What do general practitioners do differently when consulting with a medical student?

Undergraduate medical teaching with remote consultations in general practice: a realist evaluation

BACKGROUND

Supervisors historically educated students in primary care in face-to-face contexts; as a result of COVID-19, students now experience patient consultations predominantly remotely. There is a paucity of evidence regarding the facilitators and barriers to supervising students for excellent educational impact in the remote consultation environment.

AIM

To understand the facilitators and barriers to educating medical students using remote consultations in primary care, and the consequences for students in terms of educational impact.

DESIGN & SETTING

A realist evaluation methodology was adopted to identify causal chains of contexts, mechanisms, and outcomes, describing how the teaching and learning functioned on a sample of medical students and GP tutors from two medical schools in London, UK.

METHOD

An initial programme theory was developed from the literature and a scoping exercise informed the data collection tools. Qualitative data were collected through online questionnaires (49 students, 19 tutors) and/or a semi-structured interview (eight students, two tutors). The data were coded to generate context-mechanisms-outcome configurations outlining how the teaching and learning operated.

RESULTS

The results demonstrated a sequential style of supervision can positively impact student engagement and confidence, and highlighted a need to address student preparation for remote patient examinations. Students found passive observation of remote patient encounters disengaging, and, in addition, reported isolation that impacted negatively on their experiences and perceptions of primary care.

CONCLUSION

Student and tutor experiences may improve through considering the supervision style adopted by tutors, and through interventions to reduce student isolation and disengagement when using remote patient consultations in primary care.

The effect of a medical student on community preceptor productivity

BACKGROUND

Medical students are increasingly being taught in community-based hospitals and clinics in addition to university-based health systems, and there is sustained interest in the question of whether medical schools should pay healthcare organizations to allow students to precept to compensate for loss of productivity by preceptors. This study aimed to inform this subject by investigating the effect of medical students on preceptor productivity.

METHODS

The authors analysed retrospective data on preceptor productivity and time efficiency from 17 outpatient primary care physicians over 7 months and 38,205 patient visits. Then, the authors surveyed these same physicians to assess how they believe precepting medical students affected their productivity.

RESULTS

The retrospective data analysis found that physicians see slightly more patients per half-day when accompanied by a student. In surveys, these physicians reported the same number of patients seen per half-day with or without a medical student, but more time spent in clinic with a medical student. They also reported that allowing students to document in the medical record often helped reduce/offset the lengthened workday.

CONCLUSIONS

Medical students either increase or do not change the number of patients seen per half-day but can increase preceptor time spent in clinic per day. Generally, physicians accept this increased time for the sake of promoting education and the joy of teaching. These findings can inform medical schools and healthcare organizations when negotiating financial arrangements for preceptorships in community based primary care clinics. Specifically, these findings suggest that medical students precepting do not cost the hospital organization in terms of preceptor productivity.

Parallel consulting method: student and tutor evaluation in general practice

The parallel consulting method (PCM) is widely used by general practitioners (GPs) for teaching medical students. Studies have described individual aspects of bedside teaching in community settings, including the logistics of using the PCM, but there has been no evaluation of it as a teaching method. This study aimed to evaluate the PCM and whether it helped students develop consultation, clinical and clinical reasoning skills. The study was based at the Oxford University Primary Care Department. Penultimate clinical year students (n = 63) were recruited to take part in this mixed methods study. Students completed a questionnaire with closed and open-ended questions rating the PCM. A focus group explored questionnaire themes. GP tutors completed a questionnaire about the PCM and the logistics of delivering it. Three tutors took part in semi-structured interviews. The PCM helped develop students' consulting, and clinical reasoning skills. Teaching was improved when tutors were unrushed and had increased time to provide feedback and teaching. Delivery logistics of the PCM impacted on whether tutors were rushed and found it difficult to teach. Most benefit was derived when students were well briefed with sufficient debriefing time following a consultation. The following steps are recommended for effective delivery of the PCM teaching model: ensure tutors are appropriately trained; comprehensively brief the student about how to gain the most out of the learning experience; plan the logistics; ensure appropriate review and debriefing following consultation; review clinical cases after the session teaching on any outstanding aspects.

An overview of general practitioner consultations in China: a direct observational study

BACKGROUND

General practitioner (GP) consultation has long been considered an important component of general practice, but few studies have focused on its characteristics in China.

OBJECTIVE

This study aimed to explore the content and elucidate the characteristics of GP consultations in general practice in China.

METHODS

A multimethod investigation of GP consultations in eight community health centres in Guangzhou and Shenzhen, China was conducted between July 2018 and January 2019. Data from 445 GP consultations were collected by direct observation and audio tape and analysed by a modified Davis Observation Code with indicators for frequencies and detailed time durations. GP and patient characteristics were collected by post-visit surveys.

RESULTS

The mean visit duration was approximately 5.4 minutes. GPs spent the most time on treatment planning, history taking, negotiating, notetaking and physical examination and less time on health promotion, family information collecting, discussing substance use, procedures and counselling. The time spent on procedures ranked first (66 seconds), followed by history taking (65 seconds) and treatment planning (63 seconds). Besides, patients were very active in the consultation, specifically for topics related to medicine ordering and drug costs.

CONCLUSIONS

This study described the profile of GP consultations and illustrated the complexity of care provided by GPs in China. As patient activation in GP consultations becomes increasingly important, future studies need to explore how to promote the engagement of patients in the whole consultation process other than just requesting for medicine.

Medical visit time and predictors in health facilities: a mega systematic review and meta-analysis

Purpose

Visit time is a crucial aspect of patient–physician interaction; its inadequacy can negatively impact the efficiency of treatment and diagnosis. In addition, visit time is a fundamental demand of patients, and it is one of the rights of every patient. The purpose of this paper is to determine factors influencing the consultation length of physicians and to compare consultation length in different countries.

Design/methodology/approach

MEDLINE (PubMed), Web of Science, Cochrane, ProQuest, Scopus, and Google Scholar were searched. In addition, references of references were checked, and publication lists of individual scholars in the field were examined. We used data sources up to June 2018, without language restriction. We used a random-effects model for the meta-analyses. Meta-analyses were conducted using Comprehensive Meta-Analysis Version (CMA) 3.0.

Findings

Of 16,911 identified studies, 189 studies were assessed of which 125 cases (67 percent) have been conducted in the USA. A total of 189 studies, 164 (86.77 percent) involved face-to face-consultations. The effects of three variables, physician gender, patient gender, and type of consultation were analyzed. According to moderate and strong evidence studies, no significant difference was found in the consultation lengths of female and male doctors (Q=42.72, df=8,I2=81.27,p=0.891) and patients’ gender (Q=55.98, df=11,I2=80.35,p=0.314). In addition, no significant difference was found in the telemedicine or face-to-face visits (Q=41.25, df=5,I2=87.88,p=0.170).

Originality/value

In this systematic review and meta-analysis, all of physicians’ visits in 34 countries were surveyed. The evidence suggests that specified variables do not influence the length of consultations. Good relationship is essential to a safe and high-quality consultation and referral process. A high-quality consultation can improve decisions and quality of visits, treatment effectiveness, efficiency of service, quality of care, patient safety and physician and patient satisfaction.

What impact do students have on clinical educators and the way they practise?

The clinical education setting plays an important part in teaching students about the real world of clinical practice. Traditionally the educational relationship between student and clinical educator has been considered one-way, with students being the ones that benefit. This review focuses on the areas of clinician practice and behaviour that students are reported to influence through clinical placements and as such, determine the overall impact students can have on supervising clinicians. Electronic searches were conducted across MEDLINE, EMBASE, PsychINFO and CINAHL in July 2016. Retrieved articles were filtered to find those which presented data relating to students in the clinical setting. Data was extracted and analysed independently by two authors through thematic analysis. Twenty-eight studies met the inclusion criteria. Results showed that practitioners enjoy the act of teaching. Clinical student presence encourages clinicians to solidify their knowledge base, stimulates learning and causes them to re-evaluate their practice. Practitioner skills were further developed as a results of students. Clinical educator workload and time spent at work increased when a student was present with time management being the predominant challenge practitioners faced. Studies demonstrated that clinicians feel they benefit by students periodically becoming the teacher. Student placements in clinical practice cause an increase in practitioner workload and lengthen their work day. These perceived limitations are outweighed by the many benefits described by supervising clinicians. Providing clinical education can enrich both the practice, and the practitioner, and the aforementioned advantages should be highlighted when offering or considering the expansion of clinical placements.

Pediatric procedural pain: how far have we come? An ethnographic account

The aim of this ethnographic study was to explore the pediatric procedural pain management practice of health care providers in a non-pediatric emergency department. Data were collected for 5 months and included more than 100 hours of observation. Six key informants were interviewed, and 44 pediatric procedural interactions with 27 health care providers during the treatment of children aged 2 to 8 years undergoing procedures were observed. Other information gathered included documents from the institution, and pain-related information from the patient's medical record. Two major themes with categories are discussed, the treatment of pain, and procedural pain. The findings of this study provide insight into the everyday practice of emergency department health care providers for pediatric pain in a non-pediatric setting, and identify practice issues that may adversely affect the management of pediatric procedural pain, notably the nonuse of pharmacologic techniques for simple needle procedures and the common use of physical restraint during painful procedures.

Supervising international students in clinical placements: perceptions of experiences and factors influencing competency development

BACKGROUND

Health professional education programs attract students from around the world and clinical supervisors frequently report that international students find learning in clinical placement contexts particularly challenging. In existing literature clinical supervisors, who support international students on placement have identified concerns about their communication and interactions within clinical environments. However, clinical supervisors' perspectives about their experiences with international students on placement and the strategies they utilise to facilitate international student learning have not been described. As a result we have little insight into the nature of these concerns and what clinical supervisors do to support international students' competency development.

METHODS

Five focus group interviews were conducted with twenty Speech-Language Pathology clinical supervisors, recruited from 2 Australian universities. Interview data were analysed thematically. Themes identified were interpreted using cognitive load and sociocultural learning theories to enhance understanding of the findings.

RESULTS

Four themes were identified: 'Complex teaching and learning relationships', 'Conceptions of students as learners'; Student communication skills for professional practice', and 'Positive mutual learning relationships'.

CONCLUSIONS

Findings indicated that clinical supervisors felt positive about supporting international students in clinical placements and experienced mutual learning benefits. However, they also identified factors inherent to international students and the placement environment that added to workload, and made facilitating student learning complex. Clinical supervisors described strategies they used to support international students' cultural adjustment and learning, but communication skills were reported to be difficult to facilitate within the constraints of placements. Future research should address the urgent need to develop and test strategies for improving international students' learning in clinical settings.

Comparison of French training and non-training general practices: a cross-sectional study

BACKGROUND

As the medicine practiced in hospital settings has become more specialized, training in primary care is becoming increasingly essential for medical students, especially for future general practitioners (GPs). Only a few limited studies have investigated the representativeness of medical practices delivering this training. The aim of this study was to assess the representativeness of French GP trainers in terms of socio-demographics, patients and activities.

METHODS

We conducted a cross-sectional study covering all private GPs practicing in the Rhône-Alpes region of France in 2011. This population consisted of 4992 GPs, including 623 trainers and 4369 non-trainers, managing 8,198,684 individual patients. Data from 2011 to 2012 were provided by the Regional Health Care Insurance (RHCI). We compared GP trainers with non-trainers using the Pearson chi-square test for qualitative variables and the Student t-test for quantitative variables

RESULTS

GP trainers do not differ from non-trainers for gender, but they tend to be younger, more frequently in mid-career, and more likely to practice in a rural area. Their patients are broadly representative of patients attending general practice for age (with the exception of a higher consultation rate for infants), but patients with medical fee exemption status relating to low income are underrepresented. GP trainers have a heavier workload in terms of office visits and on-call duties. They prescribe a higher proportion of generic drugs, perform more electrocardiograms and cervical smears, and fewer plaster casts. GP trainers show better performance in diabetes follow-up, and to a lesser extent for seasonal flu vaccination and mammograms.

CONCLUSIONS

GPs and patients of training practices are globally representative, which is particularly critical in countries such as France, where the length of specialty training in a general practice setting is still limited to a few months. In addition, GP trainers tend to have better clinical performance, which conforms to their teaching modelling role and may encourage other GPs to become trainers.

Teaching points-do they occur and what do they contain? An observation study concerning the general practice rotation

BACKGROUND

A general practice rotation is mandatory in most undergraduate medical education programs. However, little is known about the student-teacher interaction which takes place in this setting. In this study we analyzed occurrence and content of teaching points.

METHODS

From April to December 2012, 410 individual patient consultations were observed in twelve teaching practices associated with the Philipps University Marburg, Germany. Material was collected using structured field-note forms and videotaping. Data analysis was descriptive in form. A teaching point is defined here as a general rule or specific, case-related information divulged by the teaching practitioner.

RESULTS

According to the analysis of 410 consultations, teaching points were made in 66.3% of consultations. During these consultations, 74.3% general- and 46.3% case related teaching points occurred; multiple categorizations were possible. Of seven possible topics, therapy was most common, followed, in frequency of occurrence, by patient history, diagnostic procedure, physical examination, disease pathology, differential diagnosis, risk factors and case presentation.

CONCLUSIONS

The majority of consultations conducted within student presence contained teaching points, most frequently concerning therapy. General teaching points were more common than specific teaching points. Whilst it is encouraging that most consultations included teaching points, faculty development aimed at raising awareness for teaching and learning techniques is important.

Academic outcomes of a community-based longitudinal integrated clerkships program

BACKGROUND

Longitudinal integrated clerkships (LICs) receive recognition internationally as effective, innovative alternatives to traditional block rotations (TBRs) in undergraduate medical education. No studies of LICs in the USA have assessed how students perform on all the standardized exams.

AIM

To compare performance on standardized tests of students in the first four years of LICs at the University of North Carolina School of Medicine-Asheville (UNC SOM-Asheville) with students from UNC SOM's Chapel Hill main campus in TBRs.

METHODS

LIC and TBR students' previous academic performance was considered using Medical College Admissions Test (MCAT) and United States Medical Licensing Examination (USMLE) Step 1 scores. Step 1 exam tests students' pre-clinical, basic science knowledge. Outcome measures included all eight standardized National Board of Medical Examiners (NBME) Subject Shelf Examinations and USMLE Step 2 Clinical Knowledge (CK) examinations, which are used widely in the US to assess students' progress and as prerequisites to eventual licensure. TBR students were selected using propensity scores to match LIC students. Groups were also compared on the required core clinical conditions documented, and on residency specialty choice.

RESULTS

Asheville LIC students earned higher scores on the Step 2 CK examination and the six shelf examinations linked to longitudinal clerkships than the matched TBR students (Step 2 CK exam, Family Medicine and Ambulatory Medicine shelf exams reached statistical significance). LIC students logged greater percentages of core conditions than TBR students and more often chose primary care residencies.

CONCLUSIONS

UNC School of Medicine medical students participating in a longitudinal integrated curriculum in a community setting outperformed fellow students who completed a more TBR curriculum within the school's academic medical center. Differences were found in performance on standard tests of clinical knowledge (six NBME exams and Step 2 CK exam), documented breadth of clinical experiences, and likelihood of choosing primary care residency programs.

What factors in rural and remote extended clinical placements may contribute to preparedness for practice from the perspective of students and clinicians?

BACKGROUND

Community-based rural education opportunities have expanded in Australia, attracting more medical students to placements in rural and remote settings.

AIM

To identify the factors in an integrated, community-engaged rural placement that may contribute to preparedness for practice (P4P) from the perspective of students and clinicians.

METHOD

Forty-two semi-structured interviews with medical students, supervisors and clinicians analysed thematically.

RESULTS

Opportunities for clinical learning, personal and professional development and cultural awareness were reported by students and clinicians as key factors that contribute to P4P. Potential barriers in rural and remote settings included geographical and academic isolation, perceived educational risk and differing degrees of program engagement.

CONCLUSIONS

A longitudinal clinical placement in a rural setting may enable development of enhanced competencies leading to P4P. A rural setting can provide a unique experience through hands-on learning, enhanced personal and professional development opportunities and observation of the cultural and contextual impact on health.

A systematic literature review of undergraduate clinical placements in underserved areas

CONTEXT

The delivery of undergraduate clinical education in underserved areas is increasing in various contexts across the world in response to local workforce needs. A collective understanding of the impact of these placements is lacking. Previous reviews have often taken a positivist approach by only looking at outcome measures. This review addresses the question: What are the strengths and weaknesses for medical students and supervisors of community placements in underserved areas?

METHODS

A systematic literature review was carried out by database searching, citation searching, pearl growing, reference list checking and use of own literature. The databases included MEDLINE, EMBASE, PsycINFO, Web of Science and ERIC. The search terms used were combinations and variations of four key concepts exploring general practitioner (GP) primary care, medical students, placements and location characteristics. The papers were analysed using a textual narrative synthesis.

FINDINGS

The initial search identified 4923 results. After the removal of duplicates and the screening of titles and abstracts, 185 met the inclusion criteria. These full articles were obtained and assessed for their relevance to the research question; 54 were then included in the final review. Four main categories were identified: student performance, student perceptions, career pathways and supervisor experiences.

CONCLUSIONS

This review reflects the emergent qualitative data as well as the quantitative data used to assess initiatives. Underserved area placements have produced many beneficial implications for students, supervisors and the community. There is a growing amount of evidence regarding rural, underserved areas, but little in relation to inner city, deprived areas, and none in the UK.

A scoping review of undergraduate ambulatory care education

BACKGROUND

Since a disproportionate amount of medical education still occurs in hospitals, there are concerns that medical school graduates are not fully prepared to deliver efficient and effective care in ambulatory settings to increasingly complex patients.

AIMS

To understand the current extent of scholarship in this area.

METHOD

A scoping review was conducted by searching electronic databases and grey literature sources for articles published between 2001 and 2011 that identified key challenges and models of practice for undergraduate teaching of ambulatory care. Relevant articles were charted and assigned key descriptors, which were mapped onto Canadian recommendations for the future of undergraduate medical education.

RESULTS

Most of the relevant articles originated in the United States, Australia, or the United Kingdom. Recommendations related to faculty development, learning contexts and addressing community needs had numerous areas of scholarly activity while scholarly activity was lacking for recommendations related to inter-professional practice, the use of technology, preventive medicine, and medical leadership.

CONCLUSIONS

Systems should be established to support education and research collaboration between medical schools to develop best practices and build capacity for change. This method of scoping the field can be applied using best practices and recommendations in other countries.

Outcomes of longitudinal integrated clinical placements for students, clinicians and society

CONTEXT

Longitudinal integrated clerkships (LICs) have been widely implemented in both rural and urban contexts, as is now evident in the wealth of studies published internationally. This narrative literature review aims to summarise current evidence regarding the outcomes of LICs for student, clinician and community stakeholders.

METHODS

Recent literature was examined for original research articles pertaining to outcomes of LICs.

RESULTS

Students in LICs achieve academic results equivalent to and in some cases better than those of their counterparts who receive clinical education in block rotations. Students in LICs are reported to have well-developed patient-centred communication skills, demonstrate understanding of the psychosocial contributions to medicine, and report more preparedness in higher-order clinical and cognitive skills in comparison with students in traditional block rotations (TBRs). Students in LICs take on increased responsibility with patients and describe having more confidence in dealing with ethical dilemmas. Continuity of supervision reportedly facilitates incremental knowledge acquisition, and supervisors provide incrementally progressive feedback. Despite early disorientation regarding the organising of their learning, students feel well supported by the continuity of student-preceptor relationships and value the contributions made by these. Students in LICs living and working in rural areas are positively influenced towards primary care and rural career choices.

DISCUSSION

A sound body of knowledge in the field of LIC research suggests it is time to move beyond descriptive or exploratory research that is designed to justify this new educational approach by comparing academic results. As the attributes of LIC alumni are better understood, it is important to conduct explanatory research to develop a more complete understanding of these findings and a foundation for new theoretical frameworks that underpin educational change.

CONCLUSIONS

Longitudinal integrated clerkships are now recognised as representing credible and effective pedagogical alternatives to TBRs in medical education.

The role of role: learning in longitudinal integrated and traditional block clerkships

CONTEXT

Traditional block clerkship (BC) structures may not optimally support medical student participation in the workplace, whereas longitudinal integrated clerkship (LIC) structures seem more conducive to students' active engagement in patient care over time. Understanding the ways in which these two clerkship models influence students' roles and responsibilities can inform clinical learning programme design.

METHODS

This was a multicentre qualitative study. We conducted semi-structured interviews with LIC and BC medical students at three institutions early and late in the core clinical year to explore their experiences with patients and the roles they served. Using the framework of 'workplace affordances', qualitative coding focused on students' roles and qualities of the learning environment that invited or inhibited student participation. We compared transcripts of early- and late-year interviews to assess students' changing roles and conducted discrepant case analysis to ensure that coding fit the data.

RESULTS

Fifty-four students participated in interviews. They described serving three major roles in clinical care that respectively involved: providing support to patients; sharing information about patients across health care settings, and functioning in a doctor-like role. Both LIC and BC students served in the providing support and transmitting information roles both early and late in the year. By contrast, LIC students commonly served in the doctor-like role in managing their patients' care, particularly late in the year, whereas BC students rarely served in this role. Continuity in settings and in supervisors, and preceptors' endorsement of students' legitimate role afforded opportunities for students to participate actively in patient care.

CONCLUSIONS

Although both LIC and BC students reported serving in important roles in supporting their patients and sharing information about their care, only LIC students consistently described opportunities to grow into a doctor role with patients. The high level of integration of LIC students into care systems and their deeper relationships with preceptors and patients enhanced their motivation and feelings of competence to provide patient-centred care.

A longitudinal integrated placement and medical students' intentions to practise rurally

CONTEXT

Integrated longitudinal rural placements are designed to promote favourable student attitudes towards and facilitate return to rural practice upon graduation. We explored the impact of an integrated placement on medical students' attitudes towards rural practice.

METHODS

Data were available from interviews with 10 medical students, 15 clinical supervisors and teachers, three community health staff, and focus groups made up of medical students. Socio-cognitive career theory gave insight into the personal, contextual and experiential factors, as well as the career barriers, that influence students' rural practice intentions. Framework analysis was used to develop a thematic framework illustrating the key findings.

RESULTS

The longitudinal placement enabled students to achieve personal goals, and enhanced self-efficacy beliefs and orientation towards the complex personal and professional demands of rural practice. The informal curriculum, including multifaceted interactions with patients and their families, clinical teachers and other health care staff, was a vital experiential component. Students assimilated these rich experiences into their practice and evolving notions of professional identity as rural practitioners. Some students had little intention of practising rurally, partly as a result of contextual barriers such as geographic isolation, family and relationship needs, restricted postgraduate training opportunities and limited opportunities for specialist practice.

CONCLUSIONS

The richness of the informal curriculum in a longitudinal rural placement powerfully influenced students' intentions to practise rurally. It provided an important context for learning and evolving notions of professionalism and rural professional identity. This richness could be reinforced by developing formal curricula using educational activities based around service-led and interprofessional learning. To overcome the contextual barriers, the rural workforce development model needs to focus on socialising medical students into rural and remote medicine. More generic issues include student selection, further expansion of structured vocational training pathways that vertically integrate with longitudinal rural placements and the maintenance of rurally focused support throughout postgraduate training.

Better learning, better doctors, better delivery system: possibilities from a case study of longitudinal integrated clerkships

Interest in longitudinal integrated clerkships (LICs) as an alternative to traditional block rotations is growing worldwide. Leaders in medical education and those who seek physician workforce development believe that "educational continuity" affords benefits to medical students and benefits for under-resourced settings. The model has been recognized as effective for advancing student learning of science and clinical practice, enhancing the development of students' professional role, and supporting workforce goals such as retaining students for primary care and rural and remote practice. Education leaders have created multiple models of LICs to address these and other educational and health system imperatives. This article compares three successful longitudinal integrated clinical education programs with attention to the case for change, the principles that underpin the educational design, the structure of the models, and outcome data from these educational redesign efforts. By translating principles of the learning sciences into educational redesign efforts, LICs address the call to improve medical student learning and potential and advance the systems in which they will work as doctors.

Rewards, costs and challenges: the general practitioner's experience of teaching medical students

CONTEXT

Medical student attachments in general practices play an important role in undergraduate medical education internationally. The recruitment by universities of new teaching practices or an increase in the teaching commitment of existing practices will be necessary to address rising medical student numbers. General practitioners (GPs) are likely to weigh the perceived rewards of practice-based teaching against the perceived costs and challenges in deciding whether to accept a student placement and how to teach. These aspects of the 'lived experience' of the GP-teacher have not been adequately investigated.

OBJECTIVES

This study aims to enhance understanding of the GP clinical teacher experience in order to inform strategies for the recruitment, retention, training and support of teaching general practices.

METHODS

Sixty GP clinical teachers in Brisbane-based urban teaching general practices were interviewed individually face-to-face by the principal investigator, using a semi-structured interview plan. Representativeness was ensured through quota sampling. The interview data were analysed thematically by two of the investigators independently, following member checking of interview transcripts.

RESULTS

The results demonstrate a number of key inter-related perceived rewards, costs and challenges of teaching, including intellectual stimulation, cognitive fatigue and student characteristics.

CONCLUSIONS

The findings extend reports in the previous literature by offering a richer description of current GP-teacher experience. Participants identified teaching rewards in a manner largely consistent with previous research, with the exception of enhanced practice morale and teamwork. Findings confirm that reduced productivity and increased time pressures remain key perceived negative impacts of teaching, but also reveal a number of other important costs and challenges. They emphasise the diversity of GP experience and practice cultures, and the need for teaching to enhance both GP and patient perceptions of consultation quality without increasing the load on the GP-teacher. Recruitment and retention strategies should promote the rewards of teaching, and teacher training should respond to the costs and challenges of practice-based teaching, and facilitate the growth of GPs in their role as clinical educators.