The Wonca Europe definition of general practice has greatly influenced the approach to knowledge and skills development in academic medical education (Wonca Europe, 2011). An acknowledged strength of
Wonca´s paper is its detailed definition of general practice (Gregory, 2009; Saultz, 2012). However, general practice teaching is far from static (Canadian Medical Association, 2011): given the breadth of knowledge and skills understood to characterize general practice, medical schools have been able to adapt curricular programmes to local particularities, such as epidemiological profiles, curriculum deficits and community preferences (Society of Teachers of Family Medicine, 2009). Although such variations make it harder to define the precise content of general practice training, several efforts have been made worldwide to define regional or national core curricula to help schools define their priorities. These different sets of learning objectives and outcomes have significantly influenced the way general practice is taught, learned and understood globally.
In the UK, the GMC publication Tomorrow´s Doctors (2009) (undergraduate medical education policy) has reaffirmed the necessary shift from unequally distributed hospital-based education to more evenly distributed teaching in community care, especially primary medical care (Pearson & McKinley, 2010). Some researchers argue that very pragmatic reasons are motivating this shift, such as an expansion of student numbers, hospital care reforms and shorter hospital stays (El-Bagir & Ahmed, 2002). Pearson and McKinley (2010) point to more important medical education reasons for promoting community care teaching, especially primary medical care. These include: (1) the need to understand the social and psychological aspects of ill- health; (2) the fact that 90% of medical encounters happen in a primary care setting and that 50% of medical graduates will work as general practitioners; (3) a growing acknowledgement of the complex health system pathways
being coordinated by general practices. As to what can be taught in primary medical care, the authors affirm:
“Primary medical care is an ideal setting to teach early patient contact, learning of clinical method (including consultation skills), diagnosis and management of early presentations of illness, and of chronic medical conditions including complex multiple pathologies and associated poly pharmacy. It is also an ideal setting to teach much acute medicine and a wide range of ‘specialties’ including dermatology, ENT, ophthalmology, musculoskeletal medicine, women and child health, and mental health. (Pearson & McKinley, 2010)”
A pilot study compared primary care clinical caseload data with the curriculum objectives of a medical school in the UK (Jepson & Hays, 2011). Its results showed that 40% of the intended learning objectives could be taught in general practice, while 14% could not be easily in either primary care or hospital settings. It should be noted that this research focused solely on learning objectives that could be translated into diagnostic classifications, leaving out non-disease centred knowledge, skills or attitudes.
Guidelines for Brazilian undergraduate medical courses have also promoted community care teaching but without establishing learning outcomes for this specific teaching setting (Brazil, 2001). The first attempt to define outcomes for medical teaching in primary care was published in 2007 by Gastão Campos. Campos attributed to primary care the responsibility of increasing accessibility, providing comprehensive care and promoting public health. His main focus was on creating the best conditions for students to learn in a primary care setting. This required political agreements between academia and health services, appropriate financing for professionals, consideration of the physical structure of the health units and the availability of
established and trained academic teachers to support the whole experience (Campos G. , 2007).
The Brazilian Society of Family and Community Medicine (SBMFC) and the ABEM organized workshops with general practice tutors and academic teachers from across Brazil to discuss the characteristics of medical education in primary care. The result was a series of published articles and a chapter in a medical education textbook dealing specifically with primary care teaching. These texts addressed issues such as: (1) why teaching in primary care was necessary; (2) what should be taught; and (3) when and how teaching should take place (Demarzo, et al., 2011). Regarding what should be taught, the learning outcomes were divided into individual, family and community approaches. The individual approach was patient-centred, dealing with unspecified problems and promoting the patient´s autonomy. The family approach considered the family´s particular structure and dynamics through the use of genograms and “ecomaps” in order to identify intra-familial influences on ill health. The community approach was associated with population/public health knowledge and technologies needed by particular health territories (Demarzo, et al., 2011).
Elsewhere in the world, the Society of Teachers of Family Medicine (STFM) (2009) in the USA commissioned a taskforce to develop the Family
Medicine Clerkship Core Content Curriculum (C4). This document was a
national effort to define the remit of medical schools in teaching undergraduate students. The C4 is structured into four sections: curriculum competencies and content, clerkship director roles and resources, educational methods, and assessment strategies (STFM, 2011; 2012). Canada´s attempts
to define nationally-accepted outcomes resulted in the production of the
Shared Canadian Curriculum for Family Medicine by the Society of Teachers
of the Canadian College of Family Physicians (Steyer, 2010). The structure and content of both sets of guidelines closely follow worldwide definitions of general practice, but with local variations to reflect particular contexts and developments. These two countries are examples in the literature (i.e. English language) of efforts to characterize general practice teaching.
As medical schools expanded their clinical and territorial range, medical education research also extended its focus to include general practice teaching. The result is a growing sub-field of research with a broad range of experiences, methods and results, which are detailed in the following section.