialty training (CCT) in general practice. After passing the assessments, they are eligible to use the post-nominal letters MRCGP. During the GP specialty training program, the medical practitioner must complete a variety of assessments in order to be allowed to practice independently as a GP. There is a knowledge-based exam with multiple choice questions called the Applied Knowledge Test (AKT). The practical examination takes the form of a "simulated surgery" in which the doctor is presented with 13 clinical cases and assessment is made of data gathering, interpersonal skills and clinical management. This Clinical Skills Assessment (CSA) is held on three or four occasions throughout the year and takes place at the renovated headquarters of the Royal College of General Practitioners (RCGP), at 30 Euston Square, London. Finally throughout the year the doctor must complete an electronic portfolio which is made up of case-based discussions, critique of videoed consultations and reflective entries into a "learning log".

In addition, many hold qualifications such as the DCH (Diploma in Child Health of the Royal College of Paediatrics and Child Health) and/or the DRCOG (Diploma of the Royal College of Obstetricians and Gynaecologists) and/or the DGH (Diploma in Geriatric Medicine of the Royal College of Physicians). Some General Practitioners also hold the MRCP (Member of the Royal College of Physicians) or other specialist qualifications, but generally only if they had a hospital career, or a career in another speciality, before training in General Practice.

There are many arrangements under which general practitioners can work in the UK. While the main career aim is becoming a principal or partner in a GP surgery, many become salaried or non-principal GPs, work in hospitals in GP-led acute care units, or perform locum work. Whichever of these roles they fill, the vast majority of GPs receive most of their income from the National Health Service (NHS). Principals and partners in GP surgeries are self-employed, but they have contractual arrangements with the NHS which give them considerable predictability of income.

GPs in the United Kingdom may operate in community health centres.

Visits to GP surgeries are free in all countries of the United Kingdom, but charges for prescription only medicine vary. Wales, Scotland and Northern Ireland have abolished all charges.

Recent reforms to the NHS have included changes to the GP contract. General practitioners are now not required to work unsociable hours, and get paid to some extent according to their performance, e.g. numbers of patients treated, what treatments were administered, and the health of their catchment area, through the Quality and Outcomes Framework. The IT system used for assessing their income based on these criteria is called QMAS. The amount that a GP can expect to earn does vary according to the location of their work and the health needs of the population that they serve. Within a couple of years of the new contract being introduced it became apparent that there were a few examples where the arrangements were out step with what had been expected.^[23] A full-time self-employed GP, such as a GMS or PMS practice partner, might currently expect to earn a profit share of around £95,900 before tax^[24] while a GP employed by a CCG could expect to earn a salary in the range of £54,863 to £82,789.^[25] This can equate to an hourly rate of around £40 an hour for a GP partner.^[26]

A survey by Ipsos MORI released in 2011 reports that 88% of adults in the UK "trust doctors to tell the truth".^[27]

Greece

General Practice was established as a medical specialty in Greece in 1986. To qualify as a General Practitioner (γενικός ιατρός, genikos iatros) doctors in Greece are required to complete four years of vocational training after medical school, including three years and two months in a hospital setting.^[28] General Practitioners in Greece may either work as private specialists or for the National Healthcare Service, ESY (Εθνικό Σύστημα Υγείας, ΕΣΥ).

North America

United States

A medical practitioner is a type of doctor.

The population of this type of medical practitioner is declining, however. Currently the United States Navy has many of these general practitioners, known as General Medical Officers or GMOs, in active practice. The GMO is an inherent concept to all military medical branches. GMOs are the gatekeepers of medicine in that they hold the purse strings and decide upon the merit of specialist consultation. The US now holds a different definition for the term "general practitioner". The two terms "general practitioner" and "family practice" were synonymous prior to 1970. At that time both terms (if used within the US) referred to someone who completed medical school and the one-year required internship, and then worked as a general family doctor. Completion of a post-graduate specialty training program or residency in family medicine was, at that time, not a requirement. A physician who specializes in "family medicine" must now complete a residency in family medicine, and must be eligible for board certification, which is required by many hospitals and health plans for hospital privileges and remuneration, respectively. It was not until the 1970s that family medicine was recognized as a specialty in the US.^[29]

Many licensed family medical practitioners in the United States after this change began to use the term "general practitioner" to refer to those practitioners who previously did not complete a family medicine residency. Family physicians (after completing medical school) must then complete three to four years of additional residency in family medicine. Three hundred hours of medical education within the prior six years is also required to be eligible to sit for the board certification exam ; these hours are largely acquired during residency training.

The existing general practitioners in the 1970s were given the choice to be grandfathered into the newly created specialty of Family Practice. In 1971 the American Academy of General Practice changed its name to the American Academy of Family Physicians.^[30] The prior system of graduating from medical school and completing one year of post-graduate training (rotating internship) was abolished. If one wanted to become a "house-call-making" type of physician, one needed to stay in the academic setting two or three more years.^[31]

When the American Academy of Family Practice was created, the American Academy of General Practice was abolished. Several members of the AMA were in opposition to this and predicted that another General Practice organization would inevitably result, including Susan Black, MD. She predicted a "second coming" of a "General Practice Movement". Several physicians nationwide created the American Academy of General Physicians. They prescribed a body of knowledge that defined a "General Practitioner".

General practitioners have in the past, and currently are being created by the present system of producing doctors.

Prior to recent history most postgraduate education in the United States was accomplished using the mentor system. A physician would finish a rotating internship and move to some town and be taught by the local physicians the skills needed for that particular town. This allowed each community's needs to be met by the teaching of the new general practitioner the skills needed in that community. This also allowed the new physician to start making a living and raising a family, etc. General practitioners would be the surgeons, the obstetricians, and the internists for their given communities. Changes in demographics and the growing complexities of the developing bodies of knowledge made it necessary to produce more highly trained surgeons and other specialists. For many physicians it was a natural desire to want to be considered "specialists". What was not anticipated by many physicians is that an option to be a generalist would be abolished.

Certificates of Added Qualifications (CAQs) in adolescent medicine, geriatric medicine, sports medicine, sleep medicine, and hospice and palliative medicine are available for those board-certified family physicians with additional residency training requirements. Recently, new fellowships in International Family Medicine have emerged. These fellowships are designed to train family physicians working in resource poor environments.^[32]

There is currently a shortage of primary care physicians (and also other primary care providers) due to several factors, notably the lesser prestige associated with the young specialty, the lower pay, and the increasingly frustrating practice environment. In the US physicians are increasingly forced to do more administrative work,^[33] and shoulder higher malpractice premiums.

Canada

The College of General Practice of Canada was founded in 1954 but in 1967 changed its name to College of Family Physicians of Canada (CFPC).^[34]

Oceania

Australia

General Practice in Australia and New Zealand has undergone many changes in training requirements over the past decade. The basic medical degree in Australia is the MBBS (Bachelor of Medicine, Bachelor of Surgery), which has traditionally been attained after completion of an undergraduate five or six-year course. Over the last few years, an ever increasing number of post-graduate four-year medical programs (previous bachelor's degree required) have become more common and now account more than half of all Australian medical graduates. After graduating, a one-year internship is completed in a public and private hospitals prior to obtaining full registration. Many newly registered medical practitioners undergo one year or more of pre-vocational position as Resident Medical Officers (different titles depending on jurisdictions) before specialist training begins. For general practice training, the medical practitioner then applies to enter a three- or four-year program either through the "Australian General Practice Training Program", "Remote Vocational Training Scheme" or "Independent Pathway".^[35] The Australian Government has announced an expansion of the number of GP training places through the AGPT program- 1,500 places per year will be available by 2015.^[36]

A combination of coursework and apprenticeship type training leading to the awarding of the FRACGP (Fellowship of the Royal Australian College of General Practitioners) or FACRRM (Fellowship of Australian College of Rural and Remote Medicine), if successful. Since 1996 this qualification or its equivalent has been required in order for new GPs to access Medicare rebates as a specialist general practitioner. Doctors who graduated prior to 1992 and who had worked in general practice for a specified period of time were recognized as "Vocationally Registered" or "VR" GPs, and given automatic and continuing eligibility for general practice Medicare rebates.^[37] There is a sizable group of doctors who have identical qualifications and experience, but who have been denied access to VR recognition. They are termed "Non-Vocationally Registered" or so-called "non-VR" GPs.^[38] The federal government of Australia recognizes the experience and competence of these doctors, by allowing them access to the "specialist" GP Medicare rebates for working in areas of government policy priority, such as areas of workforce shortage, and metropolitan after hours service.^[39] Some programs awarded permanent and unrestricted eligibility for VR rebate levels after 5 years of practice under the program.^[40] There is a community-based campaign in support of these so-called Non-VR doctors being granted full and permanent recognition of their experience and expertise, as fully identical with the previous generation of pre-1996 "grandfathered" GPs.^[41] This campaign is supported by the official policy of the Australian Medical Association (AMA).^[38]

Medicare is Australia's universal health insurance system, and without access to it, a practitioner cannot effectively work in private practice in Australia.

Procedural General Practice training in combination with General Practice Fellowship was first established by the "Australian College of Rural and Remote Medicine" in 2004. This new fellowship was developed in aid to recognise the specialised skills required to work within a rural and remote context. In addition it was hoped to recognise the impending urgency of training Rural Procedural Practitioners to sustain Obstetric and Surgical services within rural Australia. Each training registrar select a speciality that can be utilised in a rural area from the Advanced Skills Training list and spends a minimum of 12 months completing this specialty, the most common of which are Surgery, Obstetrics/Gynaecology and Anaesthetics. Further choices of specialty include Aboriginal and Torres Strait Islander Health, Adult Internal Medicine, Emergency Medicine, Mental Health, Paediatrics, Population health and Remote Medicine. Shortly after the establishment of the FACRRM, the Royal Australian College of General Practitioners introduced an additional training year (from the basic 3 years) to offer the "Fellowship in Advanced Rural General Practice". The additional year, or Advanced Rural Skills Training (ARST)^[42] can be conducted in various locations from Tertiary Hospitals to Small General Practice.

The Competent authority pathway is a work-based place assessment process to support International Medical Graduates (IMGs) wishing to work in General Practice. Approval for the ACRRM to undertake these assessments was granted by the Australian Medical Council In August 2010 and the process is to be streamlined in July 2014.^[43]

New Zealand

In New Zealand, most GPs work in clinics and health centres^[44] usually as part of a Primary Health Organisation (PHO). These are funded at a population level, based on the characteristics of a practice's enrolled population (referred to as capitation-based funding). Fee-for-service arrangements still exist with other funders such as Accident Compensation Corporation (ACC) and Ministry of Social Development (MSD), as well as receiving co-payments from patients to top-up the capitation-based funding.

The basic medical degree in New Zealand is the MBChB degree (Bachelor of Medicine, Bachelor of Surgery), which has traditionally been attained after completion of an undergraduate five or six-year course. In NZ new graduates must complete the GPEP (General Practice Education Program) Stages I and II in order to be granted the title Fellowship of the Royal New Zealand College of General Practitioners (FRNZCGP), which includes the PRIMEX assessment and further CME and Peer group learning sessions as directed by the RNZCGP.^[45] Holders of the award of FRNZCGP may apply for specialist recognition with the New Zealand Medical Council (MCNZ), after which they are considered specialists in General Practice by the council and the community.^[46] In 2009 the NZ Government increased the number of places available on the state-funded programme for GP training.^[47]

There is a shortage of GPs in rural areas and increasingly outer metropolitan areas of large cities, which has led to the utilisation of overseas trained doctors (international medical graduates (IMGs)).

See also

• American Board of Family Medicine
• ATC codes Anatomical Therapeutic Chemical Classification System
• Classification of Pharmaco-Therapeutic Referrals CPR
• Dental General Practitioner (GDP)
• Family medicine
• ICD-10 International Classification of Diseases
• ICPC-2 PLUS
• International Classification of Primary Care ICPC-2
• National Integrated Medical Association
• Primary care
• Quaternary prevention
• Referral (medicine)
• Sessional GP

References