General Practice Education Research Articles

General practice: the DREEM attachment? Comparing the educational environment of hospital and general practice placements

The clinical learning environment is changing. General practice placements are now a fundamental part of undergraduate medical education. There is growing recognition that changes in hospital work practices are altering the breadth of exposure available to students. Surprisingly little work has been done comparing the quality of clinical placements between the hospital and community using validated tools. Such comparisons inform curriculum planning and resource allocation. The aim of this study was to compare the quality of the educational environment experienced by junior medical students during hospital and general practice placements using a widely used tool. Following the introduction of a new integrated curriculum, all Year 3 students (n=108) completed a standardised evaluation instrument, the Dundee Ready Education Environment Measure (DREEM) at the end of each of their clinical attachments (two different hospital sites and one in general practice), giving a total of 324 questionnaires. All forms were analysed and input into Graphpad INSTAT version 3. Total DREEM scores as well as subscale scores were calculated for each site. These were compared across sites using a Mann-Whitney U non-parametric test. By comparison with international standards, clinical attachments in our new integrated curriculum were rated highly. In particular, attachments in general practice scored highly with a mean score of 156.6 and perform significantly better (P < 0.01) when compared with the mean score for hospital rotations of 149.0. Significant differences between general practice and hospital rotations exist in the domains of students' perceptions of atmosphere and students' social self-perceptions. Finally, significant differences also emerged in students' perceptions of teachers in general practice when compared to those in the hospital setting. These findings provide evidence of the high-quality educational environment afforded students in primary care. They challenge the traditional emphasis on hospital-based teaching and preempt the question - Is the community a better place for junior students to learn?

Prioritization of future genetics education for general practitioners: a Delphi study

PurposeGeneral practitioners (GPs) are increasingly expected to deliver genetics services in daily patient care. Education in primary care genetics is considered suboptimal and in urgent need of revision and innovation. The aim of this study was to prioritize topics for genetics education for general practice. MethodsA Delphi consensus procedure consisting of three rounds was conducted. A purposively selected heterogeneous panel (n = 18) of experts, comprising six practicing GPs who were also engaged in research, five GP trainers, four clinical genetics professionals, and three representatives of patient organizations, participated. Educational needs regarding genetics in general practice in terms of knowledge, skills, and attitudes were rated and ranked in a top-10 list. ResultsThe entire panel completed all three rounds. Kendall's coefficient of concordance indicated significant agreement regarding the top 10 genetic education needs (P < 0.001). “Recognizing signals that are potentially indicative of a hereditary component of a disease” was rated highest, followed by “Evaluating indications for referral to a clinical genetics centre” and “Knowledge of the possibilities and limitations of genetic tests.” ConclusionsThe priorities resulting from this study can inform the development of educational modules, including input for case-based education, to improve GP performance in genetic patient care.

Career choice and place of graduation among physicians in Norway

Objective. To investigate to what extent a physician's place of graduation is associated with the physician choosing a career as a general practitioner (GP), and identify factors in the curriculum that could predict a general practice career. Design. Cross-sectional study based on the membership database of the Norwegian Medical Association. Setting. Physicians working in Norway who graduated from four domestic medical schools, five other countries, and three groups of countries. Physicians were categorized according to their main professional activity as GPs, hospital physicians, and researchers. Subjects. A total of 2836 medical physicians who were working in Norway during 2010 and graduated from medical school between 2002 and 2005. Main outcome measures. Percentage and odds ratio for subjects working as a GP in Norway during 2010. Descriptive data for pre-graduate general practice education in Norwegian medical schools were also analysed. Results. Compared with the University of Oslo, there was a significantly higher proportion of GPs among physicians who had graduated from Denmark (OR 2.9, 95% CI 1.9–4.5), Poland (OR 2.0, 95% CI 1.4–2.9), Sweden (OR 1.8, 95% CI 1.0–3.1), and Trondheim (Norway) (OR 1.5, 95% CI 1.1–2.0). Across the four Norwegian medical schools, there were significant associations between choosing a general practice career and the sum of pre-graduate educational hours regarding general practice, general practice preceptorship, and the number of GP teachers. Conclusion. The physician's place of graduation appears to be associated with career choice. The universities’ total contribution in pre-graduate general practice education may be associated with future GP career choice.

Four year GP training is on cards for 2013

Training of GPs could be extended from three to four years from as early as 2013 if plans set out by the Committee of General Practice Education Directors (COGPED) and the Royal College of General Practitioners go ahead. If the Department of Health, the Medical Programme Board, and the secretary of state for health approve the proposals in meetings this spring, the four year programme could be implemented for junior doctors who start their GP training in 2013. Although the current three year GP programme allows trainees to attain core competences, many …

Effectiveness of simulated clinical teaching in general practice: randomised controlled trial

There are shortages in community-based general practice placements for medical students. Innovative ways to teach the skills required in general practice are needed. To assess the effectiveness of 'simulated' general practice clinics using actors, compared with standard community-based general practice attachments in medical undergraduate education. Randomised controlled trial involving medical students. Outcome measures included self-reported knowledge, clinical confidence, communication skills, and attitudes within general practice assessed at baseline and after one week. Intervention students participated in 24 simulated consultations with actor-patients over four days. Control students spent four days working with community-based general practitioners and real patients. Of 138 eligible medical students in the first clinical year, 128 (93%) participated and 106/128 (82%) completed the study. Those participating in simulated clinics improved in confidence in history-taking (p=0.03), communication skills (p=0.04), and ability to detect depression (p<0.001) compared with those undertaking community attachments. Those in community-based attachments felt more confident in managing upper respiratory tract infections (p<0.001), giving injections (p<0.001), screening in general practice (p=0.03) and managing illness in the patient's home (p=0.04). There was no difference between the groups in other measures. Simulated clinics may assist with development of communication skills within the general practice consultation and may also be used to supplement community-based attachment with real patients. Even so, confidence in the management of common conditions and procedures improves more with real patients.

London Landscape – Book Review

It seems somehow odd to review an edited collection of essays on clinical ethics consultation (CEC), a phenomenon largely identified (in the literature at least) with hospital medicine. One might ask if such a phenomenon is necessary in primary care. British GPs seem a fairly self-reflective profession. After all, the Balint movement in the UK appears to have been largely confined to general practice education.1 A small article on the difficulties of maintaining confidentiality in RCGP News2 can result in an august and furious response in the BJGP's pages3. Yet ethics is a word perceived as hard, bookish, for academics, according to the chairman of the RCGP ethics committee no less.4 So why might a text looking at theories and methods of ethics support, its implementation, and its evaluation be of interest to those working in primary care? Everyday, ordinary primary healthcare has also traditionally been of less interest both to tabloid newspapers and to bioethics.5–7 Refreshingly, the editors of Clinical Ethics Consultation have embraced this ‘everyday’ concern. In his chapter on ethical decision-making in nursing homes, Bollig laments that despite the high frequency of ethical issues occurring in nursing homes ‘all round the world, every single day,’ they are often overlooked or neglected, probably due to their ordinariness. Elsewhere Stuber describes the moral distress felt by a nurse who struggles to watch over 36 patients whilst deciding whether she can safely get a person with diarrhoea to the toilet every 30 minutes. To protest against work conditions carries a risk of unemployment, and the ward is already understaffed. Stuber uses the case to describe the difficulties that work conditions place on the moral definition of a profession. This is a point Iona Heath has been making for some decades in her arguments that GPs should not be both patient-advocates and fund-holders.8 Whether it is in a Balint group, an appraisal, or other reflexive exercise, guided introspection may be viewed warily by British GPs. Opening up behaviour to ethical scrutiny can raise the fear that behaviour will be deemed by peers to be deficient, that one will fall foul of ‘ethicality’.9,10 In the final chapter Schildmann and Vollman quote a definition of ethicality as ‘practices consistent with ethical norms and standards’. They cite the promotion of ethicality as one possible outcome by which CEC can be evaluated. In her chapter on facilitating reflection on professional norms, Stuber suggests that people do not reflect on the values that are commonly taken to constitute part of their professional competence. General physicians and GPs find help useful in facing ethical difficulties but reported having used the available services infrequently, and, paradoxically, doctors with greater confidence in their knowledge of ethics were more likely to have used available services.11 When read alongside Stuber's insight, the situation is faintly reminiscent of Tudor-Hart's inverse care law, where people with the greatest health needs were the least likely to access healthcare.12 Whether this was a problem of non-availability of services or a lack of ability to access those services,13 the analogy may apply to postgraduate ethics education and ethics support in primary care. Ethics education,11,14,15 allows GPs to engage with support and scholarship, and this book draws on a number of approaches that lend themselves to community of general practice scholars. Whether there is not enough postgraduate education in this area, or simply not enough support for its uptake is a matter that warrants further discussion. As a source text this volume has much to offer.

Commentary: Learning-style theories debunked, but still guiding educational practice

My children taught me that computers run on smoke and when the smoke comes out of the processor chips they will not work anymore. Although the fallacy is obvious, the logic is seductive. The long running credence in learning-style theories in education now looks as ephemeral as the phlogiston theory of the middle ages [1] or my children's assertion about computer function. My initial alert to the demise of learning theories came from Gary Stix writing in Scientific American [2], where he proclaimed that the notion that each child has a particular learning style is a myth. “The notion that a pupil tends to learn better by favoring a particular form of sensory input—a visual learner as opposed to one who listens better—has not received much validation in actual studies. For this and other myths, public perceptions appear to have outstripped the science. Uta Frith, a neuroscientist who chaired a British panel that looked at the promise of neuroeducation, urges parents and educators to tread cautiously. There is huge demand by the general public to have information about neuroscience for education. As a consequence, there an enormous supply of totally untested, untried, and not very scientific methods” [2]. A part of the history of creating learning-style theories is by extrapolation from the personality theory of the analytical psychologist and psychoanalyst Carl Jung. Jung's ideas were incorporated into the Myers–Briggs psychological test dating from the 1940s; a test that is still widely used. The Myers–Briggs test categorizes people into groups such as introvert and extrovert. However this test, just like learning styles, is backed by little supportive evidence from objective studies [3]. Even so the idea of classifying people into types has great appeal. Proponents of learning-style assessment contend that optimal instruction requires tailoring instruction after an assessment of learning style; typically evaluating the sort of information presentation they prefer (words, pictures, or speech. The learning-styles view has had a great influence at all levels ranging from kindergarten to graduate school. Pashler et al. [3] conclude that students can learn equally well using a variety of learning styles and students do not learn better when their preferred learning styles are used. The most common hypothesis about learning styles is the meshing hypothesis [3], which exhorts teachers to mesh learning with the preferences of the learner (i.e., provide a visual learner with visual presentations). It is no surprise that many commercial enterprises continue to publish learning-styles tests and guidebooks for teachers, and provide professional development workshops. Pashler et al. [3] set out to find evidence for learning styles that met scientific criteria. Students must be divided into groups on the basis of their measured learning styles and then students must be randomly assigned to receive one instructional mode. It is to be expected if learning styles are valid that learning will show an optimum when learning style matches learning mode. It was easy enough to find that the literature provided ample evidence that children and adults will express preferences about how they prefer information to be presented to them. However, although the literature on learning styles is enormous, very few studies used a randomized experimental methodology. Those that did commonly found results that flatly contradicted the popular meshing hypothesis. There is no evidence to justify incorporating learning-styles assessments into general educational practice. “Thus, limited education resources would better be devoted to adopting other educational practices that have a strong evidence base, of which there are an increasing number” [3]. Nature famously abhors a vacuum so what has entered the place of learning styles? Some people of course have simply not given them up and this echoes the words of Max Planck “A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die and a new generation grows up” [4]. The next generation will adhere to practices based on the evidence of MRI brain scans and objectively proven practices, perhaps using music in a synergistic manner [2]. However, for the time being it seems that no theory of learning has a clear right to dictate practice. The blended learning we are providing may be as good as it gets.

Engaging rural preceptors in new longitudinal community clerkships during workforce shortage: a qualitative study

BackgroundIn keeping with its mission to produce doctors for rural and regional Australia, the University of Wollongong, Graduate School of Medicine has established an innovative model of clinical education. This includes a 12-month integrated community-based clerkship in a regional or rural setting, offering senior students longitudinal participation in a 'community of practice' with access to continuity of patient care experiences, continuity of supervision and curriculum, and individualised personal and professional development. This required developing new teaching sites, based on attracting preceptors and providing them with educational and physical infrastructure. A major challenge was severe health workforce shortages.MethodsBefore the new clerkship started, we interviewed 28 general practitioners to determine why they engaged as clerkship preceptors. Independent researchers conducted semi-structured interviews. Responses were transcribed for inductive qualitative content analysis.ResultsThe new model motivated preceptors to engage because it enhanced their opportunities to contribute to authentic learning when compared with the perceived limitations of short-term attachments. Preceptors appreciated the significant recognition of the value of general practice teaching and the honour of major involvement in the university. They predicted that the initiative would have positive effects on general practitioner morale and improve the quality of their practice. Other themes included the doctors' commitment to their profession, 'handing on' to the next generation and helping their community to attract doctors in the future.ConclusionsSupervisors perceive that new models of clinical education offer alternative solutions to health care education, delivery and workforce. The longitudinal relationship between preceptor, student and community was seen as offering reciprocal benefits. General practitioners are committed to refining practice and ensuring generation of new members in their profession. They are motivated to engage in novel regional and rural longitudinal clinical clerkships as they perceive that they offer students an authentic learning experience and are a potential strategy to help address workforce shortages and maldistribution.

Is different better? Models of teaching and their influence on the net financial outcome for general practice teaching posts

BackgroundIn Australia, training for general practice (GP) occurs within private practices and their involvement in teaching can have significant financial costs. At the same time there are growing demands for clinical places for all disciplines and for GP there is concern that there are insufficient teaching practices to meet the demand at the medical student, prevocational and vocational training levels. One option to address this may be to change how teaching occurs in the practice. A question that arises in posing such an option is whether different models of teaching change the costs for a teaching practice. The aim of this study is to determine the net financial outcome of teaching models in private GP.MethodsModelling the financial implications for a range of teaching options using a costing framework developed from a survey of teaching practices in South Australia. Each option was compared with the traditional model of teaching where one GP supervisor is singularly responsible for one learner. The main outcome measure was net financial outcome per week. Decisions on the model cost parameters were made by the study's Steering Group which comprised of experienced GP supervisors. Four teaching models are presented. Model 1 investigates the gains from teaching multiple same level learners, Models 2 and 3, the benefits of vertically integrated teaching using different permutations, and Model 4 the concept of a GP teacher who undertakes all the teaching.ResultsThere was a significant increase in net benefits of Aus$547 per week (95% confidence intervals $459, $668) to the practice when a GP taught two same level learners (Model 1) and when a senior registrar participated in teaching a prevocational doctor (Model 3, Aus$263, 95% confidence intervals $80, $570). For Model 2, a practice could significantly reduce the loss if a registrar was involved in vertically integrated teaching which included the training of a medical student (Aus$551, 95% confidence intervals $419, $718). The GP teacher model resulted in a net remuneration of Aus$207,335 per year, sourced predominantly from the GP teacher activities, with no loss to the practice.ConclusionsOur study costed teaching options that can maximise the financial outcomes from teaching. The inclusion of GP registrars in the teaching model or the supervisor teaching more than one same level learner results in a greater financial benefit. This gain was achieved through a reduction in supervisor teaching time and the sharing of administrative and teaching activities with GP registrars. We also show that a GP teacher who carries a minimal patient load can be a sustainable option for a practice. Further, the costing framework used for the teaching models presented in this study has the ability to be applied to any number of teaching model permutations.

Promoting education within the SAPC: introducing the HoTs Group

The Society for Academic Primary Care (SAPC) exists to support, promote and develop the discipline of academic primary care. One of its stated key principles is the promotion of excellent teaching, research and critical reflection on primary care practice and policy. As some readers may recall, the original precursor of the SAPC was the AUTGP (Association of University Teachers of General Practice), later rebranded AUDGP (Association of University Departments of General Practice). Over the course of this evolution from AUTGP to SAPC, there has been a sense among at least some General Practice educators that the focus of the Society has shifted away from education and training in favour of research and development. Although there is no question of the importance of the latter, the former remain core activities and major sources of funding for most academic primary care departments. Indeed, as primary care research has become increasingly specialised, it could be argued that it is primary care education that provides the common thread to bind our discipline together and protect academic departments from potential fragmentation into alternative clinical or methodological groupings. The major contribution of primary care to the UK undergraduate medical curriculum in particular should not be underestimated. Most medical schools now deliver at least 15% of their teaching in the community. This contribution often goes beyond traditional General Practice (GP) placements, with SAPC members increasingly involved in areas such as curriculum development, quality assurance, assessment, admissions, welfare, as well as in senior educational leadership positions. The opportunities for the SAPC to increase its educational role are also increasing in the postgraduate arena as deaneries restructure and focus increasingly on commissioning rather than providing education and training. The anticipated demise of Primary Care Trusts leaves a vacuum of leadership for continuing professional development among established primary care professionals including GPs, nurses and allied health professionals. All good reasons to create new national Heads of Primary Care Teaching (HoTs) Group within the SAPC. First conceived in 2009, we aim to represent the interests of all primary care educators within medical schools around the United Kingdom, and to support the SAPC in achieving its aims in relation to primary care education and educational research. Membership of the HoTs Group currently consists of the heads of primary care teaching of all UK medical schools. The group meets twice a year, between which time our email forum provides a lively mode of exchange of information and ideas. Future activity intends to build on this strong foundation. Our immediate priorities are to address concerns of members in relation to delivering highquality undergraduate medical education and building on the position of strength that our pivotal role within medical schools now affords us. In addition, we aim, over the next two years, to address our goals around scholarship and professional development, the encouragement of high-quality educational research, and the strengthening of our contribution to postgraduate medical education. Our initial focus is admittedly on undergraduate general practice education, but we do aim over time to broaden our remit and representation to support education and training within other primary care disciplines. We should be very happy to hear from any SAPC members at any time and look forward to working together to promote the Society and the discipline of Academic Primary Care. Correspondence to: Dr Joe Rosenthal, Department of Primary Care & Population Health, University College London Medical School, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK. Email: j.rosenthal@ucl.ac.uk

Vertical integration of teaching in Australian general practice — a survey of regional training providers

To examine vertical integration of teaching and clinical training in general practice and describe practical examples being undertaken by Australian general practice regional training providers (RTPs). A qualitative study of all RTPs in Australia, mid 2010. All 17RTPs in Australia responded. Eleven had developed some vertical integration initiatives. Several encouraged registrars to teach junior doctors and medical students, others encouraged general practitioner supervisors to run multilevel educational sessions, a few coordinated placements, linkages and support across their region. Three RTPs provided case studies of vertical integration. Many RTPs in Australia use vertical integration of teaching in their training programs. RTPs with close associations with universities and rural clinical schools seem to be leading these initiatives.

The Australian General Practice Training program — reflections on the past decade

How has general practice vocational training progressed towards the original goals established by the federal government and General Practice Education and Training 10 years ago?

General practice education and training: past experiences, current issues and future challenges

Reflection on past achievements and future challenges 10 years after the establishment of the Australian General Practice Training program.

Training Australian Defence Force Medical Officers to civilian general practice training standards — reflections on military medicine and its links to general practice education and training

This article examines military medicine and its links to civilian general practice education and training, drawing attention to the variations and difficulties in, and successful approaches for, training Australian Defence Force (ADF) Medical Officers. Military medicine has been an area of change over the 10 years of the Australian General Practice Training (AGPT) program. Crisis situations like those in Timor Leste and Afghanistan have focused attention and recognition on the importance of primary health care in the work of the ADF. To train doctors in military medicine, there are several different models at different locations around Australia, as well as large variations in military course and experience recognition and approvals between AGPT regional training providers. At times, the lack of standardisation in training delays the progress of ADF registrars moving through the AGPT program and becoming independently deployable Medical Officers.

Getting governance right for a sustainable regionalised business model

The 1998 Ministerial Review of General Practice Training identified several areas for improvement that led to major changes in the provision of general practice training, including the establishment of General Practice Education and Training (GPET) and the regionalisation of training. The regionalised training business model has been in place for nearly 10 years, and several key organisations have been involved in its evolution, including the Australian Government, speciality colleges, GPET and regionalised training providers. Both the college-focused and regionalised-focused models have had some successes. These include recognition and support of general practice as a vocational specialty, increased numbers of junior doctors undertaking placements in general practice, and increased numbers of registrars training in rural areas. This period has also seen changes in the governance and decision-making processes with creation of a new framework that is inclusive of all the key players in the new regionalised training system. The future holds challenges for the regionalised training business model as the general practice education and training landscape becomes more complex. The framework in the current model will provide a base to help meet these challenges and allow for further sustainable expansion.

A ‘minimal core curriculum’ for Family Medicine in undergraduate medical education: A European Delphi survey among EURACT representatives

Background: Family Medicine/General Practice (FM/GP) has not developed in a similar way worldwide. In countries that are not primary care oriented, the discipline of FM/GP may be less developed because this is not a career option for medical graduates. In such a situation, FM/GP will not be regarded as a required clinical experience during medical school. Objectives: To define the ‘minimal requirements’ or ‘minimal core content’ for a clerkship in FM/GP of very short duration, i.e. a basic curriculum for a clinical rotation in FM/GP, taking into account that in some European countries the time allocated for this rotation may not exceed one week. Method: The Delphi method was used. The study group was composed of 40 family physicians and medical educators who act as national representatives of all European countries—plus Israel—in the Council of the European Academy of Teachers in General Practice and Family Medicine (EURACT). The representatives are elected among the EURACT members in their country. Results: After three Delphi rounds we obtained a consensual list of 15 themes regarded by the respondents as the most important to be included in a minimal core curriculum for FM/GP in undergraduate medical education.Conclusion: This list may be useful for teachers and institutions that are about to introduce GP/FM as a new topic in their medical faculty, having only limited time available for the course. They will be able to focus on topics chosen by a European expert panel as being the most important in such a situation.

Safeguard or mollycoddle? An exploratory study describing potentially harmful incidents during medical student placements in Aboriginal communities in Central Australia

To assess the number and characteristics of potentially harmful incidents occurring during placement of medical students in remote Aboriginal communities in the Northern Territory. A retrospective audit of medical students' files from Northern Territory General Practice Education placements in Central Australia for the period from January 2006 to December 2007. Number and type of potentially harmful incidents. A total of 163 placements were undertaken. Of these, 98 (60%) had adequate documentation to determine whether an incident had occurred. There were 28 cases (17%) where potentially harmful incidents were judged to have occurred. Most incidents fell under several descriptive categories, but clinical supervision, professional practice and administrative issues were most common. One in six students experienced a potentially harmful incident during remote area placement in 2006-2007. While acknowledging the exploratory nature of this investigation and the major educational benefits that clearly arise from these placements, our findings indicate problems with clinical supervision and administration.

Cost and quality of education for general practice

Cost and quality of education for general practice

Extracurricular activities in general practice teaching for medical students

One hundred and forty-four medical students were enrolled in the study, the participants were randomly divided into experimental group and control group with 72 in each. All students attended the theoretical lecture of general medicine. Students in experimental group took part in the extracurricular teaching activities including the nutritional course and practice, the clinical case study and problem based learning ( PBL), students in control group did not have the extracurricular activities. The results showed that although there was no difference in general testing scores between two groups, the problem solving ability and assay-writing ability of experimental group were significantly higher than those of control group. Key words: Family practice ; Education,medical,undergraduate ;

To teach or not to teach? A cost–benefit analysis of teaching in private general practice

To identify the financial costs and benefits associated with teaching in private general practice. Cost-benefit analysis of teaching in private general practice across three levels of training--undergraduate medical training, prevocational training and general practice vocational training--using data from a 2007 survey of general practitioners in South Australia. GPs and practices teaching in association with the Adelaide to Outback GP Training Program or the Discipline of General Practice at the University of Adelaide. Net financial outcome per week. The net financial outcome of teaching varied across the training levels. Practices incurred a net financial cost from teaching medical students that was statistically significantly different from zero. With respect to vocational training and teaching junior doctors, there were small net financial benefits to practices, although the mean estimates were not statistically significantly different from zero. This study shows a net financial cost for practices teaching medical students, while at the prevocational and vocational training levels, adequate levels of subsidies and income generated by the trainees help offset the costs of teaching. Our results suggest that a review of subsidies for undergraduate teaching is necessary, particularly as the demand for teaching practices will increase substantially over the next 5 years.