A postgraduate curriculum for integrated care: a qualitative exploration of trainee paediatricians and general practitioners' experiences

Primary care in the world of integrated care systems: education and training for general practice

Here, we discuss the required education and training for the emergent and evolving roles of GPs and other healthcare professionals within Integrated Care Systems (ICSs). We underscore the importance of collaborative skills for all medical specialties, and the need for interprofessional education and leadership development in undergraduate and postgraduate medical training. We also argue for a paradigm shift in medical education, away from traditional siloed approaches and toward comprehensive training that prepares practitioners to excel in integrated and multidisciplinary healthcare environments, within which expert generalists (GPs) and specialists collaborate in individual patient care and concurrently co-develop innovative system pathways for chronic medical conditions, including complexity and frailty. We highlight the need to align workforce development with evolving healthcare systems and the existing obstacles hindering this alignment.

Learning collaboration at the primary-secondary care interface: a dual-method study to define design principles for interventions in postgraduate training programmes

BACKGROUND

Collaboration between primary and secondary care (PSCC) is important to provide patient-centered care. Postgraduate training programmes should provide training to learn PSCC. With a design based research (DBR) approach design principles can be formulated for designing effective interventions in specific contexts. The aim of this study is to determine design principles for interventions aimed to learn PSCC in postgraduate training programmes.

METHODS

DBR is characterised by multi-method studies. We started with a literature review on learning collaboration between healthcare professionals from different disciplines within the same profession (intraprofessional) to extract preliminary design principles. These were used to inform and feed group discussions among stakeholders: trainees, supervisors and educationalists in primary and secondary care. Discussions were audiotaped, transcribed and analysed using thematic analysis to formulate design principles.

RESULTS

Eight articles were included in the review. We identified four preliminary principles to consider in the design of interventions: participatory design, work process involvement, personalised education and role models. We conducted three group discussions with in total eighteen participants. We formulated three design principles specific for learning PSCC in postgraduate training programmes: (1) The importance of interaction, being able to engage in a learning dialogue. (2) Facilitate that the learning dialogue concerns collaboration. (3) Create a workplace that facilitates engagement in a learning dialogue. In the last design principle we distinguished five subcategories: intervention emphasises the urge for PSCC and is based on daily practice, the presence of role models, the work context creates time for learning PSCC, learning PSCC is formalised in curricula and the presence of a safe learning environment.

CONCLUSION

This article describes design principles for interventions in postgraduate training programmes with the aim to learn PSCC. Interaction is key in learning PSCC. This interaction should concern collaborative issues. Furthermore, it is essential to include the workplace in the intervention and make adjacent changes in the workplace when implementing interventions. The knowledge gathered in this study can be used to design interventions for learning PSCC. Evaluation of these interventions is needed to acquire more knowledge and adjust design principles when necessary.

Components and Outcomes in Under- and Postgraduate Medical Education to Prepare for the Delivery of Integrated Care for the Elderly: A Scoping Review

Introduction

The ageing society requires physicians who can deliver integrated care, but it is unclear how they should be prepared for doing so. This scoping review aims to create an overview of educational programmes that prepare (future) physicians to deliver integrated care while addressing components and outcomes of the interventions.

Method

We included papers from five databases that contained: (1) integrated care (2) education programme (3) medical students (4) elderly, or synonyms. We divided the WHO definition of integrated care into ten components for the concept of 'integrated care'. Data were collected with a charting template, and template analysis was used to formulate themes.

Results

We found 17 educational programmes in different learning settings. All programmes addressed several components of the WHO definition. The programmes primarily focused on care for individual patients (micro-level), and the outcomes suggested that experiencing the complexity of care is key.

Conclusion

This review revealed the limited evidence on educational programmes about integrated care for the elderly. Our findings suggest that educational programmes on integrated care should not be limited to the micro-level, and that students should obtain adaptive expertise by experiencing complexity. Future research should contain an explicit description and definition of integrated care.

Midwifery Continuity of Care in Indonesia: Initiation of Mobile Health Development Integrating Midwives' Competency and Service Needs

Midwives' competence in providing continuity of care using mobile health (mHealth) applications is limited in developing countries. This study identified and explored midwives' competency and service needs to develop mHealth in Midwifery Continuity of Care (MCOC) education and training. It used an explanatory sequential mixed method, and was conducted from August to December 2021. A cross-sectional approach was used to find the characteristics and competency scope of 373 midwives in West Java, and continued with a qualitative design through a Focus Group Discussion (FGD) of 13 midwives. Descriptive data analysis (frequency, mean, deviation standard) and qualitative data analysis (coding, sub-themes, and theme) were conducted. In terms of the midwives who participated in this study, more than half were aged ≤ 35 years (58.98%), with a working period > 10 years (56.30%), had diploma degrees (71.12%), and used smartphones on average 1-12 h/day (78.28%). Most midwives needed to develop competency in the MCOC scope, including its early detection of the risk factor of complications and treatment management. They were concerned about the purposes, benefits, and design of mHealth. In summary, midwives' competency indicators for early detection are more needed in MCOC using mHealth. Further research is required to evaluate midwives' competence in MCOC using mHealth.

Community based Primary Care for Adolescents and Young Adults Transitioning From Pediatric Specialty Care: Results from a Scoping Review

Background:

Ongoing primary care during adolescence is recommended by best practice guidelines for adolescents and young adults (AYAs; ages 12-25) with chronic conditions. A synthesis of the evidence on the roles of Primary Care Physicians (PCPs) and benefits of primary care is needed to support existing guidelines.

Methods:

We used Arksey and O’Malley’s scoping review framework, and searched databases (MEDLINE, EMBASE, PsychINFO, CINAHL) for studies that (i) were published in English between 2004 and 2019, (ii) focused on AYAs with a chronic condition(s) who had received specialist pediatric services, and (iii) included relevant findings about PCPs. An extraction tool was developed to organize data items across studies (eg, study design, participant demographics, outcomes).

Results:

Findings from 58 studies were synthesized; 29 (50%) studies focused exclusively on AYAs with chronic health conditions (eg, diabetes, cancer), while 19 (33%) focused exclusively on AYAs with mental health conditions. Roles of PCPs included managing medications, “non-complex” mental health conditions, referrals, and care coordination, etc. Frequency of PCP involvement varied by AYAs; however, female, non-Black, and older AYAs, and those with severe/complex conditions appeared more likely to visit a PCP. Positive outcomes were reported for shared-care models targeting various conditions (eg, cancer, concussion, mental health).

Conclusion:

Our findings drew attention to the importance of effective collaboration among multi-disciplinary specialists, PCPs, and AYAs for overcoming multiple barriers to optimal transitional care. Highlighting the need for further study of the implementation of shared care models to design strategies for care delivery during transitions to adult care.

Intraprofessional workplace learning in postgraduate medical education: a scoping review

BACKGROUND

Residents need to be trained across the boundaries of their own specialty to prepare them for collaborative practice. Intraprofessional learning (i.e. between individuals of different disciplines within the same profession) has received little attention in the postgraduate medical education literature, in contrast to the extensive literature on interprofessional learning between individuals of different professions. To address this gap, we performed a scoping review to investigate what and how residents learn from workplace-related intraprofessional activities, and what factors influence learning.

METHODS

The PRISMA guidelines were used to conduct a scoping review of empirical studies on intraprofessional workplace learning in postgraduate medical education published between 1 January 2000 to 16 April 2020 in Pubmed, Embase, PsycINFO, ERIC and Web of Science. This study applied 'best fit' framework-based synthesis to map the existing evidence, using the presage-process-product (3P) model developed by Tynjälä (2013).

RESULTS

Four thousand three hundred thirty records were screened, and 37 articles were included. This review identified influencing (presage) factors that derived from the sociocultural environment, learner and learning context. Studies described that complexity of care can both facilitate and hinder learning. Furthermore, intraprofessional learning is threatened by professional stereotyping and negative perceptions, and awareness of learning opportunities and explicit reflection are critical in intraprofessional workplace learning. Studies described a range of informal and formal intraprofessional activities (process) under the headings of collaboration in clinical practice, rotations or placements, formal educational sessions and simulated workplace training. In general, learners responded well and their attitudes and perceptions improved, learners reported increased knowledge and skills and positive behavioural changes (product). Learning outcomes were reported in the domains of patient-centred care, collaborative attitudes and respect, mutual knowledge and understanding, collaborative decision making, communication, leadership, teamwork and reflexivity.

CONCLUSIONS

This review gives insight into the high learning potential of intraprofessional activities. Many of the included studies relied on self-reported perceptions of change, therefore, future research should focus on generating more robust evidence including objectively examined outcome measures. This review offers a comprehensive overview of the factors that influence intraprofessional workplace learning in postgraduate medical education. Finally, we provide recommendations for enhancing intraprofessional learning in clinical practice.

Competencies for collaboration between general practitioners and medical specialists: a qualitative study of the patient perspective

OBJECTIVES

To explore the patient view of competencies essential for doctors to provide good collaboration at the primary-secondary care interface.

DESIGN

We used a qualitative research approach. Focus groups with patients were conducted to explore their opinions of doctors' competencies to provide good collaboration between primary and secondary care doctors. Transcripts were analysed using thematic analysis.

SETTING

Dutch primary-secondary care interface.

PARTICIPANTS

Sixteen participants took part in five focus groups. Patients treated in both primary and secondary care, defined as having a minimum of two contacts with their general practitioner and two contacts with a medical specialty in the last 6 months, were included. Psychiatric patients and children were excluded from this study.

RESULTS

Three groups of competencies were identified: (1) relationship building, both with patients and with other doctors; (2) transparent collaborating: be able to provide clarity on the process of collaboration and on roles and responsibilities of those involved and (3) reflective practising: to be willing to acknowledge mistakes, give and receive feedback and act as a lifelong learner.

CONCLUSIONS

This focus group study enhances our understanding of the patient perspective on doctors' collaborative competencies at the primary-secondary care interface. With this information, doctors can improve their collaborative skills to a level that would meet their patients' needs. Patients expect doctors to be able to build relationships and act as reflective practitioners. Including patients in the collaborative process by giving them a role that is appropriate to their abilities and by making collaboration more explicit could help to improve collaboration between general practitioners and medical specialists.

Realist evaluation of UK medical education quality assurance

OBJECTIVES

The aim of the study was to explore what components of the General Medical Council's (GMC) Quality Assurance Framework work, for whom, in what circumstances and how?

SETTING

UK undergraduate and postgraduate medical education and training.

PARTICIPANTS

We conducted interviews with a stratified sample of 36 individuals. This included those who had direct experiences, as well as those with external insights, representing local, national and international organisations within and outside medicine.

INTERVENTION

The GMC quality assure education to protect patient and public safety utilising complex intervention components including meeting standards, institutional visits and monitoring performance. However, the context in which these are implemented matters. We undertook an innovative realist evaluation to test an initial programme theory. Data were analysed using framework analysis.

RESULTS

Across components of the intervention, we identified key mechanisms, including transparent reporting to promote quality improvement; dialogical feedback; partnership working facilitating interactions between regulators and providers, and role clarity in conducting proportionate interventions appropriate to risk. The GMC's framework was commended for being comprehensive and enabling a broad understanding of an organisation's performance. Unintended consequences included confusion over roles and boundaries in different contexts which often undermined effectiveness.

CONCLUSIONS

This realist evaluation substantiates the literature and reveals deeper understandings about quality assuring medical education. While standardised approaches are implemented, interventions need to be contextually proportionate. Routine communication is beneficial to verify data, share concerns and check risk; however, ongoing partnership working can foster assurance. The study provides a modified programme theory to explicate how education providers and regulators can work more effectively together to uphold education quality, and ultimately protect public safety. The findings have influenced the GMC's approach to quality assurance which impacts on all medical students and doctors in training.

Ethical challenges of integration across primary and secondary care: a qualitative and normative analysis

BACKGROUND

This paper explores ethical concerns arising in healthcare integration. We argue that integration is necessary imperative for meeting contemporary and future healthcare challenges, a far stronger evidence base for the conditions of its effectiveness is required. In particular, given the increasing emphasis at the policy level for the entire healthcare infrastructure to become better integrated, our analysis of the ethical challenges that follow from the logic of integration itself is timely and important and has hitherto received insufficient attention.

METHODS

We evaluated an educational intervention which aims to improve child health outcomes by making transitions between primary to secondary care more efficient, ensuring children and parents are better supported throughout. The programme provided skills for trainee paediatricians and general practitioners (GPs) in co-designing integrated clinical services.

RESULTS

The key ethical challenges of integrated care that arose from a clinical perspective are: professional identity and autonomy in an integrated working environment; the concomitant extent of professional responsibility in such an environment; and the urgent need for more evidence to be produced on which strategies for integrating at scale can be based.

CONCLUSIONS

From our analysis we suggest a tentative way forward, viewed from a normative position broadly situated at the intersection of deontology and care ethics. We adopt this position because the primary clinical ethical issues in the context of integrated care concern: how to ensure that all duties of care to individual patients are met in a newly orientated working environment where clinical responsibility may be ambiguous; and the need to orientate care around the patient by foregrounding their autonomous preferences and ensuring good patient clinician relationships in clinical decision-making.