Vertical Integration in Teaching And Learning (VITAL): an approach to medical education in general practice

There is an increasing demand to deliver medical education in general practice. With the trend for hospitals to evolve into highly specialised centres with high throughput and short patient stay,1 there is an associated shift in medical education (along with the patients) from the hospital environment to the community setting. The latter affords medical students and doctors the opportunity to see and manage common problems and chronic diseases, to put preventive health care into practice, to see patients in the context of their family environment, and to experience continuity of care — major medical curriculum learning objectives that are not so readily met in the hospital setting.

In response to a shortage of medical practitioners, Australia has seen a substantial increase in the number of medical students and new medical schools. From 2005 to 2012, the number of domestic medical graduates is projected to increase by 81% (1348 to 2442), and international graduates by 92% (260 to 500).2 A flow-on effect will be a difficulty in finding placements for junior graduates, which have traditionally been entirely in hospitals. A proposed solution is for prevocational graduates to be rotated through a general practice term; this is already occurring in some regions.3

This shift of medical education into the community is inevitably having a significant impact on general practice service delivery and resources. It is crucial that an expanded educational role for general practitioners does not become burdensome nor cause “burnout” for already busy practitioners, especially when it is predicted that the GP workforce will likely face continued chronic shortages.4 While recruiting more GPs to educate medical students will help increase the number of community placements for students (it is estimated that only 48% of GPs work in a medical practice that provides training for medical students or GP registrars5), other approaches are also needed to overcome the problem.

The concept of vertical integration can mean many things. General Practice Education and Training (GPET), the Commonwealth body funded to administer vocational general practice training in Australia, defines the vertical integration of GP education and training as “the coordinated, purposeful, planned system of linkages and activities in the delivery of education and training throughout the continuum of the learner’s stages of medical education”, with the learner’s stages including medical school, prevocational hospital training, vocational training, and continuing professional development.6 Formed in 2001, GPET has developed a national framework which supports one of its objectives: to promote the vertical and horizontal integration of general practice education and training at a regional level.6 GPET suggests that the application of this framework, which may be used by governments, other education providers and policy-makers, will require flexibility and diversity in the use of vertical integration models.6

A model that supports the concept of learning as a symbiosis,7 and could be considered in the application of GPET’s national framework, is the sharing of teaching and learning roles across all the learner stages. It is of note that the current curriculum of the Royal Australian College of General Practitioners includes, for the first time, a statement on teaching as a core component of the GP and GP registrar role.

While much medical student training in the hospital setting is provided by registrars (with benefits reported for both students and registrar equivalents when teaching skills courses have been provided8,9), this is seldom the case in general practice. Although GP registrars are present in many practices that take students, most of the training is given by experienced GPs. Possible reasons for this include the historical separation of medical student and GP training, with no coordination of practices used for these two educational purposes; the limited time spent by medical students in general practice in traditional medical programs, and hence less need for student teaching in general practice (which has changed with modern medical curricula which require substantial general practice contact); the limited time scale to develop effective teaching models in this clinical context; and the broad clinical nature of general practice, in which a relatively inexperienced doctor may take longer to feel competent.

1 The VITAL (Vertical Integration in Teaching and Learning) in General Practice Model