General practitioner

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

A general practitioner (GP) is a medical doctor who provides primary care and specializes in family medicine. A GP treats acute and chronic illnesses and provides preventive care and health education for all ages and both sexes. They have particular skills in treating people with multiple health issues and comorbidities.

The term general practitioner is common in Ireland, the United Kingdom, some other Commonwealth countries, and Bulgaria. In the English-speaking countries the word physician is largely reserved for certain other types of medical specialists, notably in internal medicine. A Principal GP in the UK is a senior doctor; like consultants (the equaivalent of an attending physician elsewhere), they usually hold a Certificate of Completion of Training in the specialty of general practice.

GPs may care for hospitalized patients; where they have hospital privileges, they may perform minor surgery and/or obstetrics. Many GPs do some minor procedures, such as removal of skin lesions, in their offices (their rooms, in UK and Commonwealth usage). In the past, GPs frequently carried out more major surgery, such as tonsillectomies, hernia repairs, and appendectomies. In the more rural parts of many countries, this style of medical practice continues. However, throughout much of the world in the last few decades, there has been an increase in the number and type of medical specialists, matched by a steady decrease in family physicians.

The Americas

Brazil

General practice in Brazil is called clínica geral or clínica médica. Any physician is legally allowed to practice without any training after graduation in the medical school, but recent efforts by the government, the Brazilian Medical Association and the specialized Sociedade Brasileira de Clínica Médica are trying to demand also a specialist title for its practice, just like for others such as cardiology, endocrinology, etc. The majority of Brazilian GPs are located in the public health sector and is constituted mostly by young, recently graduated physicians. The reason is that GP is not terribly profitable and about 40% of Brazilian doctors prefer to do specialized practice, instead. To do this, they are required to do medical residence of variable duration and submit to a board of medical examiners in order to get the title of specialist. Each medical society is in charge of organizing the examinations (which usually are carried out once a year) and granting the titles to those physicians who passed the requirements. The title is recognized by the Federal Council of Medicine (the Federal professional regulatory body), the Ministry of Education and the Ministry of Health.

Family medicine, on the other hand, has evolved only recently in Brazil as a separate specialization of general practice. It is a concept which was adapted from several community health models in Europe, such as in Italy, but particularly the one which was created successfully in Cuba, and which was felt to be the most adequate to Brazilian reality. Around 10 years ago, the government recognized that primary health care in Brazil was poorly organized and fraught with many problems, including a lack of attractiveness to young physicians, so a different approach, the Family Health Program (Programa de Saúde da Família or PSF) was tried, initially with some failures, but later with increasing strength and coverage. By spending a great deal of money in order to move the program forward, the Ministry of Health expanded and reinforced the public health care system, called Unified Health System (Sistema Único de Saúde or SUS) by decentralizing its management to the states and municipalities, by demanding in the Federal Constitution that a minimum percentage of the municipal budget should be spent in free health care to the population, and by setting up a new, multidisciplinary, family health-based system, the PSF. It is essentially based on teams composed by one to four physicians (usually a GP, a gynecologist/obstetrician and a pediatrician), one to two dentists, several nurses and a number of so called Community Health Agents (Agentes Comunitários de Saúde or ACS), who are trained lay persons who visit and have close contact with the families covered in a specific geographical location by the PSF team, in order to carry out preventative, educational and epidemiological work. Specific intensive training programs and recruiting efforts were set up in the country in order to form the PSF teams, which currently involve about 3,000 municipalities, with more than 45,000 teams already in operation; so that it can be considered one of the largest family health programs in the world.

Family physicians per se are still a rare specialty in Brazil, as the profession is generally shunning it (although economical incentive is no longer a valid reason, since physicians who work in the PSF units are generally well paid in comparison to primary health care physicians in the public sector). A few years ago a Brazilian Society of Family and Community Medicine was founded and has lobbied to have its own specialty title and board of examiners, but it has so far remained relatively small.

Canada

In Canada, there are no newly qualifying general practitioners: all medical students go on to a specialty, and family medicine accounts for almost 40% of the residency positions for graduating students. Following four years in medical school, a resident will spend 2-3 years in an accredited family medicine program. At the end of this, residents are eligible to be examined for Certification in the College of Family Physicians of Canada *[2]. Many hospitals and health regions now require this certification. To maintain their certificate, doctors must document ongoing learning and upgrade activities to accumulate "MainPro" credits. Some doctors add an extra year of training in emergency medicine and can thus be additionally certified as CCFP(EM). Extra training in anesthesia, surgery and obstetrics may also be recognized but this is not standardized across the country.

There is very little private family medicine practice in Canada. Most FPs are remunerated via their Provincial government health plans, via a variety of payment mechanisms, including fee-for-service, salaried positions, and alternate payment plans. There is increasing interest in the latter as a means to promote best practices within a managed economic environment. As standard office practice has become less financially viable in recent years, many FPs now pursue areas of special interest. In rural areas, the majority of FPs still provide a broad, well-rounded scope of practice. Manpower inequities in rural areas are now being addressed with some innovative training and inducement mechanisms. An imbalance between physician manpower and a growing patient load has resulted in orphan patients who find it difficult to access primary care, but this is not unique to Canada. Family Medicine is recently recognized as a Medical Specialty in Canada. Family Physicians who pass the Certification exam, CCFP, become Specialist in Family Medicine.

United States

The U.S. continues to have general practitioners, though they are uncommon. A physician needs to have a license to practice medicine in the U.S. The only requirement is that the physician be enrolled or have completed a post-graduate year of training, more commonly called a rotating internship. The few licensed physicians who do not go on to finish more years of post-graduate training, which would normally culminate in the completion of a residency, are legally allowed to practice medicine and surgery in the state where they are licensed.

The population of this type of physician is dwindling, however. Currently the United States Navy has several thousand of these general practitioners, formally known as General Medical Officers, in active practice. These physicians see active duty and dependent family members. Often they practice medicine in the most austere and remote environments. General practitioners are very rare in the civilian environment. The have basically been replaced by physicians that are residency trained in Family Medicine.

Family medicine differs somewhat from the European general practitioner. In the U.S. family practitioners usually complete an undergraduate degree and then complete either the M.D. degree Doctor of Medicine or a D.O. Doctor of Osteopathic Medicine degree. A physician who specializes in family medicine (also known as a family physician), however, must complete a three-year family medicine residency in addition to their medical degree, and is eligible for the board certification now required by most hospitals and health plans.

Most family physicians practice in solo or small-group private practices or as hospital employees in practices of similar sizes owned by hospitals. Still, many choose to teach medicine at medical schools or family medicine residency programs, though usually for much less pay. Others choose to practice as consultants to various medical institutions, including insurance companies.

Starting in the 1970s and 1980s, many board-certified family physicians in the United States began to consider the terms "general practitioner" and "GP" as somewhat demeaning and derogatory, discounting their additional years of training. It was not until 1969 that family medicine (formerly known as family practice) was recognized as a distinct specialty in the U.S.

A family physician is board-certified in family medicine. Training is focused on treating an individual throughout all of his or her life stages. Family physicians will see anyone with any problem, but are experts in common problems. Many family physicians deliver babies in addition to taking care of patients of all ages. Family physicians complete undergraduate school, medical school, and three more years of specialized medical residency training in family medicine. Board-certified family physicians take a written examination every six, seven, nine or 10 years to remain board certified, depending on what track they choose regarding the maintenance of their certification. Three hundred hours of continuing medical education within the prior six years is also required to be eligible to sit for the exam.

Between 2003 and 2009 the board certification process is being changed in family medicine and all other American Specialty Boards to a continuous series of yearly competency tests on differing areas within the given specialty. The American Board of Family Medicine, as well as other specialty boards, are requiring additional participation in continuous learning and self-assessment to enhance clinical knowledge, expertise and skills. The Board has created a program called the "Maintenance of Certification Program for Family Physicians" (MC-FP) which will require family physicians to continuously demonstrate proficiency in four areas of clinical practice: professionalism, self assessment/lifelong learning, cognitive expertise, and performance in practice.

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 who meet additional training and testing requirements. Additionally, fellowships are available for family physicians in adolescent medicine, geriatrics, sports medicine, rural medicine, faculty development, hospitalist, obstetrics, research, and preventative medicine.

The family medicine (FM) paradigm is bolstered by primary care physicians trained in internal medicine (IM); although these physicians are trained in internal medicine only, adult patients provide the majority of the patient base of many family medicine practices. In the United States, there is a rising contingent of physicians dually trained in internal medicine and pediatrics ("peds", Template:PronEng), which can be completed in four years, instead of the three years each for IM and pediatrics. A significant number of family medicine practices (especially in suburban and urban areas) do not provide obstetric services anymore (due to litigation issues and provider preference), and as such, this blurs the line between the FM and IM/Peds difference. One suggested difference is that the IM/Peds-trained physicians are more geared towards subspecialty training or hospital-based practice. Even so, there are many groups with FM-trained and IM/Peds-trained physicians working in seamless harmony.

There is currently a shortage of family physicians (and also other primary care providers) due to several factors, notably the lesser prestige associated with the young specialty, the lesser pay, and the increasingly frustrating practice environment in the U.S. Physicians are increasingly forced to do more administrative work, shoulder higher malpractice premiums due to highly profitable insurance monopolies that charge excessive premiums, thus forcing doctors to spend less and less time with patient care due to the current payor model stressing patient volume vs. quality of care. Things are starting to change as more insurance carriers consolidate. They are not stressing performance but more and more volume, thus increasing insurance company profit margins. Physicians are starting to shun insurance carriers to lessen the paperwork in order to focus more on patient care as they are originally trained to do. The average starting salary in the United States for family physicians is $120,000 to 150,000 a year.

There is a current trend among family physicians to adopt a practice model called the micro practice, or "Ideal Medical Practice." These practices focus on reducing their overhead and increase their utilization of technology. Because the overhead is reduced, the need to see a high volume of patients to generate more revenue is diminished. This allows the doctor to spend more time with their patients, which results in higher satisfaction for the patient and the physician.

Asia and Oceania

Australia

General Practice in Australia has undergone many changes in training requirements over the past decade. The basic medical degree in Australia is the twin MB BS degree (Bachelor of Medicine, Bachelor of Surgery), which has traditionally been attained after completion of a six-year course. Over the last few years, four-year medical programs that require a previous bachelors degree have become more common. After graduating, a one or two-year internship (dependent on state) is required for registration before specialist training begins. For general practice training, the doctor applies to enter the three-year "Australian General Practice Training Program", a combination of coursework and apprenticeship type training leading to the awarding of the FRACGP (Fellowship of the Royal Australian College of General Practitioners), if successful. Since 1996 this qualification or its equivalent has been required in order for the GP to access Medicare rebates as a general practitioner. Medicare is Australia's universal health insurance system, and without access to it, a practitioner cannot effectively work in private practice in Australia. Most GPs work under a fee-for-service arrangement although increasingly a portion of income is derived from Government payments for participation in chronic disease management programs. 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 (OTDs).

India

India has the highest number of medical schools in the world, with approximately 262. In India to become a GP or a Family Physician, one has to enroll in a Medical Council Of India (MCI) recognised medical college and complete a four and a half year course for the twin Bachelor of Medicine, Bachelor of Surgery (M.B.,B.S) degree, after which one is provisionally registered with the Medical Council of India. After one further year of compulsory rotatory internship, the Medical Council of India (or any of the State Medical Councils) confer permanent registration which licences the holder to practise as a GP. A person may qualify to attend a medical course at the age of 17 after completing a two-year pre-university course in which one of the core subjects would be Biology.

Higher medical education

An M.B.B.S. Doctor can appear for pre-post-graduate examinations (Pre-PG) at national, state or institute levels and gain entry to a MD (Doctor of Medicine), MS (Master of Surgery) or a Diploma course in a number of specialisations including Internal Medicine (or General Medicine).

One can also opt to join the National Board of Examinations (NBE)'s fellowship for Family Medicine at any of the NBE designated and recognised Health care center or hospital and appear for qualifying exams for fellowship to the National Board on successful completion of which, one is awarded the "Diplomate of National Board" degree and title.

Other than allopathic doctors, graduates of homeopathy, ayurveda, and unani courses from recognised medical colleges and institutions and duly registered with the respective state or national boards of these medical systems can also practice as family practitioners.

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, Pakistan (CPSP) in 1992 and initiated in 1993 by the Family Medicine Division of the Department of Community Health Sciences, Aga Khan University, Pakistan. In 1997, the Royal College of General Practitioners, UK, unconditionally approved the Programme for the MRCGP Examination and additionally declared it as amongst the top 10 programmes in UK.[3]

Family Medicine Residency training programme of Ziauddin University is approved for Fellowship in Family Medicine.[4]

The following centres are providing training for Diploma of College of Physicians and Surgeons, Pakistan (DCPSP)[5]:

1. Ayub Medical College/Ayub Teaching Hospital, Abbottabad
2. Dow University of Health Sciences, Karachi
3. Khyber Medical College/Khyber Teaching Hospital, Peshawar
4. PGMI / Lady Reading Hospital, Peshawar
5. PGMI / Hayatabad Medical Complex, Peshawar

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 two years and a half as a junior practitioner (interne) :

• the first year (PCEM1, premier cycle d'études médicales, première année, often abbreviated to P1 by students) is common with the dentists (and, in some universities, with students of other paramedical professions like midwifery); the rank at the final competitive examination determines in which branch the student can go on;
• 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 two years and a half of initial professional experience under the responsibility of a senior; the interne can prescribe, he can make replace physicians, 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 of a specific affection (in an epidemiological, diagnostic, or therapeutic point of view).

Low Countries

General practice in The Netherlands and Belgium is considered fairly advanced. The huisarts (literally: "home doctor") administers all first-line care, and makes required referrals. Many have a specialist interest, e.g. in palliative care.

In The Netherlands, training consists of three years of specialization after completion of internships. In Belgium, two years of specialization are required.

Spain

In Spain the médico de familia/médico general commonly called médico de cabecera, works in multidisciplinary teams (pediatrics, nurses, social workers and others) on primary care centers. They are in most cases salary-based healthcare workers.

After the graduation in medicine (with a duration of 6 years), the medical doctors pass a national written exam called MIR (Internal Resident Doctor see Association at [AEMIR]http://aemir.org). The speciality devoted to primary care is "Family and Community Medicine Specialist". To obtain it, the postgraduate doctors must complete a 4-years training period working in primary care centers (2 years) and hospitals (2 years) as residents.

Some of the specialist in family practice in Spain are forced to work in other countries (mainly UK, Portugal and France) due to lack of stable work offers in the public health system.

United Kingdom

Template:NHS medical career grades In the United Kingdom, doctors wishing to become GPs take at least 4 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).

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 houseman), 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.

This process has changed under the programme Modernising Medical Careers. Doctors graduating from 2005 onwards will 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;
• two years as 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.

At the end of the one year registrar post, the doctor must pass an examination in order to be allowed to practice independently as a GP. This summative assessment consists of a video of two hours of consultations with patients, an audit cycle completed during their registrar year, a multiple choice questionnaire (MCQ), and a standardised assessment of competencies by their trainer.

Membership of the Royal College of General Practitioners was previously optional. However new trainee GP's from 2008 are now compulsorily required to complete the nMRCGP. They will not be allowed to practice without this postgraduate qualification. After passing the exam or assessment, they are awarded the specialist qualification of MRCGP – Member of the Royal College of General Practitioners. Previously qualified general practitioners (prior to 2008) are not required to hold the MRCGP, but it is considered desirable. 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.

The (MB ChB/BS) medical degree is entirely equivalent to the North American MD medical degree. Doctors educated in the United States, Canada, Australia, New Zealand, Ireland, and Great Britain have more ability to move between the countries than other national systems.

Visits to GP surgeries are free in all countries of the United Kingdom, but charges for prescription only medicine vary. Wales has already abolished all charges, and Scotland has embarked on a phased reduction in charges to be completed by 2011. In England, however, most adults of working age who are not on benefits have to pay a standard charge for prescription only medicine of £7.10 per item from April 2008..

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

Recent reforms to the NHS have included changing 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. They are encouraged to prescribe medicines by their generic names. The IT system used for assessing their income based on these criteria is called QMAS. A GP can expect to earn about £70,000 a year without doing any overtime, although this figure is extremely variable. A recent report[6] notes that a GP can potentially earn £250k per year. These potential earnings have been the subject of much criticism in the press for being excessive [7]. However, an average full time GP can now expect to earn around £110,000 before tax. However many GPs do not earn anything near this amout (they earn much lower) and are still reqired to work very inconvinient and unsociable hours. This can include going out in childrens birthday parties on a sunday to see patients

GP Practices have been criticised by their lack of accountability, in particular with complaints procedures, as recent report described "an NHS complaints system failing to detect issues of professional misconduct or criminal activity".[8] However complaint procedures have been tightened up and there is now a growing threat that malicious complaints and unrealistic expectations from patients are making General Practitioners stress levels soar. Practices are independent contractors and thus are able to exercise discretion in how they conduct themselves, the Primary Care Trust is not able to handle complaints before the Practice has, and patients do run a risk of being removed from the practitioner's list[9].

Ireland

General Practice in Ireland largely follows the UK model, with some exceptions. GP training in Ireland requires the completion of a primary medical degree. In Ireland the title of MB BCh BAO (Doctor of Medicine, Doctor of Surgery, Doctor of Obstetrics and Gynaecology) is awarded upon successful completion of a 5 to 6 year undergraduate degree programme in one of the country's five medical schools.

Following this a further year is spent as an Intern, rotating through medical and surgical specialities. In most, but not all instances, 6 months are spent in medicine and 6 months in surgery. Some interns can gain experience in general practice, psychiatry and other specialities. The successful completion of intern training leads to full registration with the Irish Medical Council.

Those doctors wishing to pursue a career in General Practice must complete an approved training scheme. Previously completion of a training scheme was not mandatory to sit the MICGP exam (Member of the Irish College of General Practictioner) and practice as a GP in Ireland. Many doctors took up stand-alone SHO posts in the required specialities and then sat the exam without any vocational training. This route has not been abolished and vocational training is mandatory. Completion of vocational GP training in other jurisdictions (e.g. the UK) and completion of the MICGP or equivalent (e.g. MRCGP) is still possible, but anecdotal evidence would suggest Irish trained GPs are at a significant advantage when applying for Irish GP posts.

Entry to a General Practice Training Scheme is based on competitive interview. Most are of 4 years duration (one is 5 years). Generally the first 2 years are spent rotating through relevant specialities (medicine, paediatrics, obstetrics & gynaecology, psychiatry, accident & emergency, ENT etc.). Two years are then spent as a GP registrar in designated Training Practice. After successful completing the MICGP exams, the new general practitioner is free to practice.

General practice in Ireland is a desirable career for many and competition for places on training schemes is intense. There has been mush criticism of the perceived under-supply of training places and efforts are made to increase places annually. Currently there are 12 schemes - Donegal, Sligo, Western (Galway, Mayo and Roscommon), Mid-Western (Limerick, Clare and Tipperary North Riding), Southern (Cork & Kerry), South-East (Waterford, Wexford, Kilkenny and Tipperary South Riding), Midlands (Offaly, Westmeath, Laois, Kildare), North-East (Louth, Meath, Monaghan, Cavan), Ballinasloe and 3 schemes based in Dublin.

Typically Irish GPs work exclusively with private (i.e. fee-for-service paying) patients or have a mix of public and private. So-called "public" patients are those who qualify for a medical card under the General Medical Services (or GMS) system. This is free health care, provided by the government and is means tested. Other groups such as those with specified chronic illnesses and the elderly are also entitled to a medical card. A medical card entitles the holder to free GP consultations, free medications and free hospital treatment. In order to treat medical card holders a GP must apply for and be granted a GMS list. Applications for such lists are competitive as they can be very lucurative for the GP and vacancies do not often arise.

GPs deal with the entire spectrum of medical ailments. They are well placed to implement preventative measures and to manage chronic illness. They also act as "gate-keepers" for the tertiary care system, providing referrals to specialist services when appropriate. Some GPs are employed by private agencies.

See also

• World Organization of Family Doctors (Wonca)
• American Board of Family Medicine
• American Academy of Family Physicians
• Royal College of General Practitioners
• AEMIR