History, curriculum, and structure of G.P. vocational training in Flanders
1. History
Flanders (5.6 million inhabitants, ± 15.000 km², language: Dutch) the Northern part of
Belgium (33.000 km², 10 million) got the competence to run its own educational
affairs in 1988.Before that time, the Belgian (federal) Ministry of Public health set
some rules for certifying General Practitioners (1974 and 1978). In 1984 a training of
200 hours by a universitary centre of general practice and two years of practice and
seminars (100 hours), were made compulsory in order to become a certified G.P.
1984 was also the start of the I.C.H.O. (Interuniversitair Centrum voor Huisartsen
Opleiding): a co-operation of the four Flemish universitary centres of general practice
(Antwerp, Brussels, Gent, Leuven).
This structure was set up for pragmatic organisational reasons, in order to pool the
scarce means and people for vocational training and to develop more strenght in
confronting the authorities and the medical faculties. Mutual confidence and cooperation were made easier by personal relationships: the three first professors of
General Practice in Leuven, Antwerp and Ghent had collaborated in and had been
former presidents of the W.V.V.H., the Flemish scientific G.P. college.
One of the major "fights" with the own faculties was to carve out time for G.P.
vocational training in the seventh year of the medical curriculum. Internal I.C.H.O.deliberations had led to a consensus already in 1990; by the spring of 1991 the
faculties, most professional groups and the Flemish administration had agreed on the
plan. In the following years this agreement time and again came under pressure; only
the stubbornness of the G.P. departments, strongly united in I.C.H.O., has saved it.
Finally, in 1995, the Flemish government took the legislative steps to make of
vocational training an universitary degree and earmarked some financial resources
for it. The four universitary centres worked out a legal contract with their respective
universities about all aspects of collaboration.
2. The curriculum of vocational training in Flanders
The first year of G.P. training coincides with the seventh year of the basic medical
training and is organizes by the four university departments separately. At the
beginning of their seventh year, students have to make a choice between general
practice/family medicine or the pre-specialisation.
The general practice candidates work for six months in different hospital services,
appropriate for general practice (not too specialised). The other semester consists of
blocks (three to four weeks) of instruction and training alternated with blocks of work
in training practices.
Though it is given separately in each department the program has many common
traits.
Different educational methods are used: interactive small group sessions,
communication and consultation training, training in the skills lab of diagnostic and
therapeutic manual skills, interactive seminars and various forms of assessment (by
1
video, oral exam, MCQ examination, individual evaluation discussion). The practice
blocks take place in selected training practices. All departments have started with a
system of quality control and training of the trainers. For the hospital practice there is
a list of preferable training posts.
The second and third year are organised by the interuniversitary consortium:
(Dutch: Interuniversitair Centrum voor Huisartsenopleiding – I.C.H.O.).
Trainees subscribe at one university, but only after they have been registered by the
central secretariat of I.C.H.O.; they are then distributed over the seminar groups on
regional basis (and not according to their university basis). I.C.H.O. organizes the
seminars, the day release courses, the final examination, the training of the trainers
and the overall co-ordination. I.C.H.O. also produces educational materials, e.g.
handbooks for the trainee, the group trainer, the practice trainer and the examiners,
information packages about special topics in general practice, etc.
Trainees have to meet some minimal criteria: he or she is to do at least six
months (at the moment about 70 % do two years) of training in the practice of a G.P.
trainer, he has to attend fifty hours of seminars each year in a fixed seminar group
under the guidance of a group trainer and he has to follow at least two day release
courses a year. At the end of the third year he has to take part in the final
examination.
Apart from those compulsory requirements the student can suit his program to his
own needs: he may go for training in a hospital (maximum one year), or he can start
his own independent practice. The vocational training is conceived as a system of
adult education, the global aims correspond to the task profile of the general
practitioner, defined by the scientific college (Wetenschappelijke Vereniging voor
Vlaamse Huisartsen). Those global aims are laid down in a text called "Eindtermen
voor de beroepsopleiding".
These goals are made concrete in:
 the domains of competence, that are indicative for the oral examiners;
 the checklist of manual and technical clinical skills, communicative skills,
administrative skills and medical problems in primary health care;
 the blueprint for the written examination;
 the evaluation criteria used by the seminar trainers and the G.P. practice
trainers;
 the framework for the OSCE (Objective Structured Clinical Examination);
 they also form the blueprint for the choice of themes for the day release
courses.
The day release courses
In 1997 eight days with various sessions on different topics will be offered at the four
universities. The trainees have to follow a minimum of two sessions. The subjects
correspond to needs felt by trainers and/or trainees and correspond to the
requirements of the checklist. E.g. : administrative problems (sickness certificate),
communication with difficult patients, the gynaecological examination, critical reading,
resuscitation training, the orthopaedic examination of the shoulder, taping, problems
of infants, social problems in general practice, etc.
2
Each session is evaluated by the trainees; this feedback is given to the lecturer.
Satisfaction of trainees with those courses is very high.
Seminars and individual guidance by the group trainer
The function of the group trainer is crucial in the second and third year. He follows
the trainee individually, and guides the group during the whole period of v.t.
The individual guidance consists of:
 an intake discussion,
 regular short meetings before or after a seminar,
 a yearly feedback and evaluation discussion,
 a yearly meeting with the practice trainer,
 a yearly evaluation report taking into account the evaluation by the practice
trainer.
Apart from those structured encounters the trainer is always available for advice both
for the trainee and the individual trainer.
In the seminars the focus lies on critical reflection on concrete experiences. The
principle is that the group looks for sound evidence. At the same time the group
trainer pays attention to the personal growth of every trainee and to the working
atmosphere of the whole group. The function of the group is to bring together the
variety of experiences and personalities of the members and to support each other.
Various educational methods are used: case discussions, continuous registration of
patient contacts, thematic registration (e.g. diabetes in primary care), a discussion of
literature, a thematic session (e.g. on legal issues), role playing difficult consultations.
Assessments and Evaluation
Regular assessment of the trainee by all trainers is stimulated by means of the
trainee's "learning agenda": a list of goals the trainee or his trainers have set and of
which he is given feedback.
At the end of the second year a formative evaluation takes place by means of an
evaluative discussion, a written examination and a (at the moment still experimental)
OSCE examination. Candidates who do not perform well enough are identified and
are given remedial tasks.
The aims of the final assessment, at the end of the third year, are to steer the
learning process of every trainee and to detect trainees below the minimal level. The
assessment consists of 4 different parts:
 A written knowledge test:
This test is based on a blueprint (the domains of competence and the ICPC-chapters)
and consists of 200 items of the true/false/? type. A rigorous procedure is followed;
the validity and reliability of this examination are studied.
3
 An oral examination:
Each trainee does an oral examination of one hour with a jury of three GP's from at
least two different universities. The philosophy of the exam is that of delivering a
"masterpiece": the candidate prepares 5 cases from his own practice, adds the
relevant literature and is prepared to answer all kinds of questions about his handling
of the problem. The jury chooses 2 of the 5 cases and interrogates in depth focusing
on the candidate's critical reflection ability and her/his personal and professional
maturity; the jury checks whether the decisions of the trainee are based on sound
evidence.
 The (group) trainers report:
The group trainer evaluates the learning process (participation, personal
development, progress) and the competence of the trainee as a GP. He bases his
evaluation-score on his own observations and a report of the individual trainer.
 The OSCE's:
At the moment still experimental (12 sequential stations with various primary health
care problems to be handled correctly in a given period of time, observed and scored
by GP's). A first try out with 35 candidates was very promising.
3.
Mission statement.
The main aim of the ICHO (Interuniversitary Center for Training of General
Practitioners ) is to train general practitioners. But the ICHO does not see being an
institute for training as its sole purpose. It also wants to be a movement aimed at
bringing the profession of general practitioner on a higher academic level. Whoever is
involved with the training, is part of the interactive network directed to make the
expertise and the practice of general practitioners more dynamic in Flanders.
To realise these purposes, the ICHO has to be set up as an organisation with a
powerful internal dynamism. Moreover it must participate through educative means
(training and research) in changing the side-conditions under which the training and
the medical profession of general practice are taking place.
Specifically, in the years to come, the ICHO wants to :
a) develop a profile for the general practitioner of the future in consultation with the
three parties (I. The board of directors and the staff of the ICHO ; II. The coordinators
and the one-to-one trainers ; III. The general practitioners in training (HIBO’s))
and in interaction with the rest of the professional group and of this sector of society.
collect scientific evidences in proof of the profile and its relevance for society.
translate the competences necessary for this profile in a number of final standards
that can be tested.
research how to develop the models of training in order to teach these competences
to the coordinators, one-to-one trainers and the HIBO’s.
formulate the side-conditions under which this new profile can function.
4
b) offer these models of training to the three parties of the ICHO in a trainingstructure
with a maximum of freedom of choice for the HIBO’s that enables them to reach the
final standards.
set up the adequate administration, coordination and facilities to this end.
c) develop for this new concept an adequate system of tests (at the level of the
HIBO’s) and of checks of quality (at the level of coordinators, one-to-one trainers and
of the organisation).
d) support innovative research into the medicine of general practitioning in order to
realise this purpose and make own researches into this subject and develop practical
working models.
5