: (01228) 814881 Medical Education Centre Email: eastcumbriagptp@nhs.net Cumberland Infirmary Website: www.eastcumbriavts.com Carlisle CA2 7HY Proposal to seek approval for an Integrated GPStR Post Date: 18 th July 2012 1. Post details Title: Integrated Training Post in General Practice and Dermatology 2. Bases: 1. Approved training practices in East Cumbria-the practice will vary depending on availability. Educational Supervisor: GP Trainer. Clinical Supervisor (specialty post) Dr. Khurshid A Bazmi Work address Dermatology Department, Cumberland Infirmary, Newtown Road, Carlisle, CA2 7HY Telephone number: 01228 814152 (secretary) Email: khurshi.bazmi@ncuh.nhs.uk 3. Background / rationale In the UK, 15 per cent of consultations in primary care relate to problems with the skin, and skin problems are a common reason for injury and disablement benefit or periods of certified incapacity to work. In 1991 2, they were the fourth commonest reason for people consulting with their GPs in England and Wales. The vast majority of skin problems can be managed in primary care, relieving pressure on secondary care services. [Excerpt from from RCGP Curriculum Statement 15.10: Skin Problems]. Many GP trainees wish to incorporate experience in Dermatology into their training programme, potentially with a view to exploring the possibility of developing their skills with further training (for example completion of a Diploma in Dermatology) when they have gained their CCT. The department of Dermatology at the Cumberland Infirmary, Carlisle has an established record of providing high quality training to GP trainees through the standard 6 month training post which has received very good feedback. Clinical experience in Dermatology Outpatients and Nurse Led Dermatology clinics is well suited to gaining the necessary knowledge and skills to provide competent care July 2012 1
in this aspect of the General Practice curriculum and indeed to develop a good level of confidence which could have an impact in enabling more patients to be managed within the primary care setting without requiring onwards referral. The integrated training post aims to offer the opportunity to gain confidence and experience in the diagnosis and management of Dermatology problems in the context of General Practice. Additionally, In the Dermatology outpatients setting, there are many opportunities to develop skills in minor surgery which will be valuable in within primary care. This is in addition to opportunities to observe more specialist treatments, including skin surgery for malignant lesions and their subsequent discussion within the multidisciplinary team and the use of botulinum toxin in the management of hyperhidrosis. It is anticipated that the post would provide good exposure to dermatology in the outpatient setting along with minor surgery lists and seeing ward referrals. 4. Educational outcomes Generic Learning Outcomes for Integrated Posts It is anticipated that the learning outcomes of each Integrated Post will enable the GPStR to: augment existing clinical and intellectual skills in order to make decisions and problem solve for the benefit of the patient and significant others provide evidence based care which is robust and makes optimum use of available resources including local expertise and experience demonstrate in consultation and within teams the interpersonal and communication skills which are effective, empathetic and conducive to collaboration and co-operation critically evaluate the interface between primary and secondary care services and agencies discuss the impact of national health policy on the local provision of care demonstrate developing IT skills develop confidence and competence as a novice GP Individual registrars are expected to produce a set of learning outcomes which are tailored to their specific learning needs and share these with their clinical supervisor and the training programme in advance of commencing the post. Learning outcomes specific to the post (mapped to the GP curriculum) The knowledge base (Curriculum statement 15.10) Key issues in the diagnosis of skin problems will be eliciting of the appropriate signs and symptoms and subsequent investigation and/or referral of people presenting with: Rashes Hair loss A disorder of their nails itch (also known as pruritus) Pigmented skin lesions Signs of infections of the skin Bruising or purpura Lumps in and under the skin Photosensitivity and the red face. Common and/or important skin conditions: Eczema Psoriasis July 2012 2
Generalised pruritus Urticaria and vasculitis Acne and rosacea Infections (bacterial, viral and fungal) Infestations including scabies and head lice Leg ulcers and lymphoedema Skin tumours (benign and malignant) Disorders of hair and nails Drug eruptions Other less common conditions such as the bullous disorders, lichen planus, Vitiligo, photosensitivity, pemphigus, pemphigoid, discoid lupus, granuloma annulare and lichen sclerosus. Investigations: Ability to take specimens for mycology from skin, hair and nail Basic interpretation of histology reports Skin biopsy. Treatment: Those commonly used in primary care (including an awareness of appropriate Quantities to be prescribed and how to apply them) Principles of protective care (sun care, occupational health and hand care) An awareness of specialised treatments, such as retinoids, ciclosporin, Phototherapy and methotrexate The indications for, and the skills to perform, curettage, cautery and cryosurgery. Emergency care: Acute treatment of people presenting with skin problems or symptoms thought to be due to skin problems and appropriate referral if necessary. Including: disseminated herpes simplex erythroderma pustular psoriasis severe nodulo-cystic acne toxic epidermal necrolysis Stevens-Johnson syndrome Prevention: This will involve the following risk factors: Sun exposure Fixed factors: family history and genetics Person-centred care Appreciate the importance of the social and psychological impact of skin problems on the patient s quality of life, including, for example, the effects of disfigurement or sleep deprivation as a result of itching. Identify the patient s health beliefs regarding skin problems and either reinforce, modify or challenge these beliefs as appropriate. Specific problem-solving skills Intervene urgently when patients present with an emergency skin problem Demonstrate a reasoned approach to the diagnosis of skin symptoms using history, examination, incremental investigations and referral. A comprehensive approach Advise patients appropriately regarding lifestyle interventions including skin protection and occupational health advice. Describe the side effects of common medicines used to prevent and treat other conditions that may cause skin problems. July 2012 3
Community orientation Describe the rationale for restricting certain investigations and treatments in the management of skin problems, e.g. prescribing of retenoids, access to phototherapy. Describe the importance of occupational risk in the aetiology of skin disease. A holistic approach Recognise how disfigurement and cosmetic skin changes fundamentally affect patients confidence, mood and interpersonal relationships. Appreciate the importance of the social and psychological impact of skin problems on the patient s quality of life, including, for example, the effects of disfigurement. Recognise the impact that skin problems have on fitness to work. Appreciate the importance of the social and psychological impact of skin problems on the patient s family, friends, dependants and employers. Empower patients to self-manage their skin conditions as far as practicable, e.g. eczema. Contextual aspects Recognise how common skin problems are among the general population. Recognise the risk of inappropriate referrals and under-referral. Describe the need for close collaboration with primary care and specialist services in the management of many skin problems, e.g. pigmented lesions, psoriasis. Occupation and care of the hands. Genetics: Describe how genetic factors influence the inheritance of common diseases such as psoriasis and atopic eczema. 5. Post summary 5 sessions based in dermatology with one full day at West Cumberland hospital and 2 further sessions in the Cumberland Infirmary, Carlisle. The main clinical supervisor in dermatology would be Dr Bazmi with Dr Nick also available for clinical supervision. 4 sessions based in General Practice 1 session per week VTS ½ day release programme In order that there is sufficient clinic capacity to accommodate an additional GPStR within the Dermatology Department, it will be necessary for 2 of the 4 sessions within the specialty component to be carried out at the West Cumberland General Hospital. It is understood that any prospective post holder accepts allocation of this Integrated Training Post on this basis. 6. Main duties and responsibilities of GPStR General Practice: To ensure that they have adequate indemnity insurance to cover their work both in the General Practice component and the dermatology component of the post. Working as a GPR in practice. To include the full range of normal general practice duties including Out of Hours as detailed below. Specialism: July 2012 4
Working alongside consultants and other senior dermatology staff in a supernumerary capacity in a clinic and ward setting within the dermatology department. 7. Details of training programme. On call arrangements where applicable and protected teaching Give details of any on call commitments, indicating the educational benefits Specify the balance between general practice teaching and teaching in the specialism The Out of Hours commitment will all occur in the GP component of the post, following the current deanery requirement which is one out of hours session per month (therefore 6 in total for this post) with Cumbria Health On Call (CHoC). The GPR will participate in the North Cumbria Out of Hours Training programme, as defined by Deanery requirements and the Workplace Based Assessment. Typical Timetable Day of the week Monday GP Activity & venue AM GP Activity & venue PM Tuesday GP GP Wednesday CIC out-patient clinic GP VTS teaching Thursday WCH out-patient clinic WCH out-patient clinic Friday CIC day surgery CIC ward referal and reviews 8. Scope for flexible/part time training This would be possible but would need a discussion with the relevant supervisors to ensure enough clinical experience was achieved. 9. Arrangements for monitoring, support and appraisal of GPStR for both aspects of the post The GPR will outline their educational objectives and undergo an agreed induction in each component of the post. In the General Practice component, mentoring and support will be provided by the GP Trainer. The Trainer will undertake the usual range of formative assessments including beginning, midpoint and endpoint assessments and feedback to the scheme. The assessment schedule and learning log will be completed as defined by the workplace base assessment. The dermatology supervisor will also undertake regular formative assessment to assist the GPR in their educational development in the specialist component of the July 2012 5
post. Assessments will be carried out in line with the requirements of the work place based assessment. Both the GP Trainer and the dermatology supervisor will be required to complete a Clinical supervisors report at the end of the post as part of the end point assessment. This report is available to the GPR, the educational supervisor, and the scheme TPD via the GPR's e-portfolio. The Training Programme Director will see the GPR at the mid-point of all posts to assess progress. In addition any other comments about the value of the post will be taken into account. Feedback will be expected from the GPR on each component of the post, copies of which will be sent to all stakeholders. Feedback from all the stakeholders will form part of the quality assurance of the post. 10. Brief overview of experience of Trainers, practices and/or departments in GP postgraduate education All GP Training practices will be experienced training practices with experienced General Practice trainers. The Dermatology department has a long association with GP training, which has been consistently reported through feedback and Annual Departmental visits as being of high quality and highly relevant to General Practice. The aim is for the dermatology post to complement the GP post so dermatology cases and can be seen and the management reviewed with the specialist supervisor. 11. Anticipated viability of the post The post as outlined above is due to be available for a start date in February 2013. 12. Any other information To be returned to Lead Training Programme Director East Cumbria VTS Education Centre Cumberland Infirmary Carlisle CA2 7HY Email: hene.eastcumbriagptp@nhs.net July 2012 6