Training for general practice: a national survey

Family medicine training in Saudi Arabia: Are there any variations among different regions?

AIMS

The aim was to compare Eastern, Makkah, and Asir regions in term of residents' perception of the achievement of training objectives, and to assess various rotations based on residents' perception.

SETTINGS AND DESIGN

This cross-sectional study was done among family medicine residents in the Eastern, Makkah, and Asir regions.

METHODOLOGY

A questionnaire was developed by the investigator and validated by two experts. All residents, except R1 residents, were included. All data were collected by the investigator by direct contact with the residents.

STATISTICAL ANALYSIS USED

Cronbach's alpha, analysis of variance, t-test, and univariate regression model as appropriate, were used.

RESULTS

Reliability of the questionnaire was found to be 75.4%. One hundred and seven (response rate: 83.6%) residents completed the questionnaire. There were 51 (47.7%), 27 (25.2%), and 29 (27.1%) residents in the program in the Eastern region, Makkah, and Asir, respectively. The mean age was 29.1 ± 2.5 years; half of the residents were male, most of (83.2%) were married, and more than half (54.2%) of had worked in primary health care before joining the program. Overall, 45% of the residents perceived that they had achieved the training objectives. The highest rotations as perceived by the residents were psychiatry and otolaryngology while the lowest were orthopedics and ophthalmology. There were significant differences among the study regions with regard to the rotations in family medicine, internal medicine, orthopedics, general surgery, and emergency medicine.

CONCLUSIONS

Overall, a good percentage of the residents perceived that they had achieved the training objectives. The rotations differed in the studied regions. Psychiatry and otolaryngology had the highest percentage of family medicine residents who perceived that they had achieved the training objectives while lowest was in internal medicine and obstetrics and gynecology. The highest rotations as perceived by the family medicine residents were psychiatry and otolaryngology while lowest were orthopedics and ophthalmology. Sharing of experience and further studies are needed to improve the program rotations.

Physician provider type influences utilization and diagnostic utility of magnetic resonance imaging of the knee

BACKGROUND

Magnetic resonance imaging of the knee is expensive and is neither needed nor useful for all patients presenting with knee pain. Our objective was to determine the completeness of evaluation prior to ordering magnetic resonance imaging of the knee correlated to the ordering providers' postgraduate medical training and the rate of positive findings on the subsequent magnetic resonance imaging.

METHODS

Six hundred consecutive knee magnetic resonance images were reviewed, including 200 consecutive knee magnetic resonance imaging examinations from each of three provider types: orthopaedic surgeons, non-surgical physicians with sports medicine training, and primary care providers. Positive findings on magnetic resonance imaging were recorded as well as a history of present illness, a physical examination, and radiographs made prior to ordering magnetic resonance imaging of the knee. Patient and injury factors were recorded. Differences in patient factors, evaluation before magnetic resonance imaging, and positive findings were examined. A modified Poisson regression approach was used to determine predictors of a proper evaluation before magnetic resonance imaging and positive findings on knee magnetic resonance imaging.

RESULTS

Orthopaedists and non-surgical sports physicians were significantly more likely to document a physical examination, to evaluate radiographs made prior to ordering a magnetic resonance image, and to identify positive findings on the magnetic resonance image (all p < 0.001). In multivariate models, orthopaedists were more likely to document a history of present illness (relative risk, 1.05; p = 0.043). Compared with primary care physicians, a physical examination was more likely to be documented by both non-surgical sports medicine physicians (relative risk, 1.61; p < 0.001) and orthopaedists (relative risk, 1.60; p < 0.001) and positive magnetic resonance imaging findings were more likely to be found by non-surgical sports medicine physicians (relative risk, 1.41; p = 0.012) and by orthopaedists (relative risk, 1.44, p = 0.009). Other independent predictors of a magnetic resonance imaging study with positive findings were the presence of an acute injury by history (relative risk, 2.04; p < 0.001) and younger age (relative risk, 0.99; p = 0.021).

CONCLUSIONS

Orthopaedists and non-surgical sports physicians are more likely to perform and to document a complete evaluation prior to ordering a knee magnetic resonance image with a positive finding. More musculoskeletal training may be useful to enable primary care physicians to use magnetic resonance imaging of the knee in a more efficient manner.

Extending the general practice training year: experience of one model in Scotland

OBJECTIVES

These were: to describe the implementation of a scheme to extend the general practice registrar component of vocational training to 18 months in Scotland; to determine the effect of the additional attachment on registrars' confidence and skill deficits, and compare changes in these parameters with a control group of registrars who did not extend their training, and to determine whether trainers required a different training style for experienced registrars.

SUBJECTS

35 registrars extending their training, their trainers, and 39 controls who did not extend their training.

SETTING

Scottish training practices.

METHODS

Pre-attachment and post-attachment questionnaires for registrars, triangulated by semistructured telephone interviews, and post-attachment questionnaires for trainers.

RESULTS

Extended attachments were popular with registrars and with trainers, who felt they should be a normal part of training. Registrars with extended training declared themselves to have increased in confidence and addressed skill deficits better than controls. Projects completed were assessed as being of high quality. Trainers found 10% of registrars to have a remediable, important deficit in their skills.

CONCLUSION

Extended attachments appear to improve registrar confidence and to address knowledge deficits. However, only a minority of registrars had important remediable knowledge deficits and while such attachments may be desirable they may not be essential for most registrars. Overall the outcome appears to have been positive, and supports those who have argued for a change in the proportion of time spent in general practice training, but the scheme is expensive and it is difficult to set a value on what has been gained. Future schemes should have clear training objectives and be tailored towards these.

Views of primary health care trainees on their hospital training in internal medicine and pediatrics in saudi arabia

OBJECTIVE

The aim of this study is to assess the perception and satisfaction of primary health care (PHC) trainees regarding their hospital training in Internal Medicine and Pediatrics.

METHODOLOGY

A cross-sectional study was conducted by means of a self-administered questionnaire distributed to the trainees who had finished Medicine and/or Pediatrics rotation in 4 PHC training centers in Riyadh, Al-Khobar, Jeddah and Al-Medina during January 1996.

RESULTS

Trainees were more satisfied with the Pediatric rotation than the Internal Medicine rotation. Significant relationship (p<0.05) was found between trainee satisfaction in Internal Medicine rotation and both the quality of training and the relevance of training to the needs of PHC trainees. On the other hand, in Pediatrics, the only variable which was related significantly to the trainees' satisfaction was the duration of the rotation, which was found to be sufficient (p<0.05). Trainees' dissatisfaction with the rotation was due to many factors, such as the imbalance between service work and educational sessions and the lack of awareness of other specialists about PHC as a career.

CONCLUSION

Attention and effort should be directed towards the improvement of hospital training through a close collaboration between the decision-makers for PHC training and the hospital consultants. Also the needs of trainees should be taken into account during planning of hospital training.

The development and evaluation of a personal learning log for senior house officers

OBJECT

To develop and evaluate the effect of having a personal learning log on Senior House Officers knowledge and confidence.

METHODS

A multiple choice paper and a confidence checklist for two hospital specialties were developed to assess knowledge and confidence. These were administered to a control group and to an intervention group who had the learning log. Both groups completed an evaluation at the end of the post.

SETTING

The study took place in Accident & Emergency and Obstetric & Gynaecology posts in Greater Glasgow and Lanarkshire.

SUBJECTS

79 Senior House Officers in Accident & Emergency and 78 Senior House Officers in Obstetrics & Gynaecology.

RESULTS

The mean scores in the MCQ and the mode in the confidence checklist increased significantly in both specialties during the post, but there was no significant difference between the control and intervention groups. Forty two learning logs were returned at the end of the study and analysis of these revealed that there was great scope for learning but few documented the specific learning achieved. Evaluation of the posts revealed that some improvements had taken place in teaching and assessment frequency, however, there was scope for further improvement.

CONCLUSION

While the problems of hospital training are well documented, an attempt to improve the situation using a learning log did not have a statistically significant impact on SHO knowledge or confidence. A six-month hospital post appears to present many opportunities for learning but these are not exploited. It is suggested that three things are needed. Firstly, active participation by and personalized feedback from a senior member of staff, with training where needed. Secondly, protected time for tutorials with a planned system of formative assessment, and thirdly, a more positive approach to learning by both SHOs and consultants. Once this occurs, a learning log may have a more significant impact on training.

A pilot study of community-based training of hospital obstetric senior house officers

Most senior house officer (SHOs) posts have little relevance to general practice. This problem was addressed in a pilot community teaching placement, of up to one session per week over four to six months that was set up to learn community-based obstetrics from primary health care teams. The nine participating SHOs were interviewed; qualitative analysis revealed seven themes that were important to the SHOs that should help guide further community-based teaching. Such sessional release for improving the practice-based component of vocational training merits evaluation in a larger study.

The development and reliability of the Royal College of General Practitioners' questionnaire for measuring senior house officers' satisfaction with their hospital training

BACKGROUND

The training provided for senior house officers (SHOs) has been the subject of debate, and variable satisfaction with training has been reported. The reliability of the instruments used for measuring satisfaction has not been adequately addressed.

AIM

To develop a reliable questionnaire to measure SHO satisfaction with hospital training.

METHOD

A 42-item questionnaire with eight scales was developed using criteria from the joint hospital visiting guidelines of the Royal College of General Practitioners. The questionnaire was sent to SHOs in Anglia before monitoring visits from the royal colleges, the postgraduate dean and the Joint Committee on Postgraduate Training for General Practice.

RESULTS

Response rates varied from 37.0% to 100%, with an overall response rate of 58.8%. The internal reliability of the whole questionnaire was 0.82. Levels of internal reliability for the individual scales were satisfactory, Cronbach's alpha coefficient being 0.75 or more in all but two of the scales. Test-retest reliability using Pearson's product moment correlation coefficient was greater than 0.82 for six of the scales. There were significant differences in total satisfaction between SHOs reporting on posts accredited by the different royal colleges and also between SHOs training for general practice and those training to be specialists.

CONCLUSION

A reliable questionnaire has been developed to measure SHO satisfaction with hospital training that is acceptable to doctors and feasible to administer. National acceptance of a single questionnaire for monitoring SHO posts would enable standards to be monitored regularly at a time of considerable change in hospital training.

Are vocationally trained general practitioners better GPs? A review of research designs and outcomes

Implicit and explicit in reviews of and changes to vocational education for general practitioners in the 1990s is the challenge to defend the assumption that vocationally trained GPs are better GPs. This paper provides a review of the international literature which has reported on outcomes of general practice vocational training programmes. Through the review we identify both the types of research methodologies used (including a brief discussion of their strengths and limitations) and the outcomes reported of vocational training. Twenty-five studies on the outcomes of vocational training are reviewed. These studies used multiple data sources and one of four methodologies: pre- and post-training comparisons, analysis of learners' or teachers' accounts, audits of general practice or analysis of examination pass rates. When collated, the following range of outcomes from vocational training were identified: improved quality of patient care, increased knowledge, improved general practice skills, increased confidence and desirable GP attitudes and personality traits, increased adherence to practice guidelines and higher examination pass rates. The paper concludes with a summary of research and education issues which arise when we examine the question posed at the outset: are trained GPs better GPs?

Vocational training and beyond--listening to voices from a void

This paper is written from the viewpoint of a doctor who has recently undergone general practice vocational training, and has first-hand experience of some of the opportunities, difficulties, and uncertainties facing doctors at this stage of their careers. The literature on vocational training and the issues concerning young doctors are explored in the light of concerns that recruitment into general practice is falling, that registrars may feel lost in a 'void' at the end of training, and that the 'new world' of post-training work brings problems for many new general practitioners (GPs). Instead of a traditional partnership, one of the authors (RB) chose a salaried, educationally oriented introduction to inner-city general practice. Some innovative, educational schemes, which are aiming to improve the appeal of general practice, are discussed.

Predictors of the provision of intrapartum care by general practitioners: five-year cohort study

BACKGROUND

There is little published evidence that any aspect of vocational training for general practice improves the quality of care provided by general practitioners (GPs).

AIM

To investigate whether aspects of education and vocational training predict whether GPs provide intrapartum care.

METHOD

A five-year prospective cohort study was carried out in the United Kingdom (UK) using responders to a 1990 national survey of GPs for whom a current UK address could be found. Main outcome measures were factors associated with provision of GP intrapartum care in 1995.

RESULTS

In 1995, a minority of ex-trainees (65 out of 349, 18%) provided intrapartum care as GPs, although 28% would ideally have wished to do so; 8% provided home delivery care. Four education and training variables were associated with ex-trainees booking women for GP delivery in 1995: the number of partners in the ex-trainee's GP training practice providing GP intrapartum care (odds ratio (OR) = 1.30); performing forceps deliveries as an obstetric senior house officer (SHO) (OR = 1.24), witnessing episiotomies as a student (OR = 1.17), and witnessing twin deliveries as a student (OR = 0.75).

CONCLUSIONS

In the case of GP intrapartum care, future service provision is associated with certain education and training variables. There is a mismatch between GPs' ideal and actual maternity care provision. Changes to enhance such care would be needed at least at three levels: selection and approval of training practices, content and base for SHO posts, and practice arrangements for maternity cover.

Rheumatology education and management skills in general practice: a national study of trainees

OBJECTIVE

To evaluate current rheumatology education and skills during vocational training in general practice.

METHODS

A postal questionnaire survey was sent to all general practice trainees who were in United Kingdom training practices in June 1992. A second survey was made of general practice trainers in the UK.

RESULTS

Questionnaires were returned by 1624 trainees, representing 70% of all trainees known to be in a training practice on 1 April 1992. Of the 1075 responders who were at the end of their trainee year, 35% had not received any tutorials on rheumatological topics with their trainer, and only 43% had experienced specific rheumatology teaching on local day release courses. Although 84% of these trainees had injected or aspirated the knee, fewer than 40% had acquired shoulder injection skills. Lack of experience was matched by low reported confidence. Trainees rated the amount of their rheumatology education as inadequate. Nine hundred trainers returned questionnaires--a response rate of 33%. Their estimate of the amount of local training provided was similar to that among the trainees, but this sample of trainers reported a higher level of practical teaching than the trainees indicated they had received.

CONCLUSIONS

Rheumatology education during vocational training needs to be improved, particularly the component provided by trainers and local day release courses. This process might be facilitated by the development of a standard rheumatology curriculum which could be incorporated into all training schemes.

The educational component of senior house officer posts: differences in the perceptions of consultants and junior doctors

The aims of this study were to elicit general practitioner (GP) trainee's perceptions of the educational structure of their hospital posts, to compare them with those of consultants who had GP trainees as senior house officers (SHOs) in their departments and to examine the use of educational objectives in the hospital component of vocational training for general practice. A confidential postal questionnaire was sent to all the GP trainees (165 doctors) in the hospital component of their vocational training schemes (VTS) for general practice in Trent Region and all the consultants (161 doctors) in Trent who had GP trainees in their SHO posts on that date. Responses were received from 136 trainees (82%) and 134 consultants (83%). Educational objectives were stated as existing in the SHO post by 31 trainees (23%) and by 62 consultants (46%). Of those doctors who said that objectives existed, 19 of the trainees (61%) and 40 of the consultants (65%) said that the objectives were useful. Only nine (29%) of the trainees who stated that educational objectives existed felt that they were being put into practice by senior staff, compared with 41 (66%) of consultants who had made that statement. Of all respondents, 113 trainees (87%) and 100 consultants (77%) agreed or strongly agreed that the use of educational objectives would be beneficial to the trainees. Only 10 (7%) of trainees said that they received no teaching in their current posts. Forty trainees (32%) and 88 consultants (67%) said that teaching took place in protected time. Both groups cited consultants as the member of staff giving the most teaching. Ninety-six consultants (73%) replied that it was possible for GP trainees to obtain study leave, but 102 trainees (75%) either had experienced difficulties in obtaining study leave or had not attempted to obtain study leave. Trainees and consultants differed appreciably in their perceptions of the amount of assessment and feedback which was provided for GP trainees. The use of educational objectives in the hospital component of vocational training was felt to be beneficial by both consultants and GP trainees. Consultants were more likely than trainees to report the use of educational objectives, protected teaching time, GP-orientated teaching, ability of trainees to attend VTS half-day release and the provision of assessment and feedback to trainees.

Education and training for general practice

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GP trainees' views on hospital obstetric vocational training

OBJECTIVES

To examine the content of hospital obstetric vocational training for general practice, the beliefs of general practitioner trainees about this training, and their perceived competence at practical obstetric procedures and the effect of training.

DESIGN

Confidential postal questionnaire.

SUBJECTS

A random one in four sample of all general practitioner trainees in the United Kingdom on vocational training schemes or in training practices in Autumn 1990.

MAIN OUTCOME MEASURES

Trainees' competence and beliefs on Likert scale, numbers of procedures witnessed and performed, type of maternity care trainees intended to provide.

RESULTS

Of 1019 trainees sent questionnaires, 765 (75.1%) replied; 517 had done some hospital obstetric training. After six months as a senior house officer 232/367 (63%) believed they were competent to perform a normal delivery unaided, 228 (62%) to manage a severe postpartum haemorrhage, and 227 (62%) to resuscitate a newborn infant. 272 (35.6%) trainees intended to provide intrapartum care and 56 (7.5%) to book home deliveries in the future. Hospital training increased confidence in performing most obstetric procedures in all trainees. However, a greater proportion of trainees who intended to provide full care than shared care felt competent at performing a normal vaginal delivery (63% (170/272) full v 45% (215/473) shared), low forceps delivery (38% (103) v 17% (79)), manual removal of placenta (24% (65) v 17% (82)), and intubating a neonate (42% (114) v 34% (161)). Trainees who had done any obstetric training were less likely to think that training encouraged future provision of intrapartum care (113/509 (22%) training v 65/213 (31%) no training).

CONCLUSION

Hospital vocational obstetric training increases the perceived competence of trainees but fails to encourage them to use obstetric skills.

Twenty years of vocational training in the west of Scotland: the practice component

A retrospective analysis of the experience and opinions of doctors receiving vocational training in general practice was obtained by postal questionnaire. Questionnaires were received by 974 doctors who had been vocationally trained in the west of Scotland between 1968 and 1987. The response rate was 64%. It was found that 94% of the respondents had enjoyed their trainee period, 82% had been given a choice of training practice and 86% had spent 12 months in a training practice. Only 81 respondents had trained in two practices. The most common method of monitoring the trainee's consultation was the trainer sitting in on the consultation; half of the doctors had experience of this (51%). For the majority regular tutorials were commonplace, but for 41% of respondents this was not so. However, those training after 1979 were significantly less likely to have never had tutorials than those training earlier. Nearly half of the doctors (49%) felt that certain aspects had been poorly covered or omitted from their training, notably practice management and finance. Again, this was significantly less likely among those training after 1979. When asked to give a rating of the training they had received 21% of the respondents rated it as excellent, 37% as very good, 30% as fairly good and 12% as poor/fairly poor or very poor. Notably, significantly fewer respondents training after 1979 rated their training as poor/fairly poor or very poor. Very few respondents had participated in a practice exchange but virtually all of those who had felt it had been beneficial.(ABSTRACT TRUNCATED AT 250 WORDS)

Training experience of doctors certificated for general practice in 1985-90

The computerized records held by the Joint Committee on Postgraduate Training for General Practice have been reviewed to determine the post-registration experience offered by doctors who were issued with a joint committee certificate during the years 1985-90, inclusive. The percentage of certificates issued on the basis of experience prescribed in the vocational training regulations rose from 74.4% in 1985 to 89.7% in 1990. Since 1985 obstetrics/gynaecology has been the specialty in which the greatest number of successful applicants have offered experience, increasing from 86.4% in 1985 to 93.8% in 1990. The next most popular specialty was accident and emergency/general surgery (offered by 65.5% of successful applicants in 1985 and 73.6% in 1990) followed by paediatrics (56.7% in 1985 and 62.2% in 1990). The percentage of certificates issued on the basis of experience in geriatric medicine rose slowly from 35.6% in 1985 to 41.7% in 1990, for psychiatry the figures were similar (36.4% in 1985 and 40.7% in 1990), and for general medicine there was a slight decrease (46.2% in 1985 and 44.7% in 1990). There is a need for more doctors to acquire experience in general medicine, geriatric medicine and psychiatry. Since 1985, the trend has been for applicants to offer a more broadly based range of experience. In 1985, 48.5% of successful applicants offered experience in four hospital specialties and this rose to 63.6% in 1990. Although the vocational training regulations offer a degree of flexibility only a small number of successful applicants have taken advantage of this.(ABSTRACT TRUNCATED AT 250 WORDS)

An evaluation of the hospital component of general practice vocational training

The contribution of the hospital component of vocational training to the needs of the future general practitioner was investigated by undertaking semi-structured interviews with a representative sample of doctors involved. The findings indicated that, in general, training was failing to address objectives perceived to be important for general practice by the study sample. Problems related to the context and style of hospital training also emerged, which appeared to be limiting the learning potential of this type of experience for general practitioner trainees. It is apparent that there is a need to clarify priority objectives for the hospital component of vocational training, and ensure that it provides the opportunity to achieve them.

but now what? Some unresolved problems of training for general practice

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