GP Training Research Articles

19 General practitioners’ perspectives on advance care planning: a qualitative study

Abstract Background An Advance Care Plan (ACP) outlines patient preferences for future treatment for a time when capacity is lacking. With our ageing population and rising dementia prevalence, ACPs are of increasing relevance and importance; however, very few are created each year. This study aims to explore General Practitioner (GP) perspectives on ideal timing, facilitators, and barriers to ACPs. Methods To date, ten GPs with a range of clinical experience have been purposely sampled from the Irish College of General Practitioners database. Semi-structured interviews were conducted by phone, video call, or in person, concurrently recorded, and subsequently transcribed. The Braun and Clarke method of thematic analysis was utilised, and coding was performed using NVivo software. Results All GPs spoke to the importance of ACPs for care of those with dementia and believed GPs are ideally placed to have these discussions. Two themes arose regarding timing of discussion: (1) routine proactive discussion prior to potential cognitive issues arising and (2) discussion within a few appointments of diagnosis. Identified barriers to ACP include: (1) lack of patient awareness of ACPs, (2) lack of GP education on ACPs, (3) difficulty predicting disease progression, (4) poor family dynamics, (5) short appointment times, and (6) lack of remuneration. Identified facilitators include: (1) patient’s acceptance of death and understanding of diagnosis, (2) use of an established template to guide discussion, (3) presence of a trusted family member, (4) long appointment times and (5) remuneration. Conclusion There was universal agreement on the importance of ACPs. Inclusion of ACP teaching in the curriculum for undergraduate medical education and postgraduate GP training should be strongly considered. There is need for heightened public awareness of the Assisted Decision-Making Act and ACPs. Further qualitative and quantitative research is needed to explore this issue nationally and identify how it has been resolved internationally.

Employment intentions among rural order-oriented medical students in inner mongolia autonomous region, China.

The program of the "Free Training of Chinese Rural Order-Oriented Medical Students" is a plan to train general practitioners who can work at rural medical institutions. However, many students have been unwilling to fulfill their commitments and actually work in their assigned locations. This study aimed to provide some explanation by exploring factors influencing the employment intentions of rural order-oriented medical students in Inner Mongolia Autonomous Region of China to provide a basis for formulating relevant supporting policies to help increase the fulfillment rate of medical students. We conducted a cross-sectional study with a stratified cluster sampling method at four medical universities in Inner Mongolia using a survey questionnaire. Multivariate logistic regression was used to identify factors that were significantly associated with employment intentions. Approximately 67% of students were willing to work in rural areas, whereas 33% were not. Order-oriented medical students who were dissatisfied with, or indifferent to, training, were unclear about policy, were of Han ethnicity, or came from an urban area, had lower intentions to accept employment in rural areas. The training satisfaction in particular had the greatest predictive effect. The implementation of the program "Free Training of Chinese Rural Order-Oriented Medical Students" has been affected by the low actual employment intentions. This study may provide a useful basis on which medical educators and health policy makers can formulate relevant supporting policies and develop strategies to increase the number of order-oriented medical students who working in rural areas where they are most needed.

What is the role of ‘theory’ in training GP trainers?

ABSTRACT A recent evaluation paper of the London General Practitioner Trainer Course by Knight et al questions the importance of educational theory in preparing GPs to become trainers and asks ‘how much educational theory do GP trainers need to know in order to train effectively?’ This paper places the authors’ question under consideration, arguing that before the relationship between the theory and practice of education can be considered, the nature of ‘educational practice’ needs examination. There then follows a discussion of the work of Della Fish which presents two conceptualisations of educational practice in the context of postgraduate medical education in order to shed light on the different inferences contrasting epistemological and ontological conceptions can have, and the implications for curricula. This discussion is illustrated by offering the reader connections to papers in the field as evidence. At the heart of the paper is a conclusion that curriculum development and enquiry need to be sensitive to epistemological and ontological positionality as well as experiences and perceptions.

General practice registrars training part-time: a cross-sectional analysis of prevalence and associations

ABSTRACT While GPs are working fewer clinical hours and many GP trainees (registrars) do not foresee themselves working full-time in clinical practice, little is known of the epidemiology of registrars training part-time. We aimed to establish the prevalence of general practice part-time training (PTT), and part-time registrars’ characteristics and practice patterns. A cross-sectional analysis was conducted of data from the Registrar Clinical Encounters in Training project, an ongoing cohort study of Australian GP registrars’ clinical experiences over 60 consecutive consultations in each of three training terms. Univariable and multivariable logistic regression analyses were conducted with the outcome ‘training part-time’. 1790 registrars contributed data for 4,135 registrar-terms and 241,945 clinical encounters. Nine hundred and twenty-two registrar-terms (22%, 95%CI:21%–24%) and 52,339 clinical encounters (22%, 95%CI:21%–22%) involved PTT. Factors associated with PTT were registrar characteristics – female gender, older age, in a later training stage, performing other regular medical work; practice characteristics – working in a higher socioeconomic status area; and patient characteristics – seeing more patients new to the registrar and seeing more patients from a non-English-speaking background. No consultation or consultation action factors were significantly associated with PTT. Registrars, practices, and patient associations have GP training implications. The lack of registrar consultation or consultation action associations suggests there may be limited impact of PTT on patient care.

General practitioner residents’ experiences and perceptions of outpatient training in primary care settings in China: a qualitative study

ObjectivesThe implementation of outpatient training in primary care settings is an essential part of residency training for general practitioner (GP) residents. However, limited research exists on their experiences and perceptions...

Knowledge of Child Abuse and Neglect among General Practitioners and Pediatricians in Training: A Survey.

Child abuse and neglect is a common, underreported, and worldwide problem. Health care providers play an important role in detecting and reporting this problem. This study examined the knowledge on the clinical signs and mimickers of child abuse among Belgian trainees in family medicine and pediatrics. Participants filled out an anonymous online survey of 15 fictional but realistic cases with either suspicious or non-suspicious signs of abuse or neglect in the context of primary or emergency care. The overall score on all cases, the number of correct answers per case, and the median score were calculated, and the association of the participant's demographic characteristics with their score was examined using regression analysis. A total of 70 participants completed the survey. The overall median score was 73.3% (IQR 20.0%). The suspicious cases were solved more correctly than the non-suspicious cases (median: 85.7% versus 62.5%, p < 0.001). Regression analysis could not reveal a significant association of type and level of education with the performance on the survey. Knowledge of the clinical signs of child maltreatment among pediatricians and general practitioners in training is good, but there is still room for improvement.

Addressing the GP vocational training crisis in remote Australia: Lessons from the Northern Territory.

GP vocational training enrolments are declining Australia-wide and, in the Northern Territory (NT), considered by some as '…the litmus test for the national scene' the decline is precipitous. This research investigates the drivers of declining GP training uptake in the NT and identifies and ranks potential solutions. NT, Australia. Ten senior medical students, 6 junior doctors, 11 GP registrars, 11 GP supervisors and 31 stakeholders. Mixed methods: scoping review of Australian literature mapping key concepts to GP training pathway stages and marketing/communications; secondary data analyses; key informant interviews; and a stakeholder validation/prioritisation workshop. Interview data were thematically analysed. Workshop participants received summarised study findings and participated in structured discussions of potential solutions prior to nominating top five strategies in each of five categories. Highly prioritised strategies included increasing prevocational training opportunities in primary care and selecting junior doctors interested in rural generalism and long-term NT practice. Also ranked highly were: [Medical School] ensuring adequate infrastructure; [Vocational Training] offering high quality, culturally sensitive, flexible professional and personal support; [General Practice] better remunerating GPs; and [Marketing] ensuring positive aspects such as diversity of experiences and expedited GP career opportunities were promoted. Multifaceted strategies to increase GP training uptake are needed, which target different stages of GP training. Effective action is likely to require multiple strategies with coordinated action by different jurisdictional and national key stakeholder agencies. Foremost amongst the interventions required is the urgent need to expand primary care training opportunities in NT for prevocational doctors.

What affects you? A conversation analysis of exploring emotions during reflection sessions in Dutch general practitioner training.

In Dutch training for general practitioners (GPs), reflection on professional practice is key to their training. Such reflection is considered beneficial for professional development, especially when it entails discussing the emotional dimension of practice experiences. In the GP context, invitations to share the emotional side of things, such as "how did that make you feel?" are considered functional; yet, they are also sometimes viewed by participants as 'grilling', 'just too much' or 'too intimate'. Put shortly, putting emotions on the table is institutionally embedded in the GP reflection context, but not always straightforward. Thus, we ask: 'how do teachers and GP residents invite talk about emotions in educational reflection sessions?'. In this study, we explored the Dutch phrase 'raken, geraakt worden' (being affected) as one interactional practice used to initiate emotion talk. We conducted a conversation analytic collection study of instances of this phenomenon based on 40 video recordings of hour-long 'reflection sessions' at the Dutch GP specialty training. During these sessions, approximately ten GPs in training discuss recent experiences from medical practice under supervision of one or two teachers. We found that participants orientated to the relevance of 'being affected' as a topic for discussion. Variations of the form 'what affects you now?' may contribute to putting emotions on the table; they can project a stepwise exploration of the emotional dimension of an experience. The 'what affects you now', often done in interrogative format doing a noticing, in combination with a request, is a powerful tool to instigate transformative sequences. The form is less effective to put emotions on the table when the topic shift it initiates is not grounded in previously presented personal stakes or displayed emotion. The study's findings show how detailed interactional analysis of one sequentially structured practice can benefit education and contribute to theory on emotions and reflection. The mobilizing power of 'what affects you' can serve institutional purposes by doing topical work in relation to educational aims, while its power can also be deflated when prior talk does not project the relevance of unpacking the emotional dimension of an experience. Its interactional workings may translate to other helping contexts as well.

Evaluating the UK's first national prescribing assessment for GPs in training using an online survey.

GP trainees may not have experienced a systematic and comprehensive education in safe prescribing. Therefore, a self-assessment prescribing review was developed. To determine whether the assessment was feasible, had face validity, and did not disadvantage particular groups of participants. An online survey that evaluates the opinions of GPs in training of a prescribing assessment in the UK. All full-time UK trainees who started their final year of GP training in August 2019 undertook the prescribing assessment along with their trainers, after which they completed an online anonymous feedback questionnaire. The questionnaire completed by trainees sought their opinions of the assessment, and collected ethnicity and disability data. The trainer questionnaire was similar but did not include any demographic information. The questionnaire was completed by 1741 trainees and 1576 trainers. There was no evidence that ethnic group and disability were related to aspects of the review. Most of the trainees (76.4%, n = 1330) and trainers (82.0%, n = 1293) agreed or strongly agreed that the prescribing review was helpful for assessing and learning about the trainee's prescribing. However, most participants (63.2%, n = 1092) took >4 hours to review their prescriptions. A majority of trainees (90.2%, n = 1571) reported that completing the assessment had resulted in a change in their prescribing practice. The majority of trainers and trainees reported that the prescribing assessment was helpful. The study was not able to assess whether there had been an actual change in practice that resulted in an error reduction.

General practitioners’ perspectives regarding early developmental surveillance for autism within the australian primary healthcare setting: a qualitative study

BackgroundSignificant challenges remain in the early identification of child developmental disabilities in the community. Implementing supports and services early in the life course has been shown to promote positive developmental outcomes for children at high likelihood of developmental disabilities, including autism. As part of a cluster randomised controlled trial, this study seeks to examine and compare the perspectives and experiences of Australian general practitioners (GPs) in relation to a digital developmental surveillance program for autism and usual care pathway, in general practice clinics.MethodsA qualitative research methodology with semi-structured interviews and thematic inductive analysis underpinned by grounded theory was utilised. All GPs from South Western Sydney (NSW) and Melbourne (Victoria) who participated in the main program (“GP Surveillance for Autism”) were invited to the interview. GPs who provided consent were interviewed either over online or in-person meeting. Interviews were audio-recorded, transcribed, and coded using NVivo12 software. Inductive interpretive approach was adopted and data were analysed thematically.ResultsTwenty-three GPs across the two sites (NSW: n = 11; Victoria: n = 12) agreed to be interviewed; data saturation had reached following this number of participants. Inductive thematic coding and analysis yielded eight major themes and highlighted common enablers such as the role of GPs in early identification and subsequent supports, enhanced communication between clinicians/professionals, relationship-building with patients, and having standardised screening tools. Specific facilitators to the feasibility and acceptability of a digital screening program for the early identification of developmental disabilities, including the early signs of autism, and encouraging research and education for GPs. However, several practical and socioeconomic barriers were identified, in addition to limited knowledge and uptake of child developmental screening tools as well as COVID-19 lockdown impacts. Common and specific recommendations involve supporting GPs in developmental/paediatrics training, streamlined screening process, and funding and resources in the primary healthcare services.ConclusionsThe study highlighted the need for practice and policy changes, including further training of GPs alongside sufficient time to complete developmental checks and appropriate financial remuneration through a Medicare billing item. Further research is needed on implementation and scale up of a national surveillance program for early identification of developmental disabilities, including autism.

Variety is the spice of life: Academic general practice training

Variety is the spice of life: Academic general practice training

Identification of factors associated with non-adherence to recommended COVID-19 preventive behaviours: a cross-sectional study based on a survey among 1004 French primary care professionals

ObjectivesSince the beginning of the COVID-19 pandemic, adherence to preventive behaviours to limit virus spread has been a major issue. The study objective was to identify factors associated with non-adherence...

Mental health attitudes in Malta: a cross-sectional survey exploring the knowledge and perceptions of general practitioner trainees.

This study aimed to assess current levels of knowledge, opinions and attitudes regarding mental health among the local cohort of general practitioner trainees (n = 45) working in Malta. A questionnaire adapted from the Mental Health Literacy Scale was used. Data were analysed using one-way analysis of variance and Pearson correlation tests. All participants had scores equal to or more than the mean score in their knowledge and confidence assessments; 51% of the participants achieved the maximum score for a very positive attitude towards mental health, with such scores found particularly among female trainees. Increased levels of knowledge are associated with a more positive attitude, which can in turn lead to greater acceptance and reduce stigma. Knowledge is a powerful tool for reducing stigma and improving the doctor-patient relationship, indicating that regular training initiatives are necessary to equip budding general practitioner specialists with the necessary skills and confidence.

Home visiting and the housebound

Home visits by GPs, or ‘house calls’ as they were known, made up a large proportion of medical consultations until the 1960s, largely because of accessibility issues and slow transport options. Home visits now form a vastly smaller percentage of general practice workload reflecting, for example, increases in demand and a shortage of GPs. Many GPs now believe home visits should not be part of core contract work. Others fear such a change would communicate a lack of concern for the housebound. Such ambivalence is reflected in the GP training curriculum where home visits are no longer mandated, yet are simultaneously an expected competency for trainees. This article guides the trainee on how to complete a comprehensive home visit to illustrate the advantages they may offer. The latter part will explore further the differing opinions on home visits and proposals to address some of the dilemmas.

Effects of a short training workshop on the insertion/removal of intrauterine devices and contraceptive implants by general practice residents and their supervisors in France

ObjectivesThe skill of general practitioners (GPs) in performing the insertion/removal of intrauterine devices (IUDs) and contraceptive implants is one of the factors that determines patient's access to these contraceptive devices. In France, GP residents have few opportunities to perform these procedures during their internships. This study aimed to measure the effects of a single short training workshop on the number of residents and supervisors offering these procedures. Study designEach participant attended a unique 2-hour session. After a brief didactic review and video presentations, participants received hands-on training in technical procedures (insertion/removal of IUDs and contraceptive implants) using procedural simulators. The evaluation measured the number of GPs offering these procedures before, 1 month after, and 3 months after the workshops. ResultsFourteen sessions were organized from February 2017 to June 2022. Among the 387 residents and 123 supervisors invited, 143 (37.0%) and 56 (45.5%), respectively, participated in this workshop. Of 199 participants, 66.3% completed all questionnaires. There was a significant increase in the number of GPs inserting IUDs by direct method 3 months after training (20.5% vs 9.0%, p = 0.005). GPs providing information to patients about contraceptive implants were significantly higher at 1 month (80.6% vs 64.8%, p = 0.001) but this increase was no longer significant at 3 months (75.0%, p = 0.07). Residents changed their practices more than their supervisors, and women more than men. ConclusionsA short training workshop increased the number of GPs inserting IUDs, influenced by the gender and the number of years practicing. ImplicationsA single workshop had positive effects on IUD insertion and patient education about contraceptive implants. Repeating several times this training could be an option in the initial and ongoing training of general practitioners. Work on the general practitioners' own feeling of legitimacy in their practice context could also increase the effectiveness of these workshops and the practical implementation of the procedures taught.

Patient views of the good doctor in primary care: a qualitative study in six provinces in China

BackgroundChina has been striving to train primary care doctors capable of delivering high-quality service through general practitioner training programs and family doctor team reforms, but these initiatives have not adequately met patient needs and expectations. In order to guide further reform efforts to better meet patient expectations, this study generates a profile of the good doctor in primary care from the patient perspective.MethodsSemi-structured interviews were conducted in six provinces (Shandong, Zhejiang, Henan, Shaanxi, Shanxi, Heilongjiang) in China. A total of 58 interviewees completed the recorded interviews. Tape-based analysis was used to produce narrative summaries. Trained research assistants listened to the recordings of the interviews and summarized them by 30-s segments. Thematic analysis was performed on narrative summaries to identify thematic families.ResultsFive domains and 18 attributes were generated from the analysis of the interview data. The domains of the good doctor in primary care from the patient perspective were: strong Clinical Competency (mentioned by 97% of participants) and Professionalism & Humanism (mentioned by 93% of participants) during service delivery, followed by Service Provision and Information Communication (mentioned by 74% and 62% of participants, respectively). Moreover, Chinese patients expect that primary care doctors have high educational attainment and a good personality (mentioned by 41% of participants).ConclusionsThis five-domain profile of the good doctor in primary care constitutes a foundation for further primary care workforce capacity building. Further primary care reform efforts should reflect the patient views and expectations, especially in the family physician competency framework and primary care performance assessment system development. Meanwhile, frontline primary care organizations also need to create supportive environments to assist competent doctors practice in primary care, especially through facilitating the learning of primary care doctors and improving their well-being.

A realist evaluation of a London general practitioner trainer course

ABSTRACT Clinicians with teaching and training roles should be adequately trained and assessed. However, some debate exists as to what the nature of this training should be. Historically, a postgraduate certificate in education was a pre-requisite to becoming a GP trainer but this is changing with growing concern that such a pre-requisite might act as a deterrent to potential GP trainers. This research examines the impact of a scheme designed to provide an alternative, more practical and focused, pathway to becoming a GP trainer. We interviewed 26 course participants and stakeholders of the London GP Training Course (LGPTC), observed teaching sessions, and analysed course materials. We asked what elements of the course were and weren’t effective, for whom, and under what circumstances. Here, we present a summary of our main findings – that GP trainers want to know practically, not theoretically, how to be a trainer; formative assessment boosts trainees’ confidence in their own skills and abilities; short, practical GP training courses can help enhance the numbers of GP trainers; important questions remain about the role and value of educational theory in education faculty development.

Tackling differential attainment in specialist GP training in England and Scotland

ABSTRACT In this article NHS England and NHS Education for Scotland describe practical ways we are tackling differences in the attainment of people training as general practitioners (GPs). Trainees from minority ethnic groups and international medical graduates are less likely than others to qualify as GPs. It is difficult to change systemic inequalities, but over the past five years we have made practical changes to GP speciality training. Educators recognise there is an issue and are trying to tackle it. For example, people who had not successfully qualified had an opportunity to return to GP training. When we provided individualised targeted support, the proportion who completed training significantly increased (76%). This was a catalyst for reviewing unconscious bias in GP training. We implemented a national programme to tackle differential attainment and system-level bias. Educators now work with all GP trainees to identify their individual needs. Supervisors are trained to recognise bias and provide targeted support. There is mental health support and regular reviews to see whether trainees are ready to sit exams. Trainee representatives are championing the learner voice in national committees. Exams are being altered to reduce unconscious bias. We are monitoring attainment over time. The key message is that differential attainment should not be in the ‘too hard basket’. The narrative is changing from ‘can’t do’ to ‘must do’, supported by appropriate leadership, promotion and resourcing. There is much more to do, but we are making changes, evaluating and applying our learning. We have moved from talking to taking action.

What competencies do European general practice trainees value the most? A prioritisation exercise using a Delphi-informed approach

ABSTRACT General Practice has changed over the past decade. Expansion of clinicians’ roles may create uncertainty, stress, and overload – particular for those at the start of their career. The WONCA Europe network for medical education, EURACT, has published competency-based aims and requirements for speciality training in general practice. Greater understanding of the trainee perspective would support planning and delivery of postgraduate training curricula. This two-step study aims to provide a competency priority list, created by European early career general practitioners, to highlight skills that this generation considers highly essential in future speciality training. A competency list was drafted with trainee- and early career general practitioners from across Europe at the Vasco da Gama Movement Forum (Edinburgh, January 2022). Participants identified competencies that they regarded as most relevant for future speciality training in their respective national contexts. Competencies were coded into categories and ranked in two consecutive rounds, the first taking place online and the second at WONCA Europe (London, June 2022). After two rounds, a consensual list of three main competencies for each category was drafted. The top three competencies for each category remained the same throughout both rounds and may be considered competencies that early career general practitioners in Europe consider important for training. Prioritisation of these competencies by institutions and educators within general practice training programmes may support trainees’ satisfaction and perceived preparedness for practice.

Managing problematic polypharmacy: GP trainee perspectives on their role in deprescribing.

Problematic polypharmacy is an increasingly common clinical scenario in part due to increasing multimorbidity and application of multiple single condition guidelines. It is a challenging problem requiring a multifaceted management approach. This includes deprescribing, which is the structured dose reduction or stopping of medications. Qualified GPs struggle with deprescribing due to existing barriers, but little is known about how trainee GPs feel about this skill. To explore and understand the perspectives of GP trainees in managing problematic polypharmacy. A qualitative approach with focus groups using a novel love and breakup letter methodology. Purposive sampling of final year GP trainees led to two focus groups. Data from the groups were subjected to thematic analysis. Four key themes emerged: value in deprescribing, requiring a generalist skillset, undermined trainee identity, and educational barriers. Trainees recognised a value in deprescribing and the importance of tackling problematic polypharmacy using this skill. They identified key skills to facilitate this but barriers that prevented them from doing so. They also described how some aspects of the hidden curriculum and 'imposter syndrome' impact on their ability to develop confidence in these skills. Barriers within their training programme were also recognised. This study explored the complex area of problematic polypharmacy and deprescribing as relating to final year GP trainees. It identified key skills that trainees feel they need to manage this task in practice. Importantly, it also recognises barriers to be overcome before confident deprescribing can be performed. Potential improvements in training are identified with suggestions for educational opportunities.