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Editorials References 1. Raine AEG, Margreiter R, Brunner FP, et al. Report on management of renal failure in Europe, XXII, 1991. Nephrol Dial Transplant 1992; suppl 2: 7-35. 2. Port FK. Worldwide demographics and future trends in end-stage renal disease. Kidney Int 1993; 43 (suppl 41): S4-S7. 3. Gokal R. Quality of life in patients undergoing renal replacement therapy. Kidney Int 1993; 43 (suppl 40): S23-S27. 4. Hull AR, Parker TF. III. Introduction and summary: proceedings from the morbidity, mortality and prescription of dialysis symposium. Am J Kidney Dis 1990; 15: 375-383. 5. Cattran DC, Fenton SSA. Contemporary management of renal failure: outcome of the failed allograft recipient. Kidney Int 1993; 43 (suppl 41): S36-S39. 6. Beech R, Mandalia S, Melia J, et al. Purchasing services for end stage renal failure: the potential and limitations of existing information sources. Health Trends 1993; 25: 60-64. 7. Innes A, Rowe PA, Burden RP, Morgan AG. Early deaths on renal replacement therapy: the need for early nephrological referral. Nephrol Dial Transplant 1992; 7: 467-471. 8. Jungers P, Zingraff J, Albouze G, et al. Late referral to maintenance dialysis: detrimental consequences. Nephrol Dial Transplant 1993; 8: 1089-1093. 9. Clark TJ, Richards NT, Adu D, Michael J. Increased prevelance of dialysis-dependent renal failure in ethnic minorities in the West Midlands. Nephrol Dial Transplant 1993; 8: 146-148.
10. National high blood pressure education program. National high blood pressure education program working group report on hypertension and chronic renal failure. Arch Intern Med 1991; 151: 1280-1287. 11. Gabow PA, Johnson AM, Kaehny WD, et al. Factors affecting the progression of renal disease in autosomal-dominant polycystic kidney disease. Kidney Int 1992; 41: 1311-1319. 12. Zucchelli P, Zuccala A, Borghi M, et al. Long-term comparison between captopril and nifedipine in the progression of renal insufficiency. Kidney Int 1992; 42: 452-458. 13. The diabetes control and complications trial research group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. NEngl JMed 1993; 329: 977-986. 14. Kasiske BL, Kalil RSN, Ma JZ, et al. Effect of antihypertensive therapy on the kidney in patients with diabetes: a meta-regression analysis. Ann Intern Med 1993; 118: 129-138. 15. Kremer-Hovinga TK, de Jong PE, van der Hem GK, de Zeeuw D. Relief on renal artery stenosis: a tool to improve or preserve renal function in renovascular disease. Nephrol Dial Transplant 1990; 5: 481-488. 16. Sack SH, Aparicio SAJR, Bevan A, et al. Late renal failure due to prostatic outflow obstruction: a preventable disease. BMJ 1989; 298: 156-159. Address for correspondence Dr H Cairns, Institute of Urology and Nephrology, Middlesex Hospital, Mortimer Street, London WIN 8AA.
Undergraduate and postgraduate medical education: bridging the divide A SURVEY of university departments in the United Kingdom and Eire, published in this issue of the Journal, I reveals that general practice is increasingly involved in all stages of the undergraduate curriculum. In the quarter century since the Todd report on medical education,2 elective attachments have given way to formal courses for both pre-clinical and clinical students. At a pre-clinical level these often involve behavioural science and family placements,3 while at a clinical level practice attachments provide opportunities to learn about medicine in the community, the primary care team, and clinical skills with emphasis on communication.4 Some of these courses anticipated the 1993 General Medical Council report5 with experience-based, selfdirected learning and continuous assessments, which in Sheffield are part of the final degree examination and include a medical audit project and recorded feedback of interview skills using audiotape recordings.6 These developments reflect an earlier review of basic medical education which had concluded that 16 of the 20 educational objectives identified by the General Medical Council required a general practice contribution for their achievement at any reasonable level.7 Some medical schools are shifting the emphasis of teaching clinical skills from hospital to community,8 and one pilot project at Cambridge has based much of the clinical course in general practice.9 The impetus for change stems partly from reforms in National Health Service funding, partly from the reduction in hospital beds, and partly from a realization that about half of all doctors work in the community where the vast majority of patient contacts take place. However, the implications for university departments of general practice are considerable. These departments have emerged by a process of opportunistic local arrangements over the past 25 years. Some are based on a university practice but the majority are practice-linked, with academic staff working in different practices.'I University departments of general practice in the UK are anomalous as there is a split between undergraduate university
British Journal of General Practice, November 1994
departments and postgraduate training which does not happen elsewhere, or for other clinical disciplines. In North America the great majority of family medicine residences are run by university departments of general practice which are also responsible for undergraduate teaching. The reasons for this situation are both historical and political. When pressure was building up for vocational training in the 1950s and 1960s it was easier to achieve this on the education budget in North America and on the health service budget in the UK. This was partly because it was felt that fees attracted by family doctors in North America would help pay for university departments involved in postgraduate training. Whereas, in this country a separate postgraduate organization was established with health service funding and has led the way in educational innovation. When pressure mounted for undergraduate teaching of general practice following the Todd report in 19682 small university departments were established, depending upon local circumstances. There was no proper funding such as that available for other clinical disciplines from the service increment for teaching (SIFT) (or additional cost in teaching, ACT, in Scotland). At the same time, postgraduate advisers and course organizers were developing vocational training with little formal contact with undergraduate teaching or research. The result was small university departments with no critical mass, where one or two people struggled to maintain credible continuity of care for patients while organizing the growing demands of undergraduate teaching and research. The new contract for general practitioners undermined these shaky foundations, which had to be shored up initially by specially allocated payments from the Department of Health and recently by more substantial 'tasking funds' from regional health authorities. This at least enabled many departments for the first time to achieve a critical mass of four or five full time academic staff. Also for the first time, general practitioners taking medical students on attachment were remunerated by the family health services authority. Long term negotiations continue to seek a
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Editorials more permanent basis for this funding; but in the meantime there are increasing pressures for more teaching in the community as hospital stays become shorter, and for more research output as university funding becomes dependent on the outcome of research selectivity. At a postgraduate level there are also increasing demands on regional advisers and course organizers. However, there is still no satisfactory career structure for these two branches of academic general practice, with those in university departments concerned with undergraduate teaching and research, while those on the postgraduate side often lead the way in education but with little opportunity for training in research. But both sides share the problem of maintaining continuity of clinical care in their practices with no junior staff and the increasing pressures of the general practitioner contract. A considerable amount of cooperation exists between the two sides of general practice, with many people being involved in both undergraduate teaching and postgraduate training. But this cooperation is ad hoc and informal. What is required is coordination, which means formal as opposed to informal links, but not necessarily integration at an organizational level." Such coordination is essential in order to achieve a proper career structure for academic general practice. Now that course organizers are on an equivalent footing to part-time lecturers, it should be possible to develop a coordinated training programme. Such academic training could arise out of the proposals for a further two years of higher professional training for general practitioners.'2 There are already seven university departments of general practice running masters degree courses which emphasize subjects such as research methods, teaching and management.'3 Such opportunities are available in other masters courses which are increasingly being developed in higher education with an emphasis on modularization. These modules are now being integrated with Council for National Academic Awards credit accumulation and transfer schemes, which will greatly increase flexibility and therefore feasibility for general practice. 14 Medical education does not end with qualification but continues through vocational training to continuing medical education where developments in portfolio learning reflect recent learner based approaches to undergraduate teaching. 1 Undergraduate and postgraduate general practice are at the forefront of many aspects of medical education, but unless the two sides coordinate their activities, there will be no career structure for academic general practice as there is for hospital doctors. The dangers of the present changes are that undergraduate departments could become mainly teaching units within larger departments of community care, and postgraduate advisers could be seen only as purchasers within a larger postgraduate organization. If a more coordinated approach in such matters is not achieved, not only will we be failing the next generation of academic general practitioners, but also the full potential of British general practice to change medical education for the better will not be realized. DAvID HANNAY Professor ofgeneral practice, University of Sheffield
References 1. Robinson LA, Spencer JA, Jones RH. Contribution of academic departments of general practice to undergraduate teaching, and their plans for curriculum development. BrJ Gen Pract 1944; 44: 489-491. 2. Royal Commission on Medical Education. Report. London: HMSO, 1968. 3. Fox NJ, Joesbury H, Hannay DR. Family attachments and medical sociology: a valuable partnership in student learning. Med Educ 1991; 25: 155-159. 4. Joesbury H, Bax NDS, Hannay DR. Communication skills and clinical methods: a new introductory course. Med Educ 1990; 24: 433-437.
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5. General Medical Council. Tomorrow's doctors. Recommendations on undergraduate medical education. London: GMC, 1993. 6. Usherwood T, Joesbury H, Hannay DR. Student-directed problembased learning in general practice and public health medicine. Med Educ 1991; 25: 421-429. 7. Association of University Teachers in General Practice. Undergraduate medical education in general practice. Occasional paper 28. London: Royal College of General Practitioners, 1984. 8. Seabrook M, Booton P, Evans T (eds). Widening the horizons of medical education: innovation in medical eduction project. London: Kings Fund, 1994. 9. Oswald NTA. Why not base medical education in general practice? Lancet 1989; 2: 148-149. 10. Howie JGR, Hannay DR, Stevenson JSK. The Mackenzie report: general practice in the medical schools of the United Kingdom. Edinburgh: University of Edinburgh, 1986. 11. Allen J, Wilson A, Fraser RC, Gray DP. The academic base for general practice. BMJ 1993; 307: 719-722. 12. National Association of Health Authorities and Trusts. Partners in learning: developing postgraduate training and continuing education for general practice. London: NAHAT, 1994. 13. Smith LFP. Higher professional training in general practice: provision of masters' degree courses in the United Kingdom in 1993. BMJ 1994; 308: 1679-1682. 14. Higher Education Quality Council. Choosing to change: extending access, choice and mobility in higher education. London: Credit Accumulation and Transfer Development Project, 1994. 15. Royal College of General Practitioners. Portfolio-based learning in general practice. Occasional paper 63. London: RCGP, 1993.
Address for correspondence Professor D R Hannay, Department of General Practice, University of Sheffield, Beech Hill Road, Sheffield S10 2RX.
The Institute of Psycho-Analysis London WI
TRAINING IN PSYCHO-ANALYSIS Applications are invited for the Training in PsychoAnalysis at the Institute of Psycho-Analysis in London. Successful applicants have the opportunity to further their knowledge and understanding of conscious and unconscious mental processes, to study the way these contribute to normal and abnormal psychological development and to develop their clinical skills in intensive work with patients. This training involves theoretical and clinical lectures and seminars, the psychoanalysis of patients under supervision, and the candidate's personal experience of psychoanalysis with a Training Analyst of The Institute of Psycho-Analysis. The course is flexible and compatible with employment in the N.H.S. Lectures and seminars are held in the evenings, and the training usually extends over a period of four years. Financial assistance is available for students once they have been accepted and fully registered for the training. Applications can be made at any time, and preliminary inquiries should in the first instance be addressed to:
The Training Secretary The Institute ofPsycho-Analysis 63 New Cavendish Street London WIM 7RD Tel: 071 580 4952 British Journal of General Practice, November 1994
