medical careers) previous 1 foundation doctor (fy1 and fy2), 2 years pre-registration house officer (prho), 1 year 2 senior house officer (sho),minimum 2 years; often more 3 specialty registrar, general practice (gpst), minimum 3 years specialty registrar, hospital speciality (spr), minimum 5 years 4 specialist registrar, 4–6 years gp registrar, 1 year 5 general practitioner, 4 years total time in training 6–8 general practitioner, minimum 5 years total time in training 9 consultant, minimum 7 years total time in training consultant, minimum 7–9 years total time in training optional training is competency based, times shown are a minimum. training may be extended by obtaining an academic clinical fellowship for research or by dual certification in another speciality. training may be extended by pursuing medical research (usually 2–3 years), usually with clinical duties as well the postgraduate qualification membership of the royal college of general practitioners (mrcgp) was previously optional. in 2008, a requirement was introduced for physicians to succeed in the mrcgp assessments in order to be issued with a certificate of completion of their specialty training (cct) in general practice. after passing the assessments, they are eligible to use the post-nominal letters mrcgp (so long as the physicians continued to pay membership fees to the rcgp, though many do not). during the gp specialty training programme, the medical practitioner must complete a variety of assessments in order to be allowed to practice independently as a gp. there is a knowledge-based exam with multiple choice questions called the applied knowledge test (akt). the practical examination takes the form of a "simulated surgery" in which the physicians is presented with thirteen clinical cases and assessment is made of data gathering, interpersonal skills and clinical management. this clinical skills assessment (csa) is held on three or four occasions throughout the year and takes place at the renovated headquarters of the royal college of general practitioners (rcgp), at 30 euston square, london. finally, throughout the year the physician must complete an electronic portfolio which is made up of case-based discussions, critique of videoed consultations and reflective entries into a "learning log". in addition, many hold qualifications such as the dch (diploma in child health of the royal college of paediatrics and child health) or the drcog (diploma of the royal college of obstetricians and gynaecologists), the dpd (diploma in practical dermatology) or the dgh (diploma in geriatric medicine of the royal college of physicians). some general practitioners also hold the mrcp (member of the royal college of physicians) or other specialist qualifications, but generally only if they had a hospital career, or a career in another speciality, before training in general practice. there are many arrangements under which general practitioners can work in the uk. while the main career aim is becoming a principal or partner in a gp surgery, many become salaried or non-principal gps, work in hospitals in gp-led acute care units, or perform locum work. whichever of these roles they fill, the vast majority of gps receive most of their income from the national health service (nhs). principals and partners in gp surgeries are self-employed, but they have contractual arrangements with the nhs which give them considerable predictability of income. gps in the united kingdom may operate in community health centres.visits to gp surgeries are free in all countries of the united kingdom, but charges for prescriptions are applied in england. wales, scotland and northern ireland have abolished all charges. recent reforms to the nhs have included changes to the gp contract. general practitioners are no longer required to work unsociable hours, and get paid to some extent according to their performance, (e.g. numbers of patients treated, what treatments were administered, and the health of their catchment area, through the quality and outcomes framework). the it system used for assessing their income based on these criteria is called qmas. the amount that a gp can expect to earn does vary according to the location of their work and the health needs of the population that they serve. within a couple of years of the new contract being introduced, it became apparent that there were a few examples where the arrangements were out step with what had been expected. a full-time self-employed gp, such as a gms or pms practice partner, might currently expect to earn a profit share of around £95,900 before tax while a gp employed by a ccg could expect to earn a salary in the range of £54,863 to £82,789. this can equate to an hourly rate of around £40 an hour for a gp partner. a survey by ipsos mori released in 2011 reports that 88% of adults in the uk "trust doctors to tell the truth". in may 2017, there was said to be a crisis in the uk with practices having difficulties recruiting gps they need. prof. helen stokes-lampard of the royal college of general practitioners said, "at present, uk general practice does not have sufficient resources to deliver the care and services necessary to meet our patients' changing needs, meaning that gps and our teams are working under intense pressures, which are simply unsustainable. workload in general practice is escalating – it has increased 16% over the last seven years, according to the latest research – yet investment in our service has steadily declined over the last decade and the number of gps has not risen in step with patient demand ... this must be addressed as a matter of urgency.". professor azeem majeed from imperial college has also raised concerns about general practice in the uk. in 2018 the average gp worked less than three and a half days a week because of the "intensity of working day". there is an nhs england initiative to situate gps in or near hospital emergency departments to divert minor cases away from a&e and reduce pressure on emergency services. 97 hospital trusts have been allocated money, mostly for premises alterations or development. north america united states a general practitioner's office in 1940 the population of this type of medical practitioner is declining, however. currently, the medical departments of the us air force, army and navy have many of these general practitioners, known as general medical officers or gmos, in active practice. the gmo is an inherent concept to all military medical branches. gmos are the gatekeepers of medicine in that they hold the purse strings and decide upon the merit of specialist consultation. the us now holds a different definition for the term "general practitioner". the two terms "general practitioner" and "family practice" were synonymous prior to 1970. at that time both terms (if used within the us) referred to someone who completed medical school and the one-year required internship, and then worked as a general family doctor. completion of a post-graduate specialty training program or residency in family medicine was, at that time, not a requirement. a physician who specializes in "family medicine" must now complete a residency in family medicine, and must be eligible for board certification, which is required by many hospitals and health plans for hospital privileges and remuneration, respectively. it was not until the 1970s that family medicine was recognized as a specialty in the us. many licensed family medical practitioners in the united states after this change began to use the term "general practitioner" to refer to those practitioners who previously did not complete a family medicine residency. family physicians (after completing medical school) must then complete three to four years of additional residency in family medicine. three hundred hours of medical education within the prior six years is also required to be eligible to sit for the board certification exam; these hours are largely acquired during residency training. the existing general practitioners in the 1970s were given the choice to be grandfathered into the newly created specialty of family practice. in 1971 the american academy of general practice changed its name to the american academy of family physicians. the prior system of graduating from medical school and completing one year of post-graduate training (rotating internship) was not abolished as 47 of the 50 states allow a physician to obtain a medical license without completion of residency. if one wanted to become a "house-call-making" type of physician, one still needs to only complete one or two years of a residency in either pediatrics, family medicine or internal medicine. this would make a physician a non-board eligible general practitioner able to qualify and obtain a license to practice medicine in 47 of the 50 united states of america. since the establishment of the board of family medicine, a family medicine physician is no longer the same as a general practitioner. what makes a family medicine physician different than a general practitioner/physician is two-fold. first off a family medicine physician has completed the three years of family medicine residency and is board eligible or board certified in family medicine; while a general practitioner does not have any board certification and cannot sit for any board exam. secondly, a family medicine physician is able to practice obstetrics, the care of the pregnant woman from conception to delivery, while a general practitioner is not adequately trained in obstetrics. prior to recent history most postgraduate education in the united states was accomplished using the mentor system. a physician would finish a rotating internship and move to some town and be taught by the local physicians the skills needed for that particular town. this allowed each community's needs to be met by the teaching of the new general practitioner the skills needed in that community. this also allowed the new physician to start making a living and raising a family, etc. general practitioners would be the surgeons, the obstetricians, and the internists for their given communities. changes in demographics and the growing complexities of the developing bodies of knowledge made it necessary to produce more highly trained surgeons and other specialists. for many physicians it was a natural desire to want to be considered "specialists". what was not anticipated by many physicians is that an option to be a generalist would lose its prestige and be further degraded by a growing bureaucracy of insurance and hospitals requiring board certification. it has been shown that there is no statistically significant correlation between board certification and patient safety or quality of care which is why 47 states do not require board certification to practice medicine. board certification agencies have been increasing their fees exponentially since establishment and the board examinations are known to not be clinically relevant and are at least 5 years out of date. yet, there is still a misbelief that board certification is necessary to practice medicine and therefore it has made a non-board eligible general physician a rare breed of physician due to the lack of available job opportunities for them. certificates of added qualifications (caqs) in adolescent medicine, geriatric medicine, sports medicine, sleep medicine, and hospice and palliative medicine are available for those board-certified family physicians with additional residency training requirements. recently, new fellowships in international family medicine have emerged. these fellowships are designed to train family physicians working in resource-poor environments. in 2009 an ongoing shortage of primary care physicians (and also other primary care providers) was reported. it was due to several factors, notably the lesser prestige associated with the young specialty, the lower pay, and the increasingly frustrating practice environment. in the us physicians are increasingly forced to do more administrative work, and pay higher malpractice insurance premiums. canada the college of general practice of canada was founded in 1954 but in 1967 changed its name to college of family physicians of canada (cfpc). oceania australia