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Tuesday 27 September 2016
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Driving “Firm 1”, the community-based GP training course

Education & Training

Kate Thomas
MB ChB FRCGP
GP

Associate Professor and Senior Tutor, Department of Primary Care and General Practice, University of Birmingham

Kate is a GP in Sutton Coldfield, West Midlands, and is Associate Professor at the University of Birmingham School of Medicine.  She has been involved in "Firm 1" since its inception, and has had overall responsibility for the scheme for the last four years. Kate is also Senior Tutor for student welfare in the medical school, taking care of 2,028 students at present

In 1995, the University of Birmingham introduced a new curriculum for medicine. This followed advice given to all medical schools from the General Medical Council in a document entitled Tomorrow's Doctors. Part of this course, which has been modified many times but retains its original structure, is a strand that runs through the first four years, known as "Firm 1".

"Firm 1" is a scheme in which medical undergraduates spend part of their training at a GP surgery. It is designed to give students the opportunity to talk to patients in the early years of the course and then to compare and contrast primary care with hospital care in the later years. Students observe experienced GPs consulting with patients, look at how patients are managed in primary care, and spend time talking to patients about their illness.

"Firm 1" takes place in general practices across the West Midlands region. In 1995, "Firm 1" was implemented in 26 practices with 26 tutors; this has risen incrementally and now takes place in 60 practices with more than 250 tutors.

Each practice makes a formal application to take part and is visited by two members of the education team in the Department of Primary Care and General Practice. At least one of these visitors is a practising GP. The practice team makes a presentation on why they want to be part of the scheme, and a discussion about the opportunities and problems they might encounter follows.

The premises are inspected for space and facilities. If the practice is approved for teaching, it needs to provide two dedicated consulting rooms for students, as well as a seminar room. In 1995, Professor Richard Hobbs, Head of the Department of Primary Care and General Practice, and Professor Jim Parle, who led the teaching team, negotiated with the NHS to establish a capital fund to enable practices to build these additional rooms in return for 10 years of teaching. Most of these funds have now been used, so the NHS rents space from the Service Increment for Teaching (SIFT) monies.

Each group of students has its own day: for example, first years visit the practice on Thursdays, second years on Tuesdays, and so on. Monday – generally the busiest day in general practice – is left free! Students attend in groups, normally comprising four students, but, depending on fluctuations in the year size, these groups may comprise between two and six students. We try to avoid sending only two or three students as it works less well educationally.

Normally, therefore, a practice will take on 32 students in total in any year. The practice has visiting students every week, but individual student attendance is once a fortnight. This means that the practice has two groups of students for each year attending on alternate weeks. For each student, the number of days attendance varies according to year: a student attends the practice for 10 days in his or her first year; nine days in year two; 11 days in year three, and 12 days in year four, which means that the practice sees visiting students 84 days a year.

Course content varies from day to day and from year to year. In the first two years, the idea is that students get the opportunity to see patients in general practice with problems related to the topics they are studying – patients with angina when they are studying the cardiovascular system, or talking to people with chronic illness about the psychology of living with a disease. They also gain experience of talking to patients and learn to behave as a professional, to take a history and to examine patients.

In the third year, when students first begin their training in hospitals, "Firm 1" offers them the opportunity to see what happens before and after a hospital stay and to follow patients over a year, observing the pattern of their illness. In addition, they follow a patient with a serious illness and visit two mothers with babies. When, in their fourth year, students study six specialist topics in hospital, "Firm 1" gives them the opportunity to see a range of patients living in the community with problems related to those topics, and how GPs manage them.

At Birmingham, students also have a four-week attachment in general practice, which is not part of "Firm 1", in their fifth and final year. During this time they build on their learning in "Firm 1" and spend time consulting with the GP and observing the management of their patients. Some "Firm 1" practices are involved in this teaching too; other practices only take fifth-year students.

And why is it called "Firm 1"? We don't really know! We think whoever named it was a hospital consultant accustomed to hospital "firms"; the "1" perhaps refers to the newness of the scheme.

Melanie Price
Education Manager
Worcester Street Surgery, Stourbridge

Before joining primary care, Melanie worked in hospital, having obtained her AMSPAR medical secretaries' Diploma as a mature student, which she describes as "the best thing I ever did". Her free time is spent with friends and family, including six grandchildren. She also enjoys travelling with her husband and gardening, for which she is now helped by Lucy, a 12-week-old Springer Spaniel puppy

In September 1995, with mounting fear and anxiety (certainly on my part), and much anticipation and excitement, we awaited the arrival of our first-ever group of first-year medical students.

Although the "Firm 1" scheme had already been successfully piloted in some inner-city surgeries, ours was the first outer-city practice to participate in this scheme, being located 12 miles southwest of Birmingham city on the  Worcestershire/Staffordshire border.

Our "Firm 1" students were therefore intrepid explorers, the first to venture out into the wilds of the Black Country. I, the administrator, but more like a demented mother hen awaiting the arrival of her first clutch of chicks, tried to anticipate every possible obstacle for these students negotiating the hazardous journey from Birmingham Medical School to Stourbridge. The fact that many of them had calmly travelled from all corners of the British Isles, and in some cases halfway around the globe, to get to Birmingham seemed to escape me at the time. So maps, detailed directions, train and bus timetables winged their way to Birmingham – no "download the directions off the net" or "chat up the one with the car" in those days!

At last, D-Day arrived, and with it four rather bemused-looking students, who had just been collected from the train station – no doubt for the first time since they were seven years old. They were then liberally plied with tea and biscuits, plus a sandwich lunch to save them the added trauma of walking 200m into town on their first day.

Of course, in between the travelling and refreshments, some teaching also took place. The year flew by in what at times seemed a never-ending flurry of photocopying (with the copier and me joined at the hip). In those far-off days, tutor/student folders weren't as slick and organised as they are now.

That first year also saw the emergence of what has become a loyal band of patient volunteers. These volunteers thankfully filled our high demand for patients willing to talk to students about their illness and those who could spare the time to allow students to practise their clinical skills. As a result, some patients now even contact the practice to remind us that "Chest Day" or "Heart Day" will soon be upon us, and happily offer their services. One regular, when telephoned, even called out to his wife: "Nell, am I free next Tuesday? They want me to do some lecturing again to the students!"

Many patients see this as an opportunity to give something back to a practice that has always helped and supported them and their families. Even patients who may not actively participate are justly proud that their surgery is helping to train tomorrow's doctors.

In 1996, our students returned as laidback second years, and we had a new group of first-year students; still clucked over, of course, but not quite so intensively this time. Since then, years three, four and five have joined us, with all our partners now involved to some degree with student teaching.
 
It is also with great pride and much pleasure that we have seen some of our students return to work at the practice as fully qualified doctors.

At the end of that first year, we looked back at this new venture with a huge sense of satisfaction and achievement. Ten years and more than 500 students later, surgery life continues to be enriched by their presence. A continued team effort right through from patients, staff, partners and doctors contributes to the successful running of our "Firm 1" practice.