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Twenty years ago Gabbay and le May published research that described the ways in which GPs work, generating knowledge by creating practice-based evidence, or what has been termed ‘knowledge-in-context’. This is the framework that enables GPs to utilise but move beyond scientific evidence to deliver healthcare tailored to the needs of their patients and communities. The concept of knowledge-in-context is being undermined by the current pressures in the system, by the nature of workforce training and even by the way we talk about the soft skills of practice. General practice is losing control of the knowledge work of daily practice needed for whole-person healthcare. At an RCGP conference workshop in 2017, a packed room recognised these concerns and decided to take action. From that conversation grew WiseGP. WiseGP champions, fosters and maintains the knowledge work of front-line general practice. WiseGP is already delivering changes on the ground. It underpins the CATALYST programme driving workforce change in Humber & Yorkshire and delivering re-energised GPs. The Society for Academic Primary Care and the RCGP are now working to establish a WISE Institute, translating WISE approaches into practice design in order to re-vitalise the work of general practice. WiseGP is reclaiming the knowledge work of whole person healthcare which defines our speciality. Join us in reclaiming General Practice. This article first appeared in an RCGP Weekly Update on 23 Sept 2022

This blog was first published by the Innovation Research Board on the Royal College of General Practitioners website in 2019 Guidelines play an important role for GPs, but they can’t give answers on how to care for an individual. GPs use generalist wisdom to deliver personal care, but do those outside (or even inside) the general practice profession fully understand what that is? Professor Joanne Reeve, WiseGP lead and Professor of Primary Care Research, Hull York Medical School, discusses WiseGP, a new initiative championing the wisdom of daily practice. The WiseGP programme is a joint initiative between the RCGP and the Society for Academic Primary Care (SAPC) to champion the distinct clinical scholarship that lies at the heart of person-centred general practice. WiseGP recognises the need for everyone – professionals, the public, policy makers and patients - to understand the distinct intellectual work that GPs do, to ensure that practice, policy, workforce and workload solutions are designed to optimally support and use the expertise of GPs. Research suggests that there is work to be done this area. Medical students do not see general practice as intellectually stimulating[1]. Yet practising professionals report that the work is, at times, overly intellectually demanding[2] . Observation of professional practice in action[3] describes the skilled and complex process by which GPs generate explanations of individual illness to guide tailored management plans. Professional accounts of being a ‘jack of all trades’[4] also reveal the skill and complexity of practice but plans such as those for ‘digitally enabled primary care’[5] don’t, as yet, seem to recognise these challenges. Clinical guidelines offer evidence of best care for management of specific conditions. In a consultation, GPs combine these with information from patients and from professionally constructed ‘mindlines’[6] to generate new knowledge about this individual in their context. This means GPs must use the skills of clinical scholarship[7] to generate explanations of individual illness to guide a tailored management plan. The distinct intellectual skill of general practice lies not in knowing a little about a lot, but in being able to use that knowledge to generate tailored interpretations of illness. The WiseGP programme describes this as the Bananarama Principle – it ain’t what you know, it’s the way that you use it (that gets results…). But GPs tell us – both in research studies[8], and through informal conversations – that health services are not designed to adequately support this model of practice. Barriers[9],[10] include a perceived lack of permission to work beyond guidelines, failure to prioritise this challenging task within a busy workload, insufficient professional training to develop the skills as well as the confidence to use them, and performance management processes that at best ignore – and at worst inhibit – this form of practice. These problems extend beyond the clinical management of individual patients to GPs’ work to support practice development and quality improvement[11]. WiseGP aims to tackle these barriers through three activities. Raising the profile and understanding of the intellectual work of general practice – to guide conversations across the board about how to revitalise general practice. Delivering a new Skills Academy – resources to develop skills and confidence in all GPs, and access to advisors and experts from within the SAPC community. Supporting and championing new teams of GPs championing scholarship, such as the PACT initiative led by Dr Polly Duncan. If you would like to know more about the WiseGP programme, or to access any of the resources being developed, explore this website, sign up for our newsletter and follow us on Twitter (@wisgpcouk) [1] https://bjgp.org/content/69/683/309/tab-article-info [2] https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-017-0705-2 [3] https://www.tandfonline.com/doi/full/10.3109/13814788.2013.805197 [4] https://www.gponline.com/generalist-medicine-gps-celebrated-jack-trades/article/1417502 [5] https://bjgp.org/content/69/686/420 [6] Gabbay J, Le May A (2010) Practice-based evidence for healthcare: clinical mindlines (Routledge, Abingdon) [7] https://bjgp.org/content/67/659/266.long [8] https://www.publish.csiro.au/PY/PY18019 Open access version: https://hull-repository.worktribe.com/OutputFile/981617 [9] https://bmcfampract.biomedcentral.com/track/pdf/10.1186/s12875-017-0705-2 [10] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3899736/pdf/10.1177_2042533313510155.pdf [11] https://bjgpopen.org/content/2/1/bjgpopen18X101421

The Wisdom course will shortly go live on FutureLearn. In this blog, Johanna Reilly provides a personal reflection on her experiences and the process of creating the Wisdom course. “So what exactly is this other job you do?” “Well, umm, it’s sort of a thing… a website and we’re making a course and a podcast and blogs… it’s kind of about knowledge work… GP wisdom… and, ermm, scholarship..” I’ve repeated this exchange with any number of friends and colleagues (and my appraiser) and I’m used to the blank face I get in reply. My explanation is clearly somewhat lacking but it’s interesting that the idea of primary care scholarship or more specifically, promoting and celebrating primary care scholarship seems so removed from so many of my colleagues in practice. Being completely honest when I started working on this project I felt somewhat similar. As a newly qualified GP, I had replied to a job advert for a session a week as a remote intern for WiseGP. Professor Joanne Reeve had started the Wise website after feedback at conferences about the need to bridge the perceived gap between academia and front line general practice and to celebrate the scholarship and knowledge work done every day by all GPs. I had been involved in some research work after I had finished GP training and felt similarly, that primary care seemed to be divided into a small number of academic GPs and everyone else when we should be one team. I wasn’t sure what a website would do about that though, or how we could start those conversations. In the last year working for Wise, although I’m still not sure, I think we might have reached a starting point. Annabelle, Emily and I all started working as Wise interns part time. We were probably as geographically spread as we could be around the UK and had different interests and viewpoints but we all felt strongly that our day job needed something more. We took different focuses at the beginning, Emily focusing on outreach and building connections, Annabelle on updating the Gems library and planning a newsletter and me on attempting to start a podcast and blogs. Podcasting proved an interesting journey. I phoned a friend for a 30 minute tutorial on free software and audio editing and then decided to give it a go. The results are great from my guests, who have all been incredibly articulate and had fascinating stuff to say. As for me, I have a lot of “Umms” and “Errs” to edit out as I stumble around, trying to remember what questions to ask next. The amazing thing about doing a podcast has been the opportunity to talk to people in a non-pressured way about their work and their thoughts about our work and that, for me, has been a fantastic learning experience even if my interviewing technique is somewhat lacking. (Podcasts are available on the Wise website and via Spotify if anyone is interested) Then Joanne said there could be funding available for us to create a online course aimed at early career GPs about knowledge work. We were all keen – but what would we put in it? Because primary care is such a broad church there could have been multiple angles to focus on. We had some interesting discussions – could we discuss epistemology or would our target audience run a mile? (Answer – maybe, it’s in the extra notes) How could we keep it relevant for day to day clinical practice? Could we bring our personal interests while keeping the focus on knowledge work? The course is free online but that means busy GPs would be doing it in their own time. How could we keep it challenging enough to interest but easy enough to complete in an evening at the end of a busy work day? We created a logic model and wrote lots of word documents we sent round and round. Then it came to process of creating the online course and we discovered we were expected to make multiple “talking head” videos explaining our material. Never exactly comfortable on camera, this was a trial for me and I have yet to actually watch the videos so believe I might have forgotten what I said. The technical process of submitting material to the FutureLearn platform also had its challenges and I was grateful to Annabelle for her organisational expertise and keeping the rest of us on track, no one who knows me well will be surprised to learn I was still uploading content late in the evening before our final deadline loomed. It would be wrong to discuss the process of making the course without mentioning the context. The winter of 2021/22 has been exceptionally challenging I think for all of us working in primary care. The pressure has been incredible and the public dialogue unsupportive. In my practice caring for people experiencing homelessness we have had a huge toll of untimely drug related deaths and morbidity of young patients and associated stress experienced by staff. With family commitments as well there were times when I felt that discussing and writing articles about primary care scholarship and knowledge work was not something I could or should prioritise. It's easy to look back now the course is submitted and say I’ve changed my mind but I have. It feels like we are at a juncture when medicine is being increasingly technologised and depersonalised. There is a belief commonly held that in twenty or fifty years an algorithm will be doing our job, only better than we do it. I don’t think that’s right and it’s not just because personal relationships are important in medicine (although they are) but because medical learning and knowledge are not so simply fitted into a mathematical model but come from deep knowledge of systems and cultures and intuition and tacit knowledge matters too. If we are to have an NHS that survives and thrives we need strong primary care, to provide holistic whole person care, not focused on one single organ system but on a whole complex person, in the context of a community and their family. Primary care scholarship, thinking about what we do, how we learn, how we should best advocate for our patients and communities is essential to that strong primary care. So by making this course I hope that we will help inspire that spark in some new GPs and perhaps some more experienced ones too. We can’t be all things to all people and I’m fully expecting some will find the material too basic or not relevant enough… but I hope there will be something useful for some of you out there. So please consider signing up by clicking the button below and if it’s useful or if not – please send us some feedback – we’d love to hear from you. Johanna Reilly

News around the climate and ecological crisis often seems unfailingly negative and for good reason, as the evidence seems to show we are sleepwalking into an ecological disaster and political will to fix the problem is lacking. The idea of rewilding is one that has gained pace in recent years and has brought hope to many people. Restoring ecosystems might also have profound benefits for human health in ways not yet fully understood. Spending time in so called “green space” is known to be beneficial to overall health with people who live near a quality green space likely to have better health overall regardless of socioeconomic status. But why is this? It is more than simply trees and grass being pleasant to look at and making us feel better. Recent research about the effect of the microbiome on overall health and how this is affected by time in nature shows that lack of time in diverse ecosystems might be having a serious negative impact on population health. The concept of rewilding does not have a one clear definition but most proponents agree it involves giving nature space to recover and allowing ecosystems to regenerate naturally, rather than managing and attempting to control. Rewilding moves away from ideas of tidy landscapes and managing an ecosystem for one particular outcome. Much land in the UK has been intensively managed for years, even some of what we might see as “wild”. In the book Wilding Isobella Tree describes the experience of allowing nature to return to her families farm in Sussex and now Knepp farm is a beacon of rewilding practice for others to see and follow. The exciting thing about rewilding is you don’t have to have a large plot of land to help nature flourish. Small changes can help rewild urban environments. From letting a corner of your garden go wild with wildflowers to encouraging councils not to mow verges and clear up regenerating scrubland, a change of mindset in the UK can have big differences. We can also encourage others to spend time in natural environments and campaign for laws to prevent pollution and allow public access to wild spaces. Although more people than ever live in urban environments the rewilding movement reminds us we remain enmeshed in the natural environment in ways we do not always fully understand and we must find space for nature space in all our lives. Johanna Reilly

The NIHR In Practice Fellowship (IPF) scheme is open to all qualified GPs, General Dental Practitioners and Community Dentists taking their first steps in formal research training. Fellows are paid at clinical salary rates to undertake predoctoral (e.g. Masters degree) research training. But at a time when General Practice is chronically understaffed, is it right to take ‘time out’ for research? Do some consider primary care research to be an ‘unaffordable luxury’? At WiseGP, we would argue that GP research is a necessity, not a luxury, offering multiple benefits for patients, individual GPs and the profession as a whole. Here’s why we encourage you to take a closer look at the opportunities offered by the IPF scheme. Enhancing your clinical skills: “every doctor a scientist and a scholar” First and foremost, research training enhances clinical practice. This is why the GMC recognises and requires medical training to support ‘the doctor as a scholar and scientist’ As a GP, you deliver safe, effective, tailored care to individual patients. WiseGP was established to recognise, support and promote the distinct knowledge work involved in everyday primary care clinical practice. Research training enhances knowledge work and so strengths your clinical skills. Enhancing your professional practice As a GP, you are also a consultant in primary care medicine – responsible for delivery of whole-person care to a community of patients. Your knowledge work skills extend beyond individual clinical decision-making to include designing and evaluating healthcare e.g. through Quality Improvement roles, and training the primary healthcare workforce (supervision and teaching roles). These are all part of the portfolio career path of General Practice, and roles that are championed and supported by the WiseGP programme. Research training can also enhance skills and confidence in the knowledge work of extended professional practice. Improving the quality of healthcare As a GP researcher, the scope of your role shifts again – to the knowledge work needed to deliver, transform and sustain primary care practice for a wider community – whether regional, national or international. Primary Care research is a vital part of continued delivery of safe, effective and equitable healthcare. Research training develops a community of GP researchers leading and driving clinically-informed primary care service development. So have you thought about getting involved in research? Tackling the myths that put some people off looking at research training Some people worry that getting involved in research means giving up their clinical practice. The reality is exactly the opposite. We need clinician researchers, now more than ever, if we are to develop the evidence-base and scientific-informed models of practice needed to tackle the challenges facing modern healthcare. Clinical academics – included In Practice Fellows – are expected, and supported, to continue clinical work within their professional portfolio. Others have told me that research isn’t for them because they ‘never enjoyed lab science’ at medical school, or they ‘hate statistics’. In reality, primary care research is much more diverse than those two areas of practice. Take a look at the GEMS library to get a flavour of the many types of research going on in primary care. “I’ve missed the boat because I didn’t do an ACF” is perhaps one of the commonest misconceptions I hear. In Practice Fellowships are open to GPs at any career stage, and with no expectation that you have had prior formal research training. The IPF scheme: who is it for The IPF scheme looks to support GPs who want to make a difference in primary healthcare through the critical discovery creation and application of new knowledge. You don’t have to have done any formal research training before an IPF. But you will need to show how your previous experience demonstrates your commitment to improving healthcare through scholarship. For example, you might describe your roles in leading quality improvement work, or leading local service delivery change – anything that demonstrates a commitment to the systematic use of data to drive change in understanding of/actions to address a problem How to apply Your fellowship must be hosted within a suitable academic department. So your first step is to get in touch with a suitable host. You can find a list of all academic departments on the SAPC website – most have an Ambassador, a contact person who can put you in touch with people who can help prepare your application. You will need to describe a clear training plan for your two years – including an area of research that you will be involved in. Your host department will be able to help you with this. And you need to tell a clear story of why you want to train in research – how it will help your professional career, and how you as a clinical researcher can make a difference in primary care. Top Tips So if you’re thinking about applying, here’s a few tips to get you started Read up about the scheme. The 2022 application hasn’t opened yet but you can see all the details about last year’s here. And make sure you read my Chair’s report for tips on a good application. Start writing your application NOW. If you’re not already discussing things with a department you might find it hard to get a strong application together for 2022. But you should still start that conversation now – even for the 2023 scheme. These things always take longer than you think. Most important of all, START. Future general practice needs WiseGPs with the skills, confidence, experience and enthusiasm to modernise what we do. Good luck! Joanne Reeve Joanne is the Founder & Leader of the WiseGP programme. She is current panel Chair for the IPF Programme

After I qualified as a GP in 2017 I was lucky to be able to do a health inequalities fellowship, funded by NHS Education for Scotland. This involved being attached to the Access Practice, where I now work as a permanent GP. I had clinical commitments which I found challenging and a great development opportunity after CCT but having some protected learning time during the fellowship was also the first time in my career I had the chance to step off the training treadmill and think for a time about how I wanted to develop in my practice as a GP and what I found interesting. I started reading more about health inequalities and the social determinants of health and felt I was really getting a new perspective on issues that had troubled me during my training but which I had been unable to explain. Wanting to get more research training and experience I started a Masters in Primary Care from the University of Glasgow and went on to do a further academic fellowship and to complete several research projects focusing on people experiencing homelessness or other forms of social exclusion. I also had 2 babies in that time which somewhat curtailed my academic and clinical interests with family commitments but taught me a lot about time management! Why WiseGP I think I probably talk about this too much in the podcasts and the previous blog on bjgp living but for me projects like WiseGP that promote scholarship in primary care are important for several reasons. First is the fact that in an increasing technologized society there is a sense that anything important can be measured and quantified. Much of the value in primary care is difficult to measure as it’s about building a long term relationship with a patient and care over a period of time. I think it’s important we remind ourselves of the importance of this because if we don’t value what we do, there is no way governments and politicians (or the public) will do. Secondly there is the challenge of health inequalities, rising multimorbidity and an ageing population. It is increasingly clear that more technological advances in healthcare won’t solve some of these problems. We need realistic pragmatic medicine, that can discuss risks and quality of life honestly with patients and I think that can only really happen involving generalists, who are able to take a broad view of the whole patient, not just a single condition, and have the skills to come to a shared understanding with the patient of the best way forward. Health inequalities will only be improved by care that is accessible for all and for me that must be primary care, based in the community where the patients are and understanding how that community works best. Promoting GP scholarship means attracting passionate medical students and junior doctors into general practice but also means a profession which can lead on some of these important changes and future proof our NHS. Ongoing I hope to be adding more podcasts and resources to the WiseGP page and am looking forward to helping to produce a MOOC about GP scholarship in the next year so please sign up to the newsletter for updates if you are interested. Dr Johanna Reilly

A third of doctors in training become General Practitioners. I probably always knew that I would too, however, maybe to the despair of my family and friends; I did not take a direct route. Each speciality holds the interest of a generalist, each placement as a junior doctor could sway you down that path, each healthcare team seem like your ‘people’, but the common thread is working with individual patients to help solve their health problems. A GP is the ultimate specialist generalist, applying the knowledge of all those specialities to everyday problem solving for every patient. Alongside this, all of us have the capability to generate knowledge and therefore develop the scholarship skills that contribute to improving individual patient health outcomes. Yet unlike those junior doctor placements, learning to generate this knowledge does not require years of training and any member of the primary care team can contribute. This underpins the WiseGP message, and I am very excited to be able to help the team spread this message a little wider. My first taste of research was during my Master’s in Public Health at The University of Sheffield where I was a medical student. This was a unique intercalation opportunity after my fourth undergraduate year, and meant I left medical school equip with additional basic research skills and a burning curiosity of how to apply this to clinical medicine. I was then promptly thrown into life as a foundation doctor. Throughout my clinical training, I tried to engage with what I now recognise to be ‘scholarship’. Quality improvement projects in respiratory medicine, audits in paediatrics, teaching medical students and foundation doctors and minor leadership roles. Without realising it, I was slowly building a portfolio of experiences and skills that would lead me to the epiphany that a portfolio career sounded like a really rather good idea. Five years into postgraduate training, and having completed my Core Medical Training (PACES and all) I finally jumped ship into General Practice. Mainly because this came with a fantastic opportunity of an Academic Clinical Fellowship with the University of Southampton Primary Care Research Centre. This allowed me time to follow my academic interests alongside my clinical training, and the opportunity to explore the world of Academic Primary Care. A specialty incorporating the clinical generalism of being a GP, whilst being at the forefront of applied clinical research and everything in between. During my ACF I have worked as part of a large team developing and feasibility testing a digital training tool called ‘Empathica’ that applies evidence for communicating with empathy and optimism to enhance the effectiveness of therapies for Osteoarthritis pain. I worked closely with patient and public involvement representatives to lead a qualitative project exploring how patients feel about this communication approach in primary care consultations. I have also followed my interested in acute medicine, exploring the evidence for how we make acute care decisions in elderly patients presenting with pneumonia, and the experiences of non-medical healthcare professionals who undertake GP tasks in acute, out-of-hours primary care. I want to explore this theme further, to understand how we deliver optimal acute services at the interface of general practice and secondary care. I have also pursued my interest in medical education working with my local GP education team to explore the evidence for virtual international exchanges to facilitate global health education for healthcare professionals. My ACF training provided me with not only a new academic skill-set, but also the confidence to apply this to other aspects of scholarship such as training and leadership, which I view as a unique aspect of my role as a GP. As a trainee I represented the Dorset patch on the Wessex Trainee Committee, I am part of the Wessex Next Generation GP leadership programme, and I now represent early career researchers for the Wessex REACH Initiative aimed at facilitating growth in future generations of health and care-related researchers across the region. Applying to become a WiseGP Intern felt like a brilliant way to share what I have learnt during my journey to becoming a GP and to help engage those students and trainees who may be following a similar path. In this role I will be providing the resources and connections early career researchers need to explore their own journey into scholarship, as well as contributing to expanding the conversation around the uniqueness of clinical scholarship in General Practice. And…to all those in training who are just enjoying all their placements and can’t quite decide on a speciality – have you thought about becoming a WiseGP? Dr Emily Lyness

Aspirations to promote the recognition of everyday clinical scholarship in general practice. Over the past year, the COVID-19 pandemic has prompted everyone to stop and reflect on what they value in their lives. Personally, I have been reminded of the importance of a loving home and the reward that comes from a fulfilling career in general practice. It was inspiring to see primary care academics challenge advice on face coverings, question evidence on the use of ibuprofen in COVID-19, examine the connections between ethnicity and illness severity, discuss the limitations of swab and antibody tests and highlight the plight of thousands suffering from long-COVID. But alongside these academics it is important to recognise the everyday clinical scholarship in general practice. I have had a lifelong passion for learning and academia. This enabled me to obtain a prize for outstanding A-level results, to support my studies at Keele University. During my medical training I was awarded the year 2, 3, 4 and 5 progress test prizes. Obtaining a GP Academic Clinical Fellowship post and subsequent grants from the Haywood Foundation and School for Primary Care Research enabled me to complete a PhD, to understand comorbid mood problems in people with inflammatory rheumatological conditions (IRCs). During my PhD I acquired a range of research skills, performing a qualitative study, systematic review and cohort study. In addition, I was a co-investigator on a funded study (INCLUDE), which aimed to determine the feasibility and acceptability of a nurse-led review based in primary care, for people with IRCs. I led patient and public involvement and engagement (PPIE) throughout the study and facilitated a primary care stakeholder group. I co-designed and facilitated training to the nurses delivering the review, contributed to the design of an EMIS template to record consultations, developed a summary sheet to communicate outcomes of the consultation to patients and helped to evaluate the intervention. Throughout my PhD I engaged with clinical communities, presenting my research regionally and nationally. I published my research in a range of journals targeted towards GPs and rheumatologists whilst also giving talks to community groups and co-developing a leaflet on mood problems in arthritis with patients. During my PhD, I volunteered as a Personal Development Tutor, mentoring a group of medical students throughout their training. I was able to share my interest in primary care scholarship and advise them on careers in academic general practice. After passing my PhD viva, I have taken the opportunity to improve my clinical practice, whilst applying skills acquired through my academic training to teach our multidisciplinary team. I have also obtained a position with the Royal College of General Practitioners, training pharmacists to deliver the new Community Pharmacy Consultation Service. Dealing with competing clinical demands has led me to reflect on how easily GPs can lose pace with rapidly changing evidence-based practice. During my Wise GP Internship, I aspire to apply my skills to improve the impact of research in primary care and engage GPs to actively contribute ideas and participate in research. In particular, I hope to champion the distinct clinical scholarship which lies at the heart of person-centered general practice. Dr Annabelle Machin

Does the teaching of person-centred care in medical school require a little more care itself? Hannah Watson The dedication to lifelong learning of health and disease begins on day one of medical school. The type of physician a student will become is ultimately shaped by what is taught, how it is taught and the early implementation of best practice. Using professional education to teach and encourage self-directed learning of person-centred care from the very beginning of undergraduate medicine will allow great person-centred care to become second nature. So could the addition of a dedicated person-centred care strand within first year problem based learning sessions aid the development and enhancement of the skills required to provide the best care for patients – is this the missing piece of care? Person-centred care Person-centred care (PCC) focusses on the needs of a person by allowing their views and priorities to be considered during shared decision making. Although patients do not always experience disease in the same way, their unwavering expectation to receive exceptional individual care remains paramount. Patients who were treated as individuals “felt comfortable and confident when doctors, nurses and other staff were perceived as caring and responsive to their individual needs”. As Osler reminded us, “The good physician treats the disease; the great physician treats the person who has the disease”, to be a great physician, you must understand the whole person. Person-centred care requires resource The demand for high quality personalised healthcare is significantly increasing the pressure on medical professionals. A 2018 projection for the UK, estimated there would be an additional 8.6 million 65+ years olds in 2068 and for those in England it was estimated that 14.2 million people would be living with multiple conditions. Managing individual complex illness, experienced by each patient differently, in an ageing population clearly places a huge strain on the NHS and could be viewed as a barrier to sustained delivery of quality PCC. Insufficient staffing levels and experience, time and equipment, may also pose barriers to providing excellent PCC. To address these issues and alleviate the pressure on the NHS, in 2019, 1500 more medical student places were allocated to UK medical schools. Increasing the number of training healthcare professionals prepares the NHS for a future of treating ever-expanding health problems by increasing professional capacity however, what is being taught must also be innovative and relevant to provide the best care. Benefits of early PCC teaching implementation To benefit from PCC, professionals are required to quickly recognise different, and possibly complex, health needs in individuals. This may require a deviation from standard treatment. Achieving what the Kings Fund described as reaching a “compromise” between biomedical-defined priorities for care and patient defined priorities. For example, to avoid problems with concordance and wasted medications compromise has been identified as important when a patient uses multiple medication. Considering the person holistically whilst using excellent communication skills to build a relationship with the patient has long been recognised as beneficial in achieving compromise in treatment decisions. Four components of doctor-patient relationship have been identified; trust, knowledge, regard and loyalty. To achieve good health outcomes, ideally using the mutual participation model, excellent communication is required because if it is not poor communication has been noted to affect the number of medical visits, the mental health and symptom relief of patients. However, modern practice sees additional challenges to delivering this in practice. For example, the growth of the internet means patients are aware of possible treatment options. Negotiating compromise between what treatment could be given and what should be given is a challenge and a potential conflict zone. Professionals report lacking skills and confidence in knowing how to best to achieve compromise in practice. For example, the main barrier to providing PCC is fear of making a confident decision for a patient that other professionals may not agree with as it does not strictly follow guidelines. Therefore, we need to think differently about how healthcare professionals are trained. One solution may lie in enhancing early teaching and self-directed learning of undergraduates. In order for health professionals now and in the future to address this complex situation and to efficiently provide a high-quality PCC, they will need to have the appropriate education, knowledge and experience. To gain these skills and the confidence to apply them, implementing the idea of PCC through professional education as early as possible in medical training would benefit students and allow them to explore how to provide PCC in their own style, so they are able to provide PCC as a matter of urgency. Medical school is challenging, there is a huge amount of information to retain, learn and to then put into practice. This therefore highlights why timing is important. Professional implementation of PCC will mean it will likely become second nature if practiced. Current undergraduate teaching of problem based learning and person-centred care One of the many approaches to medical school teaching is problem based learning (PBL). PBL has been described as an “effective teaching and learning approach” and should continue to challenge student’s problem solving skills. PBL is a spiral curriculum that encompasses all aspects of learning including lectures, clinical placement, clinical skills, workshops, anatomy and self-directed learning. At Hull York Medical School (HYMS) this is based on four strands: applied life sciences, health and society, clinical reasoning and professionalism. Teaching is enhanced by using virtual patients in specific scenarios in which students discuss all problematic elements of a case to create learning outcomes based around the four strands. In PBL, group work is beneficial for sharing ideas, discussing with others and testing one’s own knowledge. One limitation to PBL is that students are initially only taught about one personal experience of e.g. diabetes; however, this is not always representative of the affected population. Whilst PBL allows for self-directed learning it could be enhanced to offer integration of PCC elements for more than one individual experience (health and society strand) with clinical decision making (clinical reasoning and applied life sciences strands) by exploring discrete features of the individual patient values, contexts, attitudes and preferences in a professional manner. After consolidating knowledge based on an ‘idealised’ patient, PCC learning could be extended through the PBL model in a 5th strand to explicitly include integrated scenarios to include multiple or differently treated patients. For example, those who are burdened with an overload of treatment and overwhelmed by physical and mental consequences, and those who experience ‘too little medicine’ leading to late diagnosis of disease. An example of this can be read in the appendix. Although there is opportunity to test knowledge formatively, it is rarely specifically on the PCC aspect. In order to ensure each of the four stands is discussed during every virtual patient case, it is important to recognise that the same disease can manifest in different ways by presenting similarities and differences between the same cases. A possible solution to enhance teaching of PCC within undergraduate teaching? To develop a deeper understanding of PCC and manage individuals with complex illness, I have developed an idea to introduce specific, additional PCC teaching within the PBL format which can be reinforced using an interactive mobile application that presents students with multiple scenarios of managing a particular health problem. Using valuable and reliable information from publicly available resources such as ‘healthtalk’ and ‘Speaking Clinically’ to create additional sessions and self-directed learning using a mobile application could be used to put this into practice. This could challenge students current understanding of an ‘idealised’ patient and allow them to acknowledge, explore and review the implications of inconsistent and unpredictable health of numerous patients. Facilitated reflection will allow students to critically evaluate the similarities, differences, and consequences of being either a ‘good’ or ‘great’ physician, whilst providing examples of different models of care. An excellent physician is one who not only has the appropriate knowledge to manage patient health but one who can also tailor the skills and expertise they have acquired during training to enhance patient care. Using multiple resources available to select the most appropriate course of action is in the patient’s best interest, whether this be guidelines, consulting with a colleague or through experience of treating other patients. Professionals, family and carers can use facilitated reflection to learn and begin to understand, if different interpretations of illness, affects patient treatment and by reflecting on past experience, this will help to further develop scholarship skills needed for PCC. I propose that the quicker PCC is implemented within teaching the sooner students begin to benefit and recognise the importance of PCC. My idea complements existing initiatives such as the Longitudinal Integrated Clerkship at HYMS which offers the opportunity to follow the same patient over time, my idea extends this learning opportunity across earlier years of training. Successful PCC will most likely become a natural part of patient management if students have an early awareness and experience of exposure to individual patients experiencing the same disease in a different way. Consider this, if you required medical care, would you want to be treated as an individual? Absolutely! Hannah Louise Watson is a 2nd year medical student at Hull York Medical School. She wrote this blog following her Year 1 SSIP (Scholarship and Special Interest Programme) on Goldilocks Medicine: getting medical care ‘just right’.

When we work with patients to either make sense of their illness or health concerns, or find ways to deal with them, we are actively involved in creating and using new understanding and knowledge in practice. A growing body of research describes this clinical scholarship in action. John Gabbay’s now well-recognised work on clinical mindlines describes how GPs work together to create new knowledge-in-practice-in-context (mindlines). He offers a detailed account of clinicians using their professional expertise to adapt the findings of general scientific study to fit the local needs of this population and this context. Donner Banzhoff explains why the traditional clinical model of hypothetico-deductive reasoning doesn’t fully explain the work of GPs in practice. He coined the term ‘inductive foraging’ to describe the process that GPs use to create new knowledge in practice. Yet elsewhere, clinicians describe feeling that their profession training hasn’t adequately prepared them for this important task. WiseGP recognises that clinical practice requires that clinicians not only possess the knowledge of clinical practice, but also the expertise to use that knowledge appropriately (safely, wisely, robustly) in order to generate new knowledge-in-practice and so deliver the highest standards of patient-centred healthcare. Clinical scholarship refers to the principles and practice by which clinicians make decisions as valid and trustworthy as possible. It recognises that quality practice depends on not what you know, but how you use that knowledge to interpret, explain and make judgements driving clinical action. The skills of clinical scholarship thus build on the core concepts of applied epistemology: the study of knowledge and justified belief. Yet clinical training does not routinely teach these concepts. To strengthen scholarship for modern clinical practice, we need to address that gap. We are establishing a new SAPC Special Interest Group in Clinical Epistemology. We will bring together clinicians, educators and researchers to consider how we can translate applied epistemological principles into educational practice. We will be posting details about the group on the SAPC and WiseGP websites shortly. In the meantime, if you are interested in hearing more please contact Joanne Reeve [joanne.reeve@hyms.ac.uk]

We are excited to share the news that our WiseGP Internship scheme is now open for applications. With the generous support of the NIHR School for Primary Care Research, we are now advertising to appoint two WiseGP Interns. Many people have contributed to developing the WiseGP programme to this point. We have already been able to pull together a great set of resources. But we also know there is much more out there to offer. The wider general practice community have already given us many ideas of extra things we could add to the site. To help us develop the next stages of the WiseGP programme, we are inviting two people to come and work with us: one GP and one Primary Healthcare Scientist. The internship will fund you to work with us for 1 day a week over a 6 month period. The initial priority areas for the interns will be in helping us to expand the GEMS library, develop additional resources for the WISE Learning pages, and to help us make Connections with additional WiseGP groups out there. We intend that the internships will also offer great personal development opportunities for our new team members. Full details of the application process have now been announced on the SAPC website. Closing date for applications is 10am on Monday 2nd November 2020. You will need to be a member of SAPC to apply – so why not take this opportunity to explore what additional benefits membership can bring you!

WiseGP grew out of a conversation at RCGP Conference in 2011. A packed room of GPs took a fresh look at what we do in everyday practice. As we thought about the tasks of doing person-centred care, we recognised the complexity of the job of a modern GP. Making sense of the complex illness that patients bring to our consulting room is not about ‘knowing a little bit about a lot of things’. Our job is to use the breadth of knowledge and experience that we have, to work with our patients to create a robust, tailored understanding of their illness and so a plan for how to manage it. Our job is defined not by what we know, but how we use what we know – what we have described as the Bananarama principle. This is the expertise – the wisdom - of general practice: an intellectual task that makes our role both demanding and stimulating. The intellectual challenge of person-centred healthcare underpins our clinical work with patients, our leadership roles in developing practices and the wider service, and our contributions to the educational and research practice that builds our clinical discipline. Every GP uses the skills of clinical scholarship, every day. But not everyone knows that. And not every GP has an opportunity to fully develop and use their skills. WiseGP was established to help tell a new story of building a career in General Practice underpinned by clinical scholarship. We asked you what you needed – this site is the result. You told us you wanted to hear stories from people using clinical scholarship and practical wisdom in everyday practice; to have access to resources that could help you develop your scholarship skills; and to be able to connect with WiseGPs. This site is just the start. We are looking forward to hearing your ideas, thoughts and contributions for new things we can add. Welcome to WiseGP! #Wisegp