GP Training Practices Research Articles

Levelling up or left behind? Does increasing GP training numbers inadvertently widen health inequalities?

Increasing the GP workforce will not automatically level up healthcare provision; instead, increasing GP training numbers could worsen health inequity and inequalities. This is especially of concern if there are fewer opportunities to learn, train, and build confidence in under-served, socioeconomically deprived areas. To examine how representative of wider socioeconomic deprivation the postgraduate GP training practices are in Northern Ireland (NI). The deprivation indices and scores of GP postgraduate training practices were compared against general practice in NI. Representation of practices whose patients live in blanket deprivation, higher deprivation, and higher affluence was compared. Of 319 practices in NI, 171 (54%) were registered as postgraduate training practices and had a mean deprivation score of 3.02 (95% CI [confidence interval] = 2.91 to 3.12) compared with non-training practices' higher mean deprivation score of 3.2 (95% CI = 3.01 to 3.33), P-value <0.05. The proportion of training practices with blanket deprivation and higher levels of deprivation are marginally underrepresented and training practices had higher affluence scores. Postgraduate training practices had a statistically significant lower deprivation score and did not fully reflect the socioeconomic make-up of wider NI general practice. The results, however, are more favourable than the representation in other areas of the UK and better than undergraduate teaching opportunities in general practice. As GP recruitment is increased, representation of general practice in areas of high need and high socioeconomic deprivation is essential, otherwise it risks widening health inequalities.

Levelling up or left behind? are GP training opportunities in northern Ireland widening or closing the gap on health inequalities?

Increasing the GP workforce will not necessarily level up healthcare provision: instead increasing GP training numbers could worsen health inequity and inequalities. This is especially true if there are fewer opportunities to learn, train and build confidence in under-served, socioeconomically deprived areas. To investigate the representation of socioeconomic deprivation in postgraduate GP training practices in Northern Ireland (NI). Socioeconomic deprivation indices and scores of GP practices in Northern Ireland were calculated. We compared the socioeconomic deprivation indices and scores of GP postgraduate training practices against general practice in NI by examining the representation of practices whose patients live in areas of blanket deprivation, higher deprivation and higher affluence. Of 319 practices in NI, 171 (54%) were registered as postgraduate training practices with a mean deprivation score of 3.02 (95% CI 2.91-3.12) compared with non-training practices' higher mean deprivation score of 3.2 (95% CI 3.01-3.33), P-value <0.05. The proportion of training practices with blanket deprivation and higher levels of deprivation was underrepresented, with the current postgraduate GP training practices having more affluent populations. Postgraduate training practices had a statistically significant lower deprivation score and did not fully reflect the socioeconomic make-up of wider NI general practice. The results, however, are more favourable than in other areas of the UK and better than undergraduate teaching opportunities in general practice. Health inequalities will worsen if the representation of general practice training in areas of greater social economic deprivation is not increased.

Interprofessional education and collaboration between general practitioner trainees and practice nurses in providing chronic care; a qualitative study

BackgroundEffective interprofessional collaboration (IPC) is essential for the delivery of chronic care. Interprofessional education (IPE) can help support IPC skills. This makes IPE interesting for GP practices where chronic care is delivered by GPs together with practice nurses, especially for GP trainees who have to learn to collaborate with practice nurses during their training. The aim of this study is to gain insights in how IPE and IPC occur between GP trainees and practice nurses during the delivery of chronic care in GP training practices.MethodsWe conducted a qualitative research using semi structured focus groups and interviews with GP trainees, practice nurses and GP supervisors. All respondents were primed to the subject of IPE as they had followed an interprofessional training on patient-centred communication. The verbatim transcripts of the focus groups and interviews were analysed using thematic analysis.ResultsDespite the overall positive attitude displayed by respondents towards IPE and IPC, the occurrence of IPE and IPC in GP training practices was limited. Possible explanations for this are impeding factors such as limited knowledge, prejudice, lack of role models and a hierarchical organisational structure. Contributing to IPE and IPC use was the integration of IPE in daily practice, e.g. via recurring scheduled meetings.ConclusionWe found a limited occurrence of IPE and IPC in GP training practices. Our results show a discrepancy between respondents enthusiasm for IPE and IPC and their actual behaviour. IPE activities have to be initiated in GP training practices, otherwise, despite good intentions, IPE and IPC will be ineffective.

Preparing for leadership in General Practice: a qualitative exploration of how GP trainees learn about leadership

ABSTRACTThe recent rise to prominence of healthcare leadership worldwide has prompted those involved in medical education to consider how to facilitate learning to lead effectively. Research has focused on formal curriculum activities. Curricular theory suggests that trainee doctors may also learn through the informal curriculum but there is a lack of medical education literature on this. We aimed to explore how GP trainees learn about leadership in their GP training practices. Epistemologically grounded in social constructionism, this research involved 15 semi-structured interviews with GP trainees about to complete their training. Interviews were conducted using an online video conferencing method, audio-taped, transcribed and analysed using thematic framework analysis. We identified three learning processes contributing to leadership development; evaluating leadership, formulating views on leadership and constructing a personal leadership identity. Other factors operating within the informal curriculum included leadership terminology, and the quality of relationships and networks. Paradoxically, a role model’s fallibility could positively influence leadership learning. Based on our findings, we present a model for the informal leadership learning process. This may enhance the facilitation of leadership learning by trainers and the wider clinical team, and positively influence the delivery and content of formal leadership courses.

Books: Medical Professionalism and the Public Interest: Reflections on a Life in Medicine: Making Medical Regulation More Patient Centred.

Sir Donald Irvine Royal College of General Practitioners Heritage Committee , 2018 , HB, 168pp , £ 27.67 , 978-1389188404 This is a crucial book by one of the most important leaders of the medical profession in recent times. It is a memoir that begins with interesting chapters about his childhood when his father was also a family doctor, but the wider interest will be in his professional career where as a GP he made major contributions holding several key posts in medicine. He was the regional adviser for general practice in the Northern region, achieving nationally high standards in the GP training practices. As Chairman of Council of the RCGP, he introduced the ‘quality initiative’ encouraging colleagues to describe and evaluate day-to-day care in their own practices. In 1979 he was the first RCGP nominee to the General Medical Council (GMC), which was the stage for his most important contributions. As Chairman …

Antimicrobial prescribing in post-graduate training practices: a cross-sectional study of prescribing data in general practices in England

IntroductionSeventy-five percent of all antimicrobials are prescribed in primary care. There is a growing concern about inappropriate oral antimicrobial prescribing. Interventions to enhance antimicrobial stewardship are actively promoted through educational and other means. GP training practice status has been shown to influence patient care. This study seeks to study the influence of GP training practice status on antimicrobial prescribing.MethodsA cross-sectional analysis of practice antimicrobial prescribing data was conducted for the year 2015–2016 comparing training and non-training practices across England. Data for all practices and prescribing was obtained from NHS Digital. Univariate analyses were conducted on the two measures of antibiotic prescribing included in the study. Multivariable regression models were constructed to identify the predictors of antibiotic prescribing volumes and of broad spectrum antibiotic prescribing.ResultsGP training practice status was a significant predictor of overall antibiotic prescribing volume, B = −0.009 (95% confidence intervals, −0.012, −0.005), p < 0.001. GP training practices prescribed fewer antibiotics, representing a reduction of 6.2 centiles from the median. GP training practice status was also a significant predictor of broad spectrum antibiotic prescribing, B = −0.3 (95% confidence intervals, −0.04, −0.01), p = 0.001. GP training practices prescribed fewer broad spectrum antibiotics, representing a reduction from the median of 6.0 centiles.DiscussionTraining practices prescribe fewer antimicrobials overall and specifically fewer broad spectrum oral antimicrobials (quinolones and cephalosporins). There is a need for further research to understand the interplay between postgraduate GP training and reductions in antimicrobial prescribing.

Managing the consultation with patients with medically unexplained symptoms: a grounded theory study of supervisors and registrars in general practice.

BackgroundPatients with medically unexplained symptoms (MUS) commonly present in general practice. They often experience significant disability and have difficulty accessing appropriate care. Many feel frustrated and helpless. Doctors also describe feeling frustrated and helpless when managing these patients. These shared negative feelings can have a detrimental effect on the therapeutic relationship and on clinical outcomes. The aim of this study was to explore how novice and experienced GPs manage patients with MUS and how these skills are taught and learned in GP training.MethodsA constructivist grounded theory study with 24 general practice registrars and supervisors in GP training practices across Australia.ResultsRegistrars lacked a framework for managing patients with MUS. Some described negative feelings towards patients that were uncomfortable and confronting. Registrars also were uncertain about their clinical role: where their professional responsibilities began and ended. Supervisors utilised a range of strategies to address the practical, interpersonal and therapeutic challenges associated with the care of these patients.ConclusionsNegative feelings and a lack of diagnostic language and frameworks may prevent registrars from managing these patients effectively. Some of these negative feelings, such as frustration, shame and helplessness, are shared between doctors and patients. Registrars need assistance to identify and manage these difficult feelings so that consultations are more effective. The care of these patients also raises issues of professional identity, roles and responsibilities. Supervisors can assist their registrars by proactively sharing models of the consultation, strategies for managing their own feelings and frustrations, and ways of understanding and managing the therapeutic relationship in this difficult area of practice.

Patient experience and the role of postgraduate GP training: a cross-sectional analysis of national Patient Survey data in England.

Quality indicators for primary care focus predominantly on the public health model and organisational measures. Patient experience is an important dimension of quality. Accreditation for GP training practices requires demonstration of a series of attributes including patient-centred care. The national GP Patient Survey (GPPS) was used to determine the characteristics of general practices scoring highly in responses relating to the professional skills and characteristics of doctors. Specifically, to determine whether active participation in postgraduate GP training was associated with more positive experiences of care. Retrospective cross-sectional study in general practices in England. Data were obtained from the national QOF dataset for England, 2011/12 (8164 general practices); the GPPS in 2012 (2.7 million questionnaires in England; response rate 36%); general practice and demographic characteristics. Sensitivity analyses included local data validated by practice inspections. multilevel regression models adjusted for clustering. GP training practice status (29% of practices) was a significant predictor of positive GPPS responses to all questions in the 'doctor care' (n = 6) and 'overall satisfaction' (n = 2) domains but not to any of the 'nurse care' or 'out-of-hours' domain questions. The findings were supported by the sensitivity analyses. Other positive determinants were: smaller practice and individual GP list sizes, more older patients, lower social deprivation and fewer ethnic minority patients. Based on GPPS responses, doctors in GP training practices appeared to offer more patient-centred care with patients reporting more positively on attributes of doctors such as 'listening' or 'care and concern'.

Attitudes towards obesity treatment in GP training practices: a focus group study

Both patients and government expect the GP to treat obesity. Previous studies reported a negative attitude of GPs towards this task. Little is known about the attitude of GP trainees. To assess the attitude and other factors that influence the willingness and ability of GP trainees to provide lifestyle interventions for overweight patients. A qualitative study was performed using focus groups, consisting of first- and third-year trainees, GP trainers and teachers. Two researchers analysed the data independently. First-year trainees lack knowledge and a positive attitude. Third-year trainees, although trained in motivational interviewing techniques, lack specific knowledge and feel cheated when discussing eating habits. Trainers are despondent as they rarely observe long-lasting results. Teachers warn the trainees not to have high hopes. The trainers and trainees fear ruining the relationship with their patient, and all make a request for evidence-based multidisciplinary treatment programmes, joint responsibility and an image change in society to stop the epidemic. Trainees do not feel more competent in treating overweight patients successfully over the course of their GP specialty training and GP trainers are not convinced of the success of the treatment of overweight patients. Therefore, it could be equally important to reflect on the GP trainer as a role model as to concentrate on the education of the trainee. Both need a revived attitude and evidence-based treatment programmes, help from policy makers and an attitude change in society are desired.

Who determines the patient mix of GP trainees? The role of the receptionist

During their specialty training, Dutch GP trainees work at a GP under the supervision of a GP trainer. Research suggests that the patient mix of GP trainees differs from that of their trainers. Receptionists assign patients to either the trainee or the trainer, thereby influencing the patient mix of the trainees. The decision to which doctor to assign is complex and depends on the latitude the receptionists have. Their considerations when assigning patients are unknown. To study receptionists' assigning behaviour. This was a questionnaire survey. To design the questionnaire, topics about assigning behaviour were identified in a focus group. The resulting questionnaire was sent to 478 GP training practices in the Netherlands. Response rate was 68%. Of the receptionists, 95% asked for the reason for the consultation at least 'sometimes'. Most (86.3%) of the receptionists considered the patient mix of trainees and trainers to be similar. Almost all receptionists (97%) reported 'often' or 'always' assigning 'every possible problem' to the trainee and a similar picture arose regarding specific subpopulations. However, the receptionists reported that they assigned complex and new patients to the trainers more often than to trainees. With some exceptions, receptionists try to assign trainees a varied patient mix.

Selecting GP speciality trainees: squaring the circle?

Irish and Patterson's discussion paper reviewed the current pathway for selecting GP speciality trainees. They ask how it can be improved.1 Despite Mencken's caution that ‘for every complex problem there is an answer that is clear, simple, and wrong’,2 maybe there is an easier way. The current structure (The National Recruitment Office for GP Training), the process (a single standardised recruitment system), and the specific outcome (successful completion of GP speciality training), coupled with continuing attempts to improve the process could make the journey to becoming a GP less of a maze and more a motorway to success. The ideal selection outcome is that the recruited GP subsequently provides high quality care throughout a 30-year career. An optimal outcome may be that the GP provides high quality care for 5 years and then passes revalidation. The minimum outcome is that the GP passes the MRCGP licensure examination by the end of 3 years of training. However, low pass rates in the Clinical Skills Assessment (CSA) module of the MRCGP examination suggest that either the selection process is flawed, or that the CSA is not a reliable, fair, and valid test. The flaw in selection may be that it is impossible to reconcile the need for the recruitment process to fill all the training posts every year, and ensure that all these recruits pass the MRCGP examination within their 3 years of training. Any worries that the MRCGP examination is not a good test of competence needs to be addressed by the Royal College of General Practitioners (RCGP). Although the RCGP has always wanted a longer training scheme, the recruitment process needs to select candidates who are likely to pass the MRCGP exam within their 3 years of training. The Mencken-defying improvement may be to link their selection to the results of taking real or mock modules of the MRCGP examination. These modules could be taken online at a convenient Applied Knowledge Test examination centre, remotely by reviewing the candidates' existing ePortfolios including work-place based assessments, and by a CSA at nearby GP-training practices. The candidates could pay a fee to take these assessment modules. Only those candidates with qualifying scores would be eligible to apply for GP training. The results of these tests could inform the training of recruits to improve their chances of success in the MRCGP exam. Weaker candidates may need a few attempts over a couple of years to qualify for GP training. Perhaps the best of these weaker candidates could be offered any unfilled training posts on an ad hoc basis, but they would not be in the 3-year GP training scheme. Educators and learners may be reluctant to concentrate their efforts on passing a test, but the RCGP – GP curriculum statements already point in this direction. The RCGP regularly updates a curriculum that describes what a GP needs to be able to do to work in general practice for the first 5 years and conducts a membership examination that should be a reliable, fair, and valid test of that ability. After the first 5 years, the RCGP's (and General Medical Council's) regular revalidation should ensure that GPs have the competencies to practice for the rest of their careers. Mencken also advised ‘a judge is a law student who marks his own examination papers’.2 This may describe the continuing difference between our confidence and competence in our assessment of the ability of others.

Describing the Learning Climate of General Practice Training: the learner’s perspective

The learning climate is an important aspect of educational environments that impacts on learner satisfaction, stress and attitudes to learning. Quality management of educational environments has traditionally focused on teacher development and aspects of the environment that are easily quantifiable. This study describes the learning climate of GP training practices from the perspective of the learners. The information can be used to inform a learner-centred and evidence-based system of quality management. Further development of the themes could produce a quantitative tool, to provide data on the learning climate of GP training practices. This could assist in the quality management of GP training in the UK.

Do primary care teams have easy access to information in GP training practices?

Do primary care teams have easy access to information in GP training practices?