The clinical and educational experiences of pre-registration house officers in general practice

The learner's perspective in GP teaching practices with multi-level learners: a qualitative study

BACKGROUND

Medical students, junior hospital doctors on rotation and general practice (GP) registrars are undertaking their training in clinical general practices in increasing numbers in Australia. Some practices have four levels of learner. This study aimed to explore how multi-level teaching (also called vertical integration of GP education and training) is occurring in clinical general practice and the impact of such teaching on the learner.

METHODS

A qualitative research methodology was used with face-to-face, semi-structured interviews of medical students, junior hospital doctors, GP registrars and GP teachers in eight training practices in the region that taught all levels of learners. Interviews were audio-recorded and transcribed. Qualitative analysis was conducted using thematic analysis techniques aided by the use of the software package N-Vivo 9. Primary themes were identified and categorised by the co-investigators.

RESULTS

52 interviews were completed and analysed. Themes were identified relating to both the practice learning environment and teaching methods used.A practice environment where there is a strong teaching culture, enjoyment of learning, and flexible learning methods, as well as learning spaces and organised teaching arrangements, all contribute to positive learning from a learners' perspective.Learners identified a number of innovative teaching methods and viewed them as positive. These included multi-level learner group tutorials in the practice, being taught by a team of teachers, including GP registrars and other health professionals, and access to a supernumerary GP supervisor (also termed "GP consultant teacher"). Other teaching methods that were viewed positively were parallel consulting, informal learning and rural hospital context integrated learning.

CONCLUSIONS

Vertical integration of GP education and training generally impacted positively on all levels of learner. This research has provided further evidence about the learning culture, structures and teaching processes that have a positive impact on learners in the clinical general practice setting where there are multiple levels of learners. It has also identified some innovative teaching methods that will need further examination. The findings reinforce the importance of the environment for learning and learner centred approaches and will be important for training organisations developing vertically integrated practices and in their training of GP teachers.

Rural general practice placements: alignment with the Australian Curriculum Framework for Junior Doctors

OBJECTIVES

To review the available literature regarding skills and competencies gained by junior doctors in rural and regional general practice placements and their alignment with the Australian Curriculum Framework for Junior Doctors (ACFJD).

STUDY DESIGN

A comprehensive literature review using a three-phase process. Articles were initially identified from database searches in OvidSP and Scopus. Additional information was obtained after a hand search of contents pages from relevant journals and from reports, conference abstracts and grey literature. Documented skills and procedures were mapped against the competencies from the ACFJD.

DATA SOURCES

We analysed 36 relevant articles written in English and published during 1997-2011. Articles referring to learning outcomes for junior doctors training with rural general practitioners were included.

DATA SYNTHESIS

Evidence was available of the advantages of junior doctor rural general practice placements in gaining advanced skills in the areas of communication and professionalism, as well as developing autonomy in clinical management and decision making. Less evidence was available regarding exposure to particular clinical conditions and development of specific clinical skills.

CONCLUSION

Rural and regional general practice placements for junior doctors are likely to comply with the ACFJD requirements and, further, provide excellent learning opportunities in several domains of the curriculum. However, there was little research published confirming learning outcomes for junior doctors in rural general practice settings.

Does responsibility drive learning? Lessons from intern rotations in general practice

BACKGROUND

The intern (or pre-registration) year has been criticised in the past for its emphasis on service delivery at the expense of educational achievement. It is hoped that new approaches to early postgraduate training such as the foundation programmes in the UK, will make clinical education more structured and effective. Intern placements in non-traditional settings such as general practice have been shown in the past to improve the quality of learning. Little is known however about which features of the general practice learning environment contribute most to the perception of improved learning.

AIMS

This aim of this study was to examine the learning environment in general practice from the perspective of interns, (the learners), to determine the factors that contribute most to motivating effective learning in a general practice setting.

METHODS

This study used a qualitative case study approach to explore the effects of two different learning environments, (general practice and hospital) on learner motivation amongst a small group of interns.

RESULTS

We found that the biggest difference between the hospital and general practice learning environments was the increased individual responsibility for patient care experienced by interns in general practice. Greater responsibility was associated with greater motivation for learning.

CONCLUSIONS

Increased intern responsibility for patient care does appear to motivate learning. More work needs to be done on providing interns in hospital posts with greater patient responsibility within an effective supervisory structure.

General practice placements for pre‐registration junior doctors: adding value to intern education and training

OBJECTIVE

To examine pre-registration junior doctors' perceptions of the value of a general practice term in their training program.

DESIGN, SETTING AND PARTICIPANTS

Semi-structured interviews, in five teaching hospitals in South Australia in 2005, with 20 pre-registration junior doctors (interns) who had completed a general practice term and at least one core term of intern training.

MAIN OUTCOME MEASURE

Comparisons between general practice and teaching hospital core training terms with respect to the domains of junior doctor education.

RESULTS

Interns perceived general practice and teaching hospital terms to be complementary in their overall training program. The general practice term provided them with knowledge and skills they would not have acquired in the teaching hospital terms alone. One-on-one consulting, initiating patient management, and the opportunity to practise a range of practical and procedural skills were seen to be of particular value.

CONCLUSIONS

The general practice and teaching hospital terms both contribute to the training of interns, offering contrasting environments and experiences which enhance interns' professional and personal growth. General practice terms should be considered for inclusion in intern training programs across Australia.

Flexible (part-time) preregistration house officer training: review of Thames and London deanery experiences

Flexible training has been in greatest demand at the specialist registrar grade, and to a lesser extent in the senior house officer grade. This article describes the experiences of a much smaller group, flexible preregistration house officers.

Preregistration house officers in general practice: review of evidence

OBJECTIVES

To examine the strengths and weaknesses of the national and local schemes for preregistration house officers to spend four months in general practice, to identify any added value from such placements, and to examine the impact on career choices.

DESIGN

Review of all studies that reported on placements of preregistration house officers in general practice.

SETTING

19 accounts of preregistration house officers' experience in general practice, ranging from single case reports to a national evaluation study, in a variety of locations in Scotland and England.

PARTICIPANTS

Views of 180 preregistration house officers, 45 general practitioner trainers, and 105 consultant trainers.

MAIN OUTCOME MEASURES

Main findings or themes weighted according to number of studies reporting them and weighted for sample size.

RESULTS

The studies were unanimous about the educational benefits of the placements. The additional learning included communication skills, social and psychological factors in illness, patient centred consultations, broadening of knowledge base, and dealing with uncertainty about diagnosis and referral.

CONCLUSIONS

Despite the reported benefits and recommendations of the scheme, it is not expanding. General practitioner trainers reported additional supervision that was unremunerated. The reforms of the senior house officer grade may resolve this problem by offering the placements to senior house officers, who require less supervision.