The Royal Australian College of General Practitioners

Definition of curriculum

This publication, the RACGP Curriculum for Australian General Practice ('the curriculum'), details what vocational general practitioners need to learn throughout their general practice learning life.

This curriculum details the knowledge, skills and attitudes necessary for:

• competent, unsupervised general practice
• general practitioners to be able to meet their community's health care needs
• general practitioners to be able to support current national health priorities and the future goals of the Australian health care system.

This curriculum is an essential reference for general practice registrars, general practice supervisors, medical educators, regional training providers and anyone involved in implementing the training of future general practitioners.

For this reason, this curriculum also details learning objectives for medical students and prevocational doctors who will eventually become general practitioners. The acquisition of these skills will also be of interest to many medical specialities.

The curriculum emphasises self directed learning, the development of critical self reflection and lifelong learning skills, and the maintenance of professional practice standards.

Training placements are undertaken in RACGP-accredited posts. These include both community based practices and hospital based posts.

In general practice posts, general practice registrars (ie. participants in the Training Program) are assigned a general practice supervisor who provides onsite supervision, guidance and feedback.

Other general practice teachers acting in the roles of medical educators, external clinical teachers, GP mentors and training advisors provide additional teaching, support and feedback throughout training.

Curriculum development

The RACGP Curriculum for Australian General Practice was developed after taking into account:

• the discipline of general practice as a medical speciality
• what general practitioners need to know ('the domains of general practice')
• the lifelong learning needs of general practitioners (from medical student through to prevocational doctor, vocational training and containing professional development)
• the reasons most people have for seeking the services of a General Practitioner ('common patient presentations')
• the health needs and priorities of Australia's population (national health priorities).

The common learning objectives were developed using this framework, as were the specific learning objectives in the curriculum statements that relate to various population groups and aspects of general practice.

Individual curriculum statements are grouped under four headings, depending on whether they relate to:

• problems
• patients
• populations
• processes of care.

The teaching and learning approaches and feedback and assessment mechanisms will be found in the learning resources for the RACGP Curriculum for Australian General Practice.

Context of Australian general practice

General practitioners encounter a wide variety of clinical presentations according to social, demographic, cultural and epidemiological circumstances.

These factors combine to form unique local practice characteristics, regional clinical trends and national characteristics.

Definition of general practice

The term 'general practice' is not consistently used in international literature. The terms family medical practitioner, family physician and family doctor are also used.

In Australia, The Royal Australian College of General Practitioners defines general practice as follows:

General practice is the provision of primary continuing comprehensive whole patient medical care to individuals, families and their communities.¹

General practice involves the ability to take responsible action on any medical problem the patient presents, whether or not it forms part of an ongoing doctor-patient relationship. In managing the patient, the clinician - called general practitioner in Australia - may make appropriate referral to other doctors, health care professionals and community services.

General practice as a speciality in Australia

In Australia, general practice is recognised as a specialty by a range of criteria including by statute.

A number of key events have lead to the recognition of general practice as a specialty in Australia:

• in 1978, the National Specialist Qualification Advisory Committee stated that 'general practice is a specific and defined discipline in medicine'
• in 1989, general practice was established as a specialty with the introduction of the vocational register of recognised general practitioners²
• in 1999, the Australian Medical Council (AMC) developed a model to assess recognition of medical specialties and recognised general practice as one of the then 17 medical specialties in Australia.³

Since 1989, changes to the Health Insurance Act 1973 have led to the establishment of a separate listing of general practitioners who met the RACGP training, experience and assessment requirements. As a result of the legislation and further changes:

• Fellows of the RACGP are specialists as they have met the RACGP requirements for entry into the specialty of general practice
• recognised general practitioners are specialist as they have met the RACGP requirements prior to the cutoff date in 1995 for vocational registration
• since 1996, Fellowship of the RACGP is the minimum standard of entry into unsupervised general practice and the only route to recognised general practice.

In 2003, the AMC, in line with its national processes for the review and accreditation of specialist education and training programs, accredited the RACGP education and training programs for general practitioners.⁴

A third group of nonspecialists practice in the specialty of general practice, but are not Fellows of the RACGP or recognised general practitioners and are not specialists. Generally these doctors are referred to as 'other medical practitioners' or nonvocational registered general practitioners.

General practice: core characteristics and practices

General practice has a core set of clinical characteristics and practices, unique within medicine. These characteristics and practices are defined by the general practice curriculum developed and maintained by the RACGP and reflected in the standards set for clinical practice and the award of Fellowship of the college (FRACGP).

General practice training, as determined by the standards set and maintained by the RACGP, is intended to equip graduates with both core clinical skills and the ability to assess and address the learning needs arising from differing clinical contexts over a professional lifetime.

In addition, general practitioners may need to develop, maintain and expand skills as supervisors/teachers, mentors, researchers and leaders over their professional lifetime.

National health priorities

The Australian Government has established national goals, targets and strategies for better health outcomes into the next century.⁵ These focus on the prevention, early detection and management of specific chronic problems including:

• cardiovascular health
• cancer control
• injury prevention and control
• mental health
• diabetes
• asthma
• musculoskeletal conditions
• renal disease.

General practitioners need to be aware of the Australian Population Health Development Principal Committee (APHDPC) and the Australian Health Protection Principal Committee (AHPPC), which incorporates the National Public Health Partnership, which previously brought Australian Government and States together on public health issues.

The Australian Health Protection Principal Committee and the Australian Population Health Development Committee will advise all Australian jurisdictions in the integration of prevention across all aspects of chronic disease management, and in bringing a greater focus to health protection. Issues identified include:

• controlling communicable diseases (including immunisation, HIV/AIDS Hepatitis C programs)
• bioterrorism and pandemic preparedness
• environmental health
• nutrition
• physical activity
• injury prevention
• child, youth and mothers' health
• chronic disease prevention
• Aboriginal and Torres Strait Islander health
• health of prisoners.

For more information see RACGP curriculum statement Population and public health.

References

1. The Royal Australian College of General Practitioners. What is general practice? Definition of general practice and general practitioners, 2005. Available at: www.racgp.org.au/whatisgeneralpractice.
2. Mudge P, editor. General practice in Australia: 2000. 1st edn. Canberra: Australian Government Department of Health and Ageing, 2000.
3. Australian Medical Council. Guidelines for the recognition of medical specialties and sub-specialties, November 2002. Available at: www.amc.org.au/table1.asp [Accessed 13 January 2006].
4. Australian Medical Council. Accreditation report: the education and training programs of the Royal Australian College of General Practitioners. ***: Australian Medical Council Incorporated, 2003.
5. Australian Government Department of Health and Ageing. National health priority areas. Available at: www.aihw.gov.au/nhpa/index.cfm.

Learning life of general practitioners

Examining the steps to becoming a general practitionerqualified for unsupervised practice in Australia helps define training needs at each stage of the path to becoming a competent GP.

Prior to entering general practice vocational training, medical practitioners will already have had many years of training by a variety of individuals, organisations and institutions. A uniform general practice curriculum from the earliest stage of medical education prior to vocational training helps support the diverse range of trainers to ensure that a solid foundation for general practice training has been established prior to entering vocational training.

Learning life stages

In Australia, the stages of the general practitioner's learning life have been identified as the:

• medical student
• prevocational doctor
• vocational general practice registrar
• continuing professional development stage.

Some students may enter this training path at different parts of the learning lifecycle. For example, an international medical graduate may enter at various parts of the cycle depending on previous levels of educational qualifications.

Due to the comprehensive nature of general practice, some of these steps crossover with training pathways to other medical specialities and therefore have competing training priorities.

The medical student

A medical student is defined as a student who is enrolled in a primary medical degree and will undertake a general practice placement.

Medical student teaching in Australia has undergone major change in recent times.

Consistent with the principle of the journey of general practice, medical student teaching now emphasises active learning, learning of key principles and preparation for lifelong learning.¹ In addition, the places where medical students are trained have also changed, with students spending more time in community health settings, doctors' private rooms and private hospitals, small urban and rural hospitals, as well as the more traditional tertiary teaching hospitals.

The content of medical courses has changed with the rise of evidence based medicine, the rapid increase in medical knowledge, new developments in areas such as molecular medicine and genetics, and the incorporation of issues driven by consumers and regulatory bodies.

Medical students have also changed. About half of Australia's medical schools only admit students who have a degree in another discipline, resulting in a much more diverse age group than in the past. More than half of medical students are female, medical schools are committed to a higher proportion of rural and indigenous students, and the cultural diversity of students matches the changing ethnic mix of Australia.⁵

In addition, some medical courses are undergraduate while other courses are postgraduate. The term 'medical student' reflects the vocational nature of the medical course.

Around 30% of Australian medical graduates are currently entering general practice and this is the largest proportion of students that are entering a medical speciality in Australia.^2,3

General practice teaching therefore has an obvious place in undergraduate medical curricula where the medical students are planning to become general practitioners.

However, these learning requirements need to intersect and overlap with the needs of students planning careers outside of general practice, or for the many students who have not yet decided on their future career paths.

General practice: the foundation discipline

While there will be many undergraduates not planning a career in general practice, there will be many areas of curriculum overlap that will be of mutual benefit for all future graduates, regardless of their final vocation.

There are many skills that are common to all medical specialities, and these generalist skills are the core values of the medical speciality of general practice. General practice training can provide the basic foundation, or at least a significant proportion, of the professional skills required for other medical disciplines including the patient-doctor relationship, advocacy and decision making, and dealing with uncertainty and difficulty in complex situations.

Generalist skills involve a holistic approach to managing the health of individuals: a skill that should ideally cross all medical specialties.⁴ Rather than just dealing with diseases, general practitionersmanage health within biomedical, psychological and social contexts, based on firm epidemiological foundations. Medical management decisions are patient centred, made jointly between the doctor and the patient, understanding the personal significance of illnesses and clinical information.

At practice level, general practitioners are required to manage the complex microeconomy of a practice, deploying resources to maximum effect and to work closely with hospital colleagues, practice teams and community services and multidisciplinary teams. Doctors must build partnerships, advocate for patients and their profession, in often difficult and complex situations.

Many of the defined general practice skills, such as those described across the domains of general practice, are mutually necessary training requirements for medical specialties. These include elements in which general practice training departments have considerable expertise such as communication skills, health care ethics and the behavioural sciences.

The knowledge, skills and attitudes described in the RACGP Curriculum for Australian General Practice therefore have much to offer all future medical graduates regardless of their final professional destination.

In addition, as general practice is the first point of contact for the majority of people seeking health care and often therefore the point of referral, knowledge of general practice is an essential part of the education of all multidisciplinary health team members.

For this reason, much of general practice training can provide a sound foundation and starting point for other medical specialties, and provide an opportunity for other specialties to educate future general practitioners on their needs when interacting with general practice.

This helps to develop better links between primary care, hospitals and community based care, given that quality of health care is increasingly concerned with continuity, cooperation and communication between different health services as medical practice of the future increasingly moves to a multidisciplinary approach.⁵

Medical student general practice teaching attachments are generally attachments to practices and not to an individual general practitionerteacher alone, so that students spend time with many members of the primary health care team. There is considerable potential for integration of common elements of core health and social care from other medical specialties.

Departments of general practice and primary care are actively engaged in facilitating such processes, through their increasing involvement with the central planning and delivery of medical curricula.

In addition, departments of general practice and primary care are now multidisciplinary, multifunctional organisations interacting with colleagues in specialist clinical medicine and other specialties, public health, nursing and the professions allied to medicine.

As such, they are ideally placed to support interprofessional education.³

Figure 1. Generalist training common to all medical specialties sits within the discipline of general practice training and provides the foundation for many medical specialties.

The prevocational doctor

Prevocational doctors are defined as junior doctors who are undertaking supervised work in a hospital, but have not yet enrolled in a speciality training program.

Junior doctors undertaking postgraduate work while working in hospitals may enter specialist training paths at various times. General practice education training needs to recognise the multiple priorities and demands affecting prevocational doctors, as while some may have chosen a future career paths in general practice, others won't have.

In Australia, the curriculum and learning needs of prevocational doctors have been areas of much debate and work. The Australian curriculum framework for junior doctors developed by the Confederation for Postgraduate Medical Councils⁵ provides a common level of skills for junior doctors in Australia. Most of these skills sit well within the generalist skills required for general practice, although many junior doctors will start to acquire additional skills and competencies in preparation for entering other vocational training programs beyond those listed in the curriculum. This will usually involve self directed learning and mentoring as the prevocational doctor takes the step towards vocational training.

The vocational doctor

A vocational general practice registrar is defined as a registered medical practitioner who is enrolled in a general practice training program approved by the RACGP to achieve Fellowship of the RACGP.

Completion of vocational training and the award of Fellowship of the RACGP equip medical practitioners with the core competencies required for unsupervised practice in Australia.

Here the learning life is easier to focus upon as the training requirements are documented in the RACGP Curriculum for Australian General Practice.

For many general practitioners, the qualification of FRACGP is only one more step in their learning life.

Continuing professional development

After qualifying as a vocational general practitioneras part of their professional learning life requirements, all general practitioners need to ensure ongoing professional development and continuing quality assurance activities in order to maintain core general practice competencies.

As part of continuing professional development, many general practitioners also choose to become general practice educators and supervisors, or to participate in the ongoing development of general practice standards through the RACGP.

General practitioners may also need to develop skills beyond basic vocational requirements where they may need to provide general practice services that other general practitioners may not need to provide. For example, a rural general practitionermay need to maintain a level of obstetric and anaesthetic skills not required by an inner city GP. There may be intercollegiate committees that regulate these activities, and general practitioners may need to participate in designated ongoing professional development programs. An Australian example would be the joint consultative committees that work across medical colleges (www.racgp.org.au/jcc).

In these situations, general practitioners need to self direct their learning requirements and may need to comply with regulatory requirements to be eligible to provide services, such as medical imaging, or to be eligible for medical indemnity cover.

Other general practitioners may take further formal postgraduate training, and the learning professional life of general practitioners needs to recognise a the diversity of ongoing learning activities that general practitioners may choose to participate in.

Principles of lifelong learning of the GP

Over a GP's professional lifetime, each level of learning builds upon the previous learning level, and assumes that all previous requirements have been met.

In reality, the path is continuous rather than consisting of discrete steps. Most learning levels will overlap to some extent (see Figure 2), so that:

• a medical student may have a special interest in women's health and decide to study beyond the undergraduate curriculum, gaining knowledge that others would not gain until reaching the vocational level
• a first year prevocational doctor may have already decided to develop a special interest in public health, but have decided to train as a vocationally general practitioneron their way to their final goal and may already have acquired high level skills in their special interest area.

The curriculum requirements must be met at each level to ensure that minimum core competencies are reached at each stage of the learning lifecycle.

Figure 2. Each level of lifelong learning builds upon the previous level of knowledge.

Key adult learning educational principles and concepts

This RACGP Curriculum for Australian General Practice is based on the following key adult learning educational concepts and principles that are applied across the general practitionerlearning lifetime:

• needs focused training
  - directed towards meeting the health care needs and priorities of the Australian community
• learning as a continuum
  - integrates vocational training with undergraduate, postgraduate and continuing medical education
• lifelong learning
  - encourages a commitment to continuous improvement of knowledge and skills in throughout a GP's learning life
• experiential learning
  - emphasises training as a supervised 'real world' clinical experience of consulting, with patients presenting with the common and significant conditions which exemplify general practice
• purpose driven learning
  - clearly states purposes and curriculum requirements, to enable learners make informed choices about learning pathways
• integrated training
  - balances and integrates experiential, information based and reflective learning
• adult learning
  - uses of models of learning based on recognition of different learning styles and needs
• self directed learning
  - expects adult learners to exercise significant autonomy in making choices about their learning
• feedback
  - requires high quality and regular feedback to learners on their performance as an integral and critical part of the teaching and supervision
• assessment
  - regular assessment of learner achievement of curriculum learning objectives during and at the end of training to determine satisfactory completion of training requirements.

General practice educators and the learning life

The maintenance of high quality general practice education and training depends upon recruitment and training of educators in each generation of GPs.

The nature of this teaching varies from informal settings to strictly regulated training programs with summative examination processes.

In reality, each level is often involved in the education of those in earlier lifecycle stages. For example, a prevocational doctor may educate or mentor medical students, a third year junior doctor may teach procedural skills to a first junior doctor, and a qualified general practitionermay teach all levels of GPs.

Attention to the levels of training and teaching skills required at each level of the learning life helps to maintain and improve ongoing training and skills levels.

For example, as part of continuing professional development, general practitioners may consider their role in teaching medical students, or general practice registrars, and may need to examine their skill requirements.

General practice research and the learning lifecycle

'Family medicine (general practice) research is important, not only for its own sake but also because it improves patient care, enables teachers to contribute to their discipline, and stimulates intellectual rigor and critical thinking.'⁶

The rise of evidence based medicine and the concurrent need for equipping students with appropriate analytical skills now means that skills that were normally only part of the domain of researchers are now commonplace among medical practitioners.

As general practice research becomes more common, the skills involved in participating and conducting research can now be incorporated at all stages of the general practice professional life.

Learning lifecycles help planning and accountability

A uniform general practice curriculum across the professional learning life provides a transparent process to ensure that, in addition to professional requirements, the community expectations and obligations of general practitioners are met.

Defining requirements at each level provides a common ground for negotiating medical student curricula with other medical specialities to achieve cross-discipline curricular consistency. Such a process is likely to be iterative as knowledge and fields evolve. However, an explicit process ultimately will clarify mutual learning objectives, plan skills development and ultimately ensure that patient care needs are met.

An explicit lifecycle learning approach importantly also provides an open, transparent and robust process by which governments, regulators, other general practice stakeholders and community groups can influence the curriculum process across the entire field of medical education to ensure both professional and societal accountability.

References

1. Horvath J. Medical education towards 2010: shared visions and common goals. Medical Education Conference 2005, Canberra, 7-9 March 2005.
2. Australian Medical Workforce Advisory Committee. Career decision making by postgraduate doctors, main report. Sydney: AMWAC, 2005.
3. Joyce CM, McNeil JJ. Fewer medical graduates are choosing general practice: a comparison of four cohorts, 1980-1995. Med J Aust 2006;185:102-4.
4. Society for Academic Primary Care. New century, new challenges: a report from the heads of departments of general practice and primary care in the medical schools of the United Kingdom. London: Royal College of General Practitioners, 2002.
5. Confederation for Postgraduate Medical Councils. Australian curriculum framework for junior doctors, 2006. Available at: www.cpmec.org.au/curriculum/index.cfm
6. Del Mar C, Askew D. Building family medicine research capacity. Ann Fam Med 2004;2(Suppl 2):S35-S40.

The five domains of general practice

The five domains of general practice represent the critical areas of knowledge, skills and attitudes necessary for competent unsupervised general practice. They are relevant to every general patient consultation.

This RACGP Curriculum for Australian General Practice bases lifelong teaching and learning on these domains.

They are:

Domain 1 - Communication skills and the patient-doctor relationship
- eg. communication skills, patient centredness, health promotion, whole person care

Domain 2 - Applied professional knowledge and skills
- eg. physical examination and procedural skills, medical conditions, decision making

Domain 3 - Population health and the context of general practice
- eg. epidemiology, public health, prevention, family influence on health, resources

Domain 4 - Professional and ethical role
- eg. duty of care, standards, self appraisal, teacher role, research, self care, networks

Domain 5 - Organisational and legal dimensions
- eg. information technology, records, reporting, confidentiality, practice management.

The domains provide a comprehensive framework for ensuring that the key skill areas of general practice are included in education and training.

'Star of general practice' and development of new curriculum framework

Combining the domains of general practice with lifelong learning provides a powerful conceptual framework for positioning the RACGP Curriculum for General Practice in the Australian clinical context in which the knowledge and skills are applied. Diagrammatically, this can be represented as the 'Star of general practice' (see Figure 3).

This framework enables educators to flexibly train general practitioners across the diverse and wide range of clinical presentations, which vary according to social, demographic, cultural and epidemiological circumstances.

Even though local practice characteristics, regional clinical trends or national characteristics may vary, this model provides a common ground for the essential discipline of general practice knowledge across the learning life cycle and domains of general practice.

Figure 3. The 'star of general practice' provides a model of the discipline of general practice that meets the training requirements across the general practice learning life.

Contact details

For more information about the RACGP Curriculum for Australian General Practice, please contact Clare Kaczkowski at curriculum@racgp.org.au.

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