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Kinston R, Gay S, McKinley RK, Sam S, Yardley S, Lefroy J. How well do UK assistantships equip medical students for graduate practice? Think EPAs. Adv Health Sci Educ Theory Pract 2024; 29:173-198. [PMID: 37347459 DOI: 10.1007/s10459-023-10249-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 05/28/2023] [Indexed: 06/23/2023]
Abstract
The goal of better medical student preparation for clinical practice drives curricular initiatives worldwide. Learning theory underpins Entrustable Professional Activities (EPAs) as a means of safe transition to independent practice. Regulators mandate senior assistantships to improve practice readiness. It is important to know whether meaningful EPAs occur in assistantships, and with what impact. Final year students at one UK medical school kept learning logs and audio-diaries for six one-week periods during a year-long assistantship. Further data were also obtained through interviewing participants when students and after three months as junior doctors. This was combined with data from new doctors from 17 other UK schools. Realist methods explored what worked for whom and why. 32 medical students and 70 junior doctors participated. All assistantship students reported engaging with EPAs but gaps in the types of EPAs undertaken exist, with level of entrustment and frequency of access depending on the context. Engagement is enhanced by integration into the team and shared understanding of what constitutes legitimate activities. Improving the shared understanding between student and supervisor of what constitutes important assistantship activity may result in an increase in the amount and/or quality of EPAs achieved.
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Affiliation(s)
- Ruth Kinston
- School of Medicine, Keele University, Clinical Education Centre, University Hospital of North Midlands, Newcastle Road, Staffordshire, ST4 6QG, UK.
| | - Simon Gay
- University of Leicester School of Medicine, Leicester, UK
- Keele University School of Medicine, Keele, UK
| | | | - Sreya Sam
- Keele University School of Medicine, Keele, UK
| | - Sarah Yardley
- Marie Curie Palliative Care Research Department, University College London, London, UK
- Central & North West London NHS Foundation Trust, London, UK
| | - Janet Lefroy
- School of Medicine and Faculty Lead for the Health Professionals Education Research Theme, Keele University, Keele, UK
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Allsop S, McKinley RK, Douglass C, Pope L, Macdougall C. Every doctor an educator? Med Teach 2023; 45:559-564. [PMID: 36622887 DOI: 10.1080/0142159x.2022.2158069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
INTRODUCTION The education of the future health care workforce is fundamental to ensuring safe, effective, and inclusive patient care. Despite this there has been chronic underinvestment in health care education and, even though there is an increased need for educators, the true number of medical educators has been in relative decline for over a decade. PURPOSE In this paper, we focus on the role of doctors as medical educators. We reflect on the culture in which medical education and training are delivered, the challenges faced, and their origins and sustaining factors. We propose a re-framing of this culture by applying Maslow's principles of the hierarchy of needs to medical educators, not only as individuals but as a specialist group and to the system in which this group works, to instigate actionable change and promote self-actualization for medical educators. DISCUSSION Promoting and supporting the work of doctors who are educators is critically important. Despite financial investment in some practice areas, overall funding for and the number of medical educators continues to decline. Continuing Professional Development (CPD) schemes such as those offered by specialised medical education associations are welcomed, but without time, funding and a supportive culture from key stakeholders, medical educators cannot thrive and reach their potential. CONCLUSION We need to revolutionise the culture in which medical education is practised, where medical educators are valued and commensurately rewarded as a diverse group of specialists who have an essential role in training the health care workforce to support the delivery of excellent, inclusive health care for patients. By reimagining the challenges faced as a hierarchy we show that until the fundamental needs of value, funding and time are realised, it will remain challenging to instigate the essential change that is needed.
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Affiliation(s)
- Sarah Allsop
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Lindsey Pope
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
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Yeates P, Maluf A, Kinston R, Cope N, McCray G, Cullen K, O'Neill V, Cole A, Goodfellow R, Vallender R, Chung CW, McKinley RK, Fuller R, Wong G. Enhancing authenticity, diagnosticity and equivalence (AD-Equiv) in multicentre OSCE exams in health professionals education: protocol for a complex intervention study. BMJ Open 2022; 12:e064387. [PMID: 36600366 PMCID: PMC9730346 DOI: 10.1136/bmjopen-2022-064387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/12/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Objective structured clinical exams (OSCEs) are a cornerstone of assessing the competence of trainee healthcare professionals, but have been criticised for (1) lacking authenticity, (2) variability in examiners' judgements which can challenge assessment equivalence and (3) for limited diagnosticity of trainees' focal strengths and weaknesses. In response, this study aims to investigate whether (1) sharing integrated-task OSCE stations across institutions can increase perceived authenticity, while (2) enhancing assessment equivalence by enabling comparison of the standard of examiners' judgements between institutions using a novel methodology (video-based score comparison and adjustment (VESCA)) and (3) exploring the potential to develop more diagnostic signals from data on students' performances. METHODS AND ANALYSIS The study will use a complex intervention design, developing, implementing and sharing an integrated-task (research) OSCE across four UK medical schools. It will use VESCA to compare examiner scoring differences between groups of examiners and different sites, while studying how, why and for whom the shared OSCE and VESCA operate across participating schools. Quantitative analysis will use Many Facet Rasch Modelling to compare the influence of different examiners groups and sites on students' scores, while the operation of the two interventions (shared integrated task OSCEs; VESCA) will be studied through the theory-driven method of Realist evaluation. Further exploratory analyses will examine diagnostic performance signals within data. ETHICS AND DISSEMINATION The study will be extra to usual course requirements and all participation will be voluntary. We will uphold principles of informed consent, the right to withdraw, confidentiality with pseudonymity and strict data security. The study has received ethical approval from Keele University Research Ethics Committee. Findings will be academically published and will contribute to good practice guidance on (1) the use of VESCA and (2) sharing and use of integrated-task OSCE stations.
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Affiliation(s)
- Peter Yeates
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Adriano Maluf
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Ruth Kinston
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Natalie Cope
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Gareth McCray
- School of Medicine, Keele University, Keele, Staffordshire, UK
| | - Kathy Cullen
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Vikki O'Neill
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Aidan Cole
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | | | | | - Ching-Wa Chung
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, Scotland, UK
| | | | - Richard Fuller
- School of Medicine, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford Division of Public Health and Primary Health Care, Oxford, Oxfordshire, UK
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Lukšaitė E, Fricker RA, McKinley RK, Dikomitis L. Conceptualising and Teaching Biomedical Uncertainty to Medical Students: an Exploratory Qualitative Study. Med Sci Educ 2022; 32:371-378. [PMID: 35528309 PMCID: PMC9055000 DOI: 10.1007/s40670-021-01481-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Certainty/uncertainty in medicine is a topic of popular debate. This study aims to understand how biomedical uncertainty is conceptualised by academic medical educators and how it is taught in a medical school in the UK. METHODS This is an exploratory qualitative study grounded in ethnographic principles. This study is based on 10 observations of teaching sessions and seven semi-structured qualitative interviews with medical educators from various biomedical disciplines in a UK medical school. The data set was analysed via a thematic analysis. RESULTS Four main themes were identified after analysis: (1) ubiquity of biomedical uncertainty, (2) constraints to teaching biomedical uncertainty, (3) the 'medic filter' and (4) fluid distinction: core versus additional knowledge. While medical educators had differing understandings of how biomedical uncertainty is articulated in their disciplines, its presence was ubiquitous. This ubiquity did not translate into teaching due to time constraints and assessment strategies. The 'medic filter' emerged as a strategy that educators employed to decide what to include in their teaching. They made distinctions between core and additional knowledge which were defined in varied ways across disciplines. Additional knowledge often encapsulated biomedical uncertainty. DISCUSSION Even though the perspective that knowledge is socially constructed is not novel in medical education, it is neither universally valued nor universally applied. Moving beyond situativity theories and into broader debates in social sciences provides new opportunities to discuss the nature of scientific knowledge in medical education. We invite a move away from situated learning to situated knowledge.
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Affiliation(s)
- Eva Lukšaitė
- School of Medicine, David Weatherall Building, Keele University, Keele, ST5 5BG Staffordshire UK
| | - Rosemary A. Fricker
- School of Medicine, David Weatherall Building, Keele University, Keele, ST5 5BG Staffordshire UK
| | - Robert K. McKinley
- School of Medicine, David Weatherall Building, Keele University, Keele, ST5 5BG Staffordshire UK
| | - Lisa Dikomitis
- School of Medicine, David Weatherall Building, Keele University, Keele, ST5 5BG Staffordshire UK
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Abstract
INTRODUCTION Communication skills are assessed by medically-enculturated examiners using consensus frameworks which were developed with limited patient involvement. Assessments consequently risk rewarding performance which incompletely serves patients' authentic communication needs. Whilst regulators require patient involvement in assessment, little is known about how this can be achieved. We aimed to explore patients' perceptions of students' communication skills, examiner feedback and potential roles for patients in assessment. METHODS Using constructivist grounded theory we performed cognitive stimulated, semi-structured interviews with patients who watched videos of student performances in communication-focused OSCE stations and read corresponding examiner feedback. Data were analysed using grounded theory methods. RESULTS A disconnect occurred between participants' and examiners' views of students' communication skills. Whilst patients frequently commented on students' use of medical terminology, examiners omitted to mention this in feedback. Patients' judgements of students' performances varied widely, reflecting different preferences and beliefs. Participants viewed variability as an opportunity for students to learn from diverse lived experiences. Participants perceived a variety of roles to enhance assessment authenticity. DISCUSSION Integrating patients into communications skills assessments could help to highlight deficiencies in students' communication which medically-enculturated examiners may miss. Overcoming the challenges inherent to this is likely to enhance graduates' preparedness for practice.
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Affiliation(s)
- Alice Moult
- School of Medicine, Keele University, Keele, UK
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Rajendran K, Walters B, Kemball B, McKinley RK, Khan N, Melville CA. Pilot Evaluation of an Online Resource for Learning Paediatric Chest Radiograph Interpretation. Cureus 2021; 13:e12762. [PMID: 33489639 PMCID: PMC7813975 DOI: 10.7759/cureus.12762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction and aims Assessment of chest radiographs is a fundamental clinical skill, often taught opportunistically. Medical students are taught how to read adult chest radiographs, however, in our experience, there is often a lack of structured training for the interpretation of pediatric chest radiographs. Our aim was to develop and evaluate an online approach for medical students to learn this skill. Materials and methods Ericsson's expertise acquisition theory was used to develop 10 sets of 10 practice radiographs which were graded using the X-ray difficulty score. Medical student volunteers (from Keele University School of Medicine) were recruited in the paediatric rotation of their first clinical year. Pre- and post-training tests of identical difficulty were offered. A semistructured focus group was conducted after the tests, the transcription of which was analyzed using grounded theory. Results Of 117 students in the year, 54 (46%) originally volunteered. The engagement was initially high but fell during the year, particularly during the pre-examination block. The high drop-out rate made the quantitative measurement of effectiveness difficult. The focus group suggested that pressure of other work, exam preparation, technical factors, and inflexibility of the study protocol reduced engagement. Conclusions Although the topic covered was seen as important and relevant to exams, the current system requires development to make it more effective and engaging.
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Affiliation(s)
- Karthik Rajendran
- Department of Trauma and Orthopaedics, Royal Free NHS Foundation Trust, London, GBR
| | - Ben Walters
- Department of Medicine, University Hospitals of North Midlands NHS Trust, Stoke-On-Trent, GBR
| | - Bridget Kemball
- Department of Medicine, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, GBR
| | | | - Nadir Khan
- Department of Radiology, University Hospitals of North Midlands NHS Trust, Stoke-On-Trent, GBR
| | - Colin A Melville
- Department of Paediatrics, University Hospitals of North Midlands NHS Trust, Stoke-On-Trent, GBR
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Hyde C, Yardley S, Lefroy J, Gay S, McKinley RK. Clinical assessors' working conceptualisations of undergraduate consultation skills: a framework analysis of how assessors make expert judgements in practice. Adv Health Sci Educ Theory Pract 2020; 25:845-875. [PMID: 31997115 PMCID: PMC7471149 DOI: 10.1007/s10459-020-09960-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 01/18/2020] [Indexed: 06/10/2023]
Abstract
Undergraduate clinical assessors make expert, multifaceted judgements of consultation skills in concert with medical school OSCE grading rubrics. Assessors are not cognitive machines: their judgements are made in the light of prior experience and social interactions with students. It is important to understand assessors' working conceptualisations of consultation skills and whether they could be used to develop assessment tools for undergraduate assessment. To identify any working conceptualisations that assessors use while assessing undergraduate medical students' consultation skills and develop assessment tools based on assessors' working conceptualisations and natural language for undergraduate consultation skills. In semi-structured interviews, 12 experienced assessors from a UK medical school populated a blank assessment scale with personally meaningful descriptors while describing how they made judgements of students' consultation skills (at exit standard). A two-step iterative thematic framework analysis was performed drawing on constructionism and interactionism. Five domains were found within working conceptualisations of consultation skills: Application of knowledge; Manner with patients; Getting it done; Safety; and Overall impression. Three mechanisms of judgement about student behaviour were identified: observations, inferences and feelings. Assessment tools drawing on participants' conceptualisations and natural language were generated, including 'grade descriptors' for common conceptualisations in each domain by mechanism of judgement and matched to grading rubrics of Fail, Borderline, Pass, Very good. Utilising working conceptualisations to develop assessment tools is feasible and potentially useful. Work is needed to test impact on assessment quality.
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Affiliation(s)
- Catherine Hyde
- School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Sarah Yardley
- School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK.
- Palliative Care Service, Central and North West London NHS Foundation Trust, St Pancras Hospital, 5th Floor South Wing, 4 St. Pancras Way, London, NW1 0PE, UK.
| | - Janet Lefroy
- School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Simon Gay
- University of Leicester School of Medicine, Leicester, UK
| | - Robert K McKinley
- School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK
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Yardley S, Kinston R, Lefroy J, Gay S, McKinley RK. 'What do we do, doctor?' Transitions of identity and responsibility: a narrative analysis. Adv Health Sci Educ Theory Pract 2020; 25:825-843. [PMID: 31960189 PMCID: PMC7471202 DOI: 10.1007/s10459-020-09959-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 01/14/2020] [Indexed: 05/09/2023]
Abstract
Transitioning from student to doctor is notoriously challenging. Newly qualified doctors feel required to make decisions before owning their new identity. It is essential to understand how responsibility relates to identity formation to improve transitions for doctors and patients. This multiphase ethnographic study explores realities of transition through anticipatory, lived and reflective stages. We utilised Labov's narrative framework (Labov in J Narrat Life Hist 7(1-4):395-415, 1997) to conduct in-depth analysis of complex relationships between changes in responsibility and development of professional identity. Our objective was to understand how these concepts interact. Newly qualified doctors acclimatise to their role requirements through participatory experience, perceived as a series of challenges, told as stories of adventure or quest. Rules of interaction within clinical teams were complex, context dependent and rarely explicit. Students, newly qualified and supervising doctors felt tensions around whether responsibility should be grasped or conferred. Perceived clinical necessity was a common determinant of responsibility rather than planned learning. Identity formation was chronologically mismatched to accepting responsibility. We provide a rich illumination of the complex relationship between responsibility and identity pre, during, and post-transition to qualified doctor: the two are inherently intertwined, each generating the other through successful actions in practice. This suggests successful transition requires a supported period of identity reconciliation during which responsibility may feel burdensome. During this, there is a fine line between too much and too little responsibility: seemingly innocuous assumptions can have a significant impact. More effort is needed to facilitate behaviours that delegate authority to the transitioning learner whilst maintaining true oversight.
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Affiliation(s)
- Sarah Yardley
- Keele University School of Medicine, Keele, UK.
- Palliative Care Service, Central and North West London NHS Foundation Trust, St Pancras Hospital, 5th Floor South Wing, 4 St. Pancras Way, London, NW1 0PE, UK.
| | | | | | - Simon Gay
- University of Leicester School of Medicine, Leicester, UK
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Abstract
Undergraduate medical education has expanded substantially in recent years, through both establishing new programs and increasing student numbers in existing programs. This expansion has placed pressure on the capacity for training students in clinical placements, raising concerns about the risk of dilution of experience, and reducing work readiness. The concerns have been greatest in more traditional environments, where clinical placements in large academic medical centers are often the "gold standard". However, there are ways of exposing medical students to patient interactions and clinical supervisors in many other contexts. In this paper, we share our experiences and observations of expanding clinical placements for both existing and new medical programs in several international locations. While this is not necessarily an easy task, a wide range of opportunities can be accessed by asking the right questions of the right people, often with only relatively modest changes in resource allocation.
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Affiliation(s)
- Richard B Hays
- a Remote and Rural Health , James Cook University , Townsville , Australia
| | | | - Tarun K Sen Gupta
- c Medical Education , James Cook University , Townsville , Australia
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Alberti H, McKinley RK. Response to medical education in (and for) areas of socio-economic deprivation in the UK. Education for Primary Care 2019; 30:56. [DOI: 10.1080/14739879.2018.1563871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Hugh Alberti
- School of Medical Education, Newcastle University, UK
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McKinley RK, Bartlett M, Coventry P, Gay SP, Gibson SH, Hays RB, Jones RG. The systematic development of a novel integrated spiral undergraduate course in general practice. Educ Prim Care 2018; 26:189-96. [PMID: 26092149 DOI: 10.1080/14739879.2015.11494338] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Robert K McKinley
- Professor of Education in General Practice, School of Medicine, Keele University, Staffordshire ST5 5BG, UK.
| | - Maggie Bartlett
- Clinical Senior Lecturer in Medical Education, Keele University School of Medicine, UK
| | - Peter Coventry
- Clinical Senior Lecturer in Medical Education, Director of Curriculum, Keele University School of Medicine, UK
| | - Simon P Gay
- Clinical Senior Lecturer in Medical Education, Keele University School of Medicine, UK
| | - Sheena H Gibson
- Clinical Lecturer in Medical Education, Keele University School of Medicine, UK
| | - Richard B Hays
- Dean of Medicine, University of Tasmania. Previously Head of School, Keele University School of Medicine, UK
| | - Robert G Jones
- Clinical Lecturer in Medical Education, Keele University School of Medicine, UK
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McKinley RK, Bartlett M, Gay SP, Gibson S, Panesar A, Webb M. An innovative long final year assistantship in general practice: description and evaluation. Education for Primary Care 2018; 29:35-42. [DOI: 10.1080/14739879.2017.1399829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - M. Bartlett
- Keele University School of Medicine, Keele, UK
| | - S. P. Gay
- Keele University School of Medicine, Keele, UK
| | - S. Gibson
- Keele University School of Medicine, Keele, UK
| | - A. Panesar
- Keele University School of Medicine, Keele, UK
| | - M. Webb
- Keele University School of Medicine, Keele, UK
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Bartlett M, Gay SP, List PA, McKinley RK. Teaching and learning clinical reasoning: tutors' perceptions of change in their own clinical practice. Educ Prim Care 2017; 26:248-54. [PMID: 26253061 DOI: 10.1080/14739879.2015.11494350] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Clinical reasoning is an important skill for all clinicians and historically has rarely been formally taught either at undergraduate or postgraduate level. Clinical reasoning is taught as a formal course in the fourth year of the undergraduate programme at Keele School of Medicine by tutors who are all practicing general practitioners. AIM We aimed to explore the tutors' perceptions about how teaching on the course has impacted on their own consultation skills. DESIGN AND SETTING All 11 course tutors who had taught on the course for at least one full academic year were invited to take part in recorded individual semi-structured interviews with an experienced, non-clinical, qualitative researcher. The data were analysed using qualitative methods. RESULTS Eleven tutors participated, with a range of 7 to 32 years of clinical experience. They reported better decision-making, greater use of metacognition, more self-awareness, more reflective practice, more confidence and greater job satisfaction. They also reported positive impacts on their own knowledge and learning, and assumed concomitant benefits for their patients. CONCLUSION All clinicians in this group perceived benefits on their consultation skills as a result of teaching clinical reasoning. There is a need to provide education, training and continuing professional development in cognitive consultation skills to students, trainees and established practitioners.
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Affiliation(s)
- Maggie Bartlett
- Medical Education, Keele University School of Medicine, David Weatherall Building, Keele University, Keele, Staffordshire ST5 5BG, UK.
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Gay S, McKinley RK. 'When I say… dual-processing theory': evidence, not assertion. Med Educ 2017; 51:1086. [PMID: 28901650 DOI: 10.1111/medu.13351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Simon Gay
- Medical Education Centre, School of Medicine, The University of Nottingham, Nottingham, UK
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Abstract
BACKGROUND Keele Medical School has a small accommodation hub for students placed within ten associated general practices in a predominantly rural area of England. Groups of up to eleven final year students spend fifteen weeks learning generic and transferable clinical skills in these practices. AIM To explore the evolving perceptions on students on their experiences throughout their placements. METHOD All ten students placed at the hub between August and December 2013 were invited to participate in focus groups in weeks zero, seven, and fifteen. Analysis was qualitative and thematic. RESULTS Ten, five and eight students chose to participate in successive focus groups. Five themes were identified from the data; acceptance, learning opportunities, relationships, development, and injustice with a subtheme of isolation. CONCLUSION The placements had a powerful impact on students' learning and development. Their perceptions changed from seeing themselves as 'knowledge leeches' to legitimate contributors to health care over the course of fifteen weeks. They did not recognise that managing perceived adversity led to personal development. This illustrates the need to both identify perceived adversity and explicitly signpost and scaffold life learning. The students described experiences which challenged them intellectually and offered them opportunities to recognise the breadth and complexity of general practice.
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Affiliation(s)
| | - Simon P Gay
- Keele University School of Medicine, Keele ST5 5BG, UK
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Abstract
OBJECTIVE A multidisciplinary support team for general practice was established in April 2014 by a local National Health Service (NHS) England management team. This work evaluates the team's effectiveness in supporting and promoting change in its first 2 years, using realist methodology. SETTING Primary care in one area of England. PARTICIPANTS Semistructured interviews were conducted with staff from 14 practices, 3 key senior NHS England personnel and 5 members of the support team. Sampling of practice staff was purposive to include representatives from relevant professional groups. INTERVENTION The team worked with practices to identify areas for change, construct action plans and implement them. While there was no specified timescale for the team's work with practices, it was tailored to each. PRIMARY AND SECONDARY OUTCOME MEASURES In realist evaluations, outcomes are contingent on mechanisms acting in contexts, and both an understanding of how an intervention leads to change in a socially constructed system and the resultant changes are outcomes. RESULTS The principal positive mechanisms leading to change were the support team's expertise and its relationships with practice staff. The 'external view' provided by the team via its corroborative and normalising effects was an important mechanism for increasing morale in some practice contexts. A powerful negative mechanism was related to perceptions of 'being seen as a failing practice' which included expressions of 'shame'. Outcomes for practices as perceived by their staff were better communication, improvements in patients' access to appointments resulting from better clinical and managerial skill mix, and improvements in workload management. CONCLUSIONS The support team promoted change within practices leading to signs of the 'green shoots of recovery' within the time frame of the evaluation. Such interventions need to be tailored and responsive to practices' needs. The team's expertise and relationships between team members and practice staff are central to success.
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Affiliation(s)
| | - Ruth Basten
- Keele School of Medicine, Keele University, Keele, UK
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Affiliation(s)
- Eliot L. Rees
- School of Medicine, Keele University, North Staffordshire, UK
| | - Simon P. Gay
- School of Medicine, Keele University, North Staffordshire, UK
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Affiliation(s)
- Robert K McKinley
- Keele University School of Medicine, ST5 5BG, Keele, Staffordshire UK.
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Abstract
BACKGROUND Keele School of Medicine has an innovative new MBChB curriculum with a strong focus on primary care. Our students spend a minimum of 115 days in general practice. AIM To describe the investment by the school in the local primary care community. METHOD We collated data on list sizes of current undergraduate teaching practices, county populations and the investment in practices' teaching skills and physical premises. RESULTS Between academic years 2010-11 and 2012-13 a total of 118 (annual mean of 99) practices contributed to teaching across six counties, providing care for 655 229 people. Forty-five per cent of 243 practices in Staffordshire and Shropshire teach. They serve 51% of the two counties' population. We have invested £1.62 million in the premises of 25 practices providing services for 18% of people in Staffordshire and Shropshire, £273 000 in a rural campus in Shropshire, and £99 387 in set-up grants. We have conducted 249 practice development visits. There were 540 attendances at tutor development sessions. We have had a total of 2300 hours of face-to-face contact with our practices. CONCLUSION The school has made a major investment in general practice in its area, contributing to the development of general practitioners and investing in practice premises.
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Affiliation(s)
- Maggie Bartlett
- Senior Clinical Lecturer in Medical Education, Keele University School of Medicine, David Weatherall Building, Keele University, Keele, Staffordshire ST5 5BG, UK.
| | - Matthew Webb
- Clinical Teaching Fellow, Keele University School of Medicine, UK
| | - Robert K McKinley
- Professor of Education in General Practice, Keele University Medical School, UK
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Lefroy J, Hawarden A, Gay SP, McKinley RK, Cleland J. Grades in formative workplace-based assessment: a study of what works for whom and why. Med Educ 2015; 49:307-20. [PMID: 25693990 DOI: 10.1111/medu.12659] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 08/01/2014] [Accepted: 11/13/2014] [Indexed: 05/15/2023]
Abstract
CONTEXT Grades are commonly used in formative workplace-based assessment (WBA) in medical education and training, but may draw attention away from feedback about the task. A dilemma arises because the self-regulatory focus of a trainee must include self-awareness relative to agreed standards, which implies grading. OBJECTIVES In this study we aimed to understand the meaning which medical students construct from WBA feedback with and without grades, and what influences this. METHODS Year 3 students were invited to take part in a randomised crossover study in which each student served as his or her own control. Each student undertook one WBA with and one without grades, and then chose whether or not to be given grades in a third WBA. These preferences were explored in semi-structured interviews. A realist approach to analysis was used to gain understanding of student preferences and the impact of feedback with and without grades. RESULTS Of 83 students who were given feedback with and without grades, 65 (78%) then chose to have feedback with grades and 18 (22%) without grades in their third WBA. A total of 24 students were interviewed. Students described how grades locate their performance and calibrate their self-assessment. For some, low grades focused attention and effort. Satisfactory and high grades enhanced self-efficacy. CONCLUSIONS Grades are concrete, powerful and blunt, can be harmful and need to be explained to help students create helpful meaning from them. Low grades risk reducing self-efficacy in some and may encourage others to focus on proving their ability rather than on improvement. A metaphor of the semi-permeable membrane is introduced to elucidate how students reduced potential negative effects and enhanced the positive effects of feedback with grades by selective filtering and pumping. This study illuminates the complexity of the processing of feedback by its recipients, and informs the use of grading in the provision of more effective, tailored feedback.
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Affiliation(s)
- Robert K McKinley
- Keele University School of Medicine, Keele University, Keele, ST5 5BG, UK,
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Lefroy J, Thomas A, Harrison C, Williams S, O'Mahony F, Gay S, Kinston R, McKinley RK. Development and face validation of strategies for improving consultation skills. Adv Health Sci Educ Theory Pract 2014; 19:661-85. [PMID: 24449128 DOI: 10.1007/s10459-014-9493-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 01/08/2014] [Indexed: 05/15/2023]
Abstract
While formative workplace based assessment can improve learners' skills, it often does not because the procedures used do not facilitate feedback which is sufficiently specific to scaffold improvement. Provision of pre-formulated strategies to address predicted learning needs has potential to improve the quality and automate the provision of written feedback. To systematically develop, validate and maximise the utility of a comprehensive list of strategies for improvement of consultation skills through a process involving both medical students and their clinical primary and secondary care tutors. Modified Delphi study with tutors, modified nominal group study with students with moderation of outputs by consensus round table discussion by the authors. 35 hospital and 21 GP tutors participated in the Delphi study and contributed 153 new or modified strategies. After review of these and the 205 original strategies, 265 strategies entered the nominal group study to which 46 year four and five students contributed, resulting in the final list of 249 validated strategies. We have developed a valid and comprehensive set of strategies which are considered useful by medical students. This list can be immediately applied by any school which uses the Calgary Cambridge Framework to inform the content of formative feedback on consultation skills. We consider that the list could also be mapped to alternative skills frameworks and so be utilised by schools which do not use the Calgary Cambridge Framework.
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Affiliation(s)
- Janet Lefroy
- Keele University School of Medicine, Keele, Staffordshire, UK,
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Bartlett M, McKinley RK, Wynn Jones J, Hays RB. A rural undergraduate campus in England: virtue from opportunity and necessity. Rural Remote Health 2011; 11:1841. [PMID: 22098058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
The implementation of new curriculum at Keele University Medical School, UK has made heavy use of general practice as a locus for learning. This has necessitated a substantial expansion in the School's teaching network. The School's hinterland includes a large rural area with a number of excellent general practices and associated community hospitals that, to date, have been unable to teach undergraduates because of their inaccessibility. This article describes how the School and its partners articulated a vision to establish a rural campus with an associated rural accommodation hub, and the challenges involved in establishing and sustaining the campus.
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Affiliation(s)
- M Bartlett
- School of Medicine, Keele University, Keele, Staffordshire, UK.
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Lefroy J, McKinley RK. Skilled communication: comments further to 'Creativity in clinical communication: from communication skills to skilled communication'. Med Educ 2011; 45:958-962. [PMID: 21848724 DOI: 10.1111/j.1365-2923.2011.04009.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Affiliation(s)
- Robert G Jones
- Keele University School of Medicine, Keele University, Keele, Staffordshire ST5 5BG, UK.
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Patel S, Peacock SM, McKinley RK, Clark-Carter D, Watson PJ. GPs' perceptions of the service needs of South Asian people with chronic pain: a qualitative enquiry. J Health Psychol 2010; 14:909-18. [PMID: 19786517 DOI: 10.1177/1359105309341003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This qualitative study describes GPs' experiences of and needs for management of people from a South Asian community who have chronic pain. Semi-structured interviews were conducted with 18 GPs from practices in two PCTs in Leicester. The data was analysed using grounded theory. The results indicate that managing patients from a South Asian community with chronic pain can be challenging due to differing pain expression and presentation. Emerging themes refer to shortages of services for these patients including the need for CBT, counselling, community support and GP education and training. Potential implications of the results for service provision are discussed.
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Affiliation(s)
- S Patel
- University of Warwick, Coventry, UK.
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McKinley RK, Hastings AM. Tools to assess clinical skills of medical trainees. JAMA 2010; 303:332; author reply 332. [PMID: 20103756 DOI: 10.1001/jama.2010.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Affiliation(s)
- David J Pearson
- Academic Unit of Primary Care, Leeds Institute of Health Sciences, Charles Thackrah Building 101 Clarendon Road, Leeds LS2 9JL, UK.
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Jiwa M, McKinley RK, Spilsbury K, Arnet H, Smith M. Deploying a clinical innovation in the context of actor-patient consultations in general practice: a prelude to a formal clinical trial. BMC Med Res Methodol 2009; 9:54. [PMID: 19615058 PMCID: PMC2716367 DOI: 10.1186/1471-2288-9-54] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 07/17/2009] [Indexed: 12/03/2022] Open
Abstract
Background Innovations to be deployed during consultations with patients may influence the clinical performance of the medical practitioner. This study examined the impact on General Practitioners' (GPs) consultation performance of novel computer software, designed for use while consulting the patient. Methods Six GPs were video recorded consulting six actor-patients in a simulated clinical environment. Two sessions were recorded with six consultations per GP. Five cases presented cancer symptoms which warranted a referral for specialist investigation. Practitioners were invited to use a novel software package to process referrals made during the consultations in the second session. Two assessors independently reviewed the consultation performance using the Leicester Assessment Package (LAP). Inter-rater agreement was assessed by a Bland-Altman plot of the difference in score against the average score. Results Sixty of the seventy two consultations were successfully recorded. Each video consultation was scored twice by two assessors leaving 120 LAP scores available for analysis. There was no evidence of a difference in the variance with increasing score (Pitmans test p = 0.09). There was also no difference in the mean differences between assessor scores whether using the software or not (T-test, P = 0.49) Conclusion The actor-patient consultation can be used to test clinical innovations as a prelude to a formal clinical trial. However the logistics of the study may impact on the validity of the results and need careful planning. Ideally innovations should be tested within the context of a laboratory designed for the purpose, incorporating a pool of practitioners whose competencies have been established and assessors who can be blinded to the aims of the study.
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Affiliation(s)
- Moyez Jiwa
- Western Australian Centre for Cancer and Palliative Care, Curtin Health Innovation Research Institute, Curtin University of Technology, Perth, Western Australia, Australia.
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Deaville JA, Wynn-Jones J, Hays RB, Coventry PJ, McKinley RK, Randall-Smith J. Perceptions of UK medical students on rural clinical placements. Rural Remote Health 2009; 9:1165. [PMID: 19522554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Rural clinical placements are now commonly used to both promote awareness of rural health careers and expand clinical placement networks in Australia, North America and elsewhere. However in the United Kingdom (UK) there is no clear workforce or health education policy that encourages rural background student recruitment, rural clinical placements, rural oriented curricula or rural health education infrastructure, because deprivation and poor health status are regarded as urban phenomena. The question for one new medical school in regional/rural UK is: can increasing the utilisation of rural primary care practices both resolve teaching capacity constraints and offer students valuable learning opportunities about rural health? This article reports an exploration of students' views on the value of rural clinical placements in a new curriculum designed to address regional deprivation and workforce needs. METHODS Medical students in Year 1 and Year 3 of a regional medical school were invited to attend focus group discussions that explored their understanding of rural health and life and the attractions of and barriers to expanding rural clinical placements. The Year 1 students were in the new curriculum and therefore more likely to be allocated a rural clinical placement in their more senior years. The discussions were audio-recorded, transcribed and thematically analysed. RESULTS Themes that emerged were: what is rural? how different is rural from urban?; differences in rural and urban learning, logistic issues, and choosing a rural placement. Student perceptions in both groups were rather negative about rural placements. Rural practices were thought to provide a narrow range of patient contact and learning opportunities, and rural life was thought to be unattractive, especially out of formal placement hours. Even relatively small distances from friends and social outlets were regarded as barriers. Year 1 students were more positive about the possibility of a rural placement, although they knew at admission that the school would be expanding into rural communities and may therefore have been more open to the concept. CONCLUSION Ruralization of health professional education in the UK faces substantial challenges. More may need to be done to increase recruitment of rural-interested students, foster rural career interest during courses, recruit rural role models, develop rural curricula and establish the infrastructure to support rural clinical placements. These initiatives will require greater political will and some investment by education, heath and community development agencies.
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Thomas M, McKinley RK, Mellor S, Watkin G, Holloway E, Scullion J, Shaw DE, Wardlaw A, Price D, Pavord I. Breathing exercises for asthma: a randomised controlled trial. Thorax 2008; 64:55-61. [PMID: 19052047 DOI: 10.1136/thx.2008.100867] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND The effect of breathing modification techniques on asthma symptoms and objective disease control is uncertain. METHODS A prospective, parallel group, single-blind, randomised controlled trial comparing breathing training with asthma education (to control for non-specific effects of clinician attention) was performed. Subjects with asthma with impaired health status managed in primary care were randomised to receive three sessions of either physiotherapist-supervised breathing training (n = 94) or asthma nurse-delivered asthma education (n = 89). The main outcome was Asthma Quality of Life Questionnaire (AQLQ) score, with secondary outcomes including spirometry, bronchial hyper-responsiveness, exhaled nitric oxide, induced sputum eosinophil count and Asthma Control Questionnaire (ACQ), Hospital Anxiety and Depression (HAD) and hyperventilation (Nijmegen) questionnaire scores. RESULTS One month after the intervention there were similar improvements in AQLQ scores from baseline in both groups but at 6 months there was a significant between-group difference favouring breathing training (0.38 units, 95% CI 0.08 to 0.68). At the 6-month assessment there were significant between-group differences favouring breathing training in HAD anxiety (1.1, 95% CI 0.2 to 1.9), HAD depression (0.8, 95% CI 0.1 to 1.4) and Nijmegen (3.2, 95% CI 1.0 to 5.4) scores, with trends to improved ACQ (0.2, 95% CI 0.0 to 0.4). No significant between-group differences were seen at 1 month. Breathing training was not associated with significant changes in airways physiology, inflammation or hyper-responsiveness. CONCLUSION Breathing training resulted in improvements in asthma-specific health status and other patient-centred measures but not in asthma pathophysiology. Such exercises may help patients whose quality of life is impaired by asthma, but they are unlikely to reduce the need for anti-inflammatory medication.
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Affiliation(s)
- M Thomas
- Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Aberdeen, UK.
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McKinley RK, Strand J, Gray T, Schuwirth L, Alun-Jones T, Miller H. Development of a tool to support holistic generic assessment of clinical procedure skills. Med Educ 2008; 42:619-627. [PMID: 18435710 DOI: 10.1111/j.1365-2923.2008.03023.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
CONTEXT The challenges of maintaining comprehensive banks of valid checklists make context-specific checklists for assessment of clinical procedural skills problematic. OBJECTIVES This paper reports the development of a tool which supports generic holistic assessment of clinical procedural skills. METHODS We carried out a literature review, focus groups and non-participant observation of assessments with interview of participants, participant evaluation of a pilot objective structured clinical examination (OSCE), a national modified Delphi study with prior definitions of consensus and an OSCE. Participants were volunteers from a large acute teaching trust, a teaching primary care trust and a national sample of National Health Service staff. Results In total, 86 students, trainees and staff took part in the focus groups, observation of assessments and pilot OSCE, 252 in the Delphi study and 46 candidates and 50 assessors in the final OSCE. We developed a prototype tool with 5 broad categories amongst which were distributed 38 component competencies. There was > 70% agreement (our prior definition of consensus) at the first round of the Delphi study for inclusion of all categories and themes and no consensus for inclusion of additional categories or themes. Generalisability was 0.76. An OSCE based on the instrument has a predicted reliability of 0.79 with 12 stations and 1 assessor per station or 10 stations and 2 assessors per station. CONCLUSIONS This clinical procedural skills assessment tool enables reliable assessment and has content and face validity for the assessment of clinical procedural skills. We have designated it the Leicester Clinical Procedure Assessment Tool (LCAT).
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Affiliation(s)
- Robert K McKinley
- Department of Health Sciences, University of Leicester, Leicester, UK.
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McKinley RK, Strand J, Ward L, Gray T, Alun-Jones T, Miller H. Checklists for assessment and certification of clinical procedural skills omit essential competencies: a systematic review. Med Educ 2008; 42:338-349. [PMID: 18338987 DOI: 10.1111/j.1365-2923.2007.02970.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To develop generic criteria for the global assessment of clinical procedural competence and to quantify the extent to which existing checklists allow for holistic assessment of procedural competencies. METHODS We carried out a systematic review and qualitative analysis of published clinical procedural skills assessment checklists and enumerated the contents of each. Source materials included all English-language papers published from 1990 to June 2005, identified from 18 databases, which described or referred to an assessment document for any clinical procedural skill. A pair of reviewers identified key generic themes and sub-themes through in-depth analysis of a subset of 20 checklists with iterative agreement and independent retesting of a coding framework. The resulting framework was independently applied to all checklists by pairs of reviewers checking for the emergence of new themes and sub-themes. Main outcome measures were identification of generic clinical procedural skills and the frequency of occurrence of each in the identified checklists. RESULTS We identified 7 themes ('Procedural competence', represented in 85 [97%] checklists; 'Preparation', 65 [74%]; 'Safety', 45 [51%]; 'Communication and working with the patient', 32 [36%]; 'Infection control', 28 [32%]; 'Post-procedural care', 24 [27%]; 'Team working', 13 [15%]) and 37 sub-themes, which encapsulated all identified checklists. Of the sub-themes, 2 were identified after the initial coding framework had been finalised. CONCLUSIONS It is possible to develop generic criteria for the global assessment of clinical procedural skills. A third and a half of checklists, respectively, do not enable explicit assessment of the key competencies 'Infection control' and 'Safety'. Their assessment may be inconsistent in assessments which use such checklists.
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Thomas M, McKinley RK, Freeman E, Foy C, Price D. The prevalence of dysfunctional breathing in adults in the community with and without asthma. Prim Care Respir J 2007; 14:78-82. [PMID: 16701702 PMCID: PMC6743552 DOI: 10.1016/j.pcrj.2004.10.007] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 06/15/2004] [Accepted: 10/31/2004] [Indexed: 11/29/2022]
Abstract
Functional breathing problems, including symptomatic hyperventilation, may impair quality of life. Symptoms associated with functional breathing disorders have been reported as being common in secondary care settings, and can affect 29% of adults with current asthma in the community. The prevalence of dysfunctional breathing in the general adult population is unknown. The Nijmegen Questionnaire has been reported to have useful sensitivity and specificity for diagnosing dysfunctional breathing. A cross-sectional postal survey of adults without current asthma was undertaken in a single UK general practice. The results were analysed in conjunction with a previously described survey of adults with current asthma from the same population. The questionnaire was posted to a random sample of 300 people aged 16-65 without current asthma, and 69% were returned. 8% (95% confidence intervals 4-12%) had positive screening scores. Positive screening scores were more common in women (14%, 7-20%) than men (2%, 0-5%, p=0.003). Comparison with the previous survey showed that the prevalence of positive screening scores was higher in those with current asthma than those without (29% vs. 8%, p<0.001). Dysfunctional breathing may affect up to one in 10 people, and is more common in women and in people with asthma.
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Affiliation(s)
- Mike Thomas
- GPIAG Clinical Research Fellow, Department of General Practice and Primary Care, University of Aberdeen, UK.
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Affiliation(s)
- Robert K McKinley
- Keele University Medical School, Keele University, Staffordshire ST5 5BG
| | - Richard H Baker
- Department of Health Sciences, University of Leicester, Leicester LE1 6TP
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Fraser RC, Sarkhou ME, McKinley RK, Van der Vleuten C. Regulatory end-point assessment of the consultation competence of family practice trainees in Kuwait. Eur J Gen Pract 2007; 12:100-7. [PMID: 17002957 DOI: 10.1080/13814780600898353] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND No single approach to the regulatory assessment of global consultation competence has been shown to possess the required levels of validity, reliability and feasibility. OBJECTIVE To evaluate the approach adopted in Kuwait to the regulatory end-point assessment of the global consultation competence of family practice trainees with particular reference to validity, reliability and feasibility. METHODS Family practice trainees in Kuwait were individually and directly observed for 3 hours in consultation with a minimum of 10 patients by a pair of examiners. Performance was judged against the explicit criteria of consultation competence as contained in the Leicester Assessment Package (LAP). RESULTS The marks independently allocated by the pairs of examiners to 126 trainees between 1994 and 2001 were within five percentage points on 91% of occasions. A reliability coefficient of 0.82 was achieved when two examiners independently marked candidates consulting with 10 real patients; this rose to 0.95 at the critical 50% pass-fail margin. The main sources of variance contributing to the reliability of marks allocated were candidate performance (42%) and the interaction of candidate performance across cases, i.e., case specificity (30%). The clinical challenges presented by the patients were judged by both examiners to be sufficient to enable performance to be assessed across the seven LAP consultation categories as follows: behaviour and relationship with patients (100% of consultations), interviewing/history taking (100%), record keeping (99%), patient management (99%), problem solving (98%), physical examination (95%), and anticipatory care (86%). Each assessment involved a pair of examiners and lasted approximately 3.5 hours. CONCLUSION The Kuwait clinical examination achieves high content validity and authenticity as it uses direct observation of performance, validated and explicit criteria against which performance is judged, and real patient challenges. It can discriminate between different levels of consultation performance and satisfies the recognized reliability threshold for regulatory examinations (0.82 vs 0.80). Accordingly, we recommend the use of such an approach in the regulatory end-point assessment of the global consultation competence of trainees in family practice. Such an approach is more valid, and is likely to be more feasible, than simulated surgeries or the short-case OSCE format.
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Affiliation(s)
- Robin C Fraser
- Clinical Division of General Practice and Primary Health Care, University of Leicester, Leicester, UK
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Middleton JF, McKinley RK, Gillies CL. Effect of patient completed agenda forms and doctors' education about the agenda on the outcome of consultations: randomised controlled trial. BMJ 2006; 332:1238-42. [PMID: 16707508 PMCID: PMC1471934 DOI: 10.1136/bmj.38841.444861.7c] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the effect of patient completed agenda forms for the consultation and doctors' education on identifying patients' agendas on the outcome of consultations. DESIGN Randomised controlled trial. SETTING General practices in Leicestershire and Nottinghamshire, United Kingdom. PARTICIPANTS 46 general practitioners and 976 patients. INTERVENTIONS Education for general practitioners, with an embedded clustered randomised controlled trial of a patient agenda form. MAIN OUTCOME MEASURES Number of problems identified, time required to manage each problem, duration of consultations, number of problems raised after the doctor considered the consultation finished ("by the way" questions), and patient satisfaction. RESULTS Data were available from 45 doctors (98%) and 857 patients (88%). The number of problems identified in each consultation increased by 0.2 (95% confidence interval 0.1 to 0.4) with the agenda form, by 0.3 (0.1 to 0.6) with education, and by 0.5 (0.3 to 0.7) with both interventions. The time required to manage each problem was not affected. The duration of consultations with the agenda form was increased by 0.9 minutes (0.3 to 1.5 minutes) and with the combined intervention by 1.9 minutes (1.0 to 2.8 minutes). Patient satisfaction with the depth of the doctor-patient relationship was increased with the agenda form. The occurrence of "by the way" presentations did not change. CONCLUSION A patient completed agenda form before the consultation or general practitioner education about the agenda form, or both, enabled the identification of more problems in consultations even though consultations were longer.
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Affiliation(s)
- J F Middleton
- Leics, Northants and Rutland Deanery, University of Leicester
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Hastings A, McKinley RK, Fraser RC. Strengths and weaknesses in the consultation skills of senior medical students: identification, enhancement and curricular change. Med Educ 2006; 40:437-43. [PMID: 16635123 DOI: 10.1111/j.1365-2929.2006.02445.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
INTRODUCTION This paper seeks to describe the consultation strengths and weaknesses of senior medical students, the explicit and prioritised strategies for improvement utilised in student feedback, and curriculum developments informed by this work. METHODS Prospective, descriptive study of students on clinical placements in general practice. All were observed directly by 2 assessors in consultation with 5 patients in a general practice setting. Performance was judged against 5 categories of consultation competence and 35 component competences as contained in a modified version of the Leicester Assessment Package. Specific strategies for improvement were selected from a list of 69 previously formulated strategies. RESULTS Data from 1116 students were included. The consultation competences identified most frequently as strengths related to interpersonal skills, while weaknesses were mainly in the domain of clinical problem-solving. The median number of key strengths identified per student was 5, with 5 additional but lesser strengths. A median of 3 key and lesser weaknesses were identified. The average number of strategies selected to address an identified weakness was 1.2. Students rated the assessment process and its impact very positively. CONCLUSION The systematic assessment of the consultation competence of medical students by direct observation involving real patients is feasible and facilitates the 'educational diagnosis' of individuals and of their peer group. It has informed development of teaching and generated research hypotheses.
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Affiliation(s)
- Am Hastings
- Department of Medical and Social Care Education, University of Leicester, Leicester, UK.
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Abstract
BACKGROUND General practitioners state the reason for referring patients in referral letters. The paucity of information in these letters has been the source of criticism from specialist colleagues. OBJECTIVE To invite general practitioners to set standards for referral letters to gastroenterologists and to apply these standards to actual referral letters to one specialist gastroenterology unit. METHODS A scoring schedule was designed based on the responses to a questionnaire survey of a large sample of all general practitioners in one locality. Altogether 350 consecutive letters to a district general hospital about patients referred for an upper gastrointestinal specialist opinion were subsequently scored using the schedule. RESULTS 102 practitioners responded to the survey. Their responses imply that colleagues assess and record findings on 18 potential features of upper bowel disease. In practice most referral letters address fewer than six features of upper bowel disease. The mean number of positive features of upper gastrointestinal disease reported in each letter was one. CONCLUSIONS This study reported a failure to meet "peer defined" standards for the content of referral letters set by colleagues in one locality. Referral letters serve many purposes, however, encouraging full documentation of specific clinical findings may serve to increase the pre-referral assessments performed in practice.
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Affiliation(s)
- M Jiwa
- Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Armthorpe Road, Doncaster DN2 5LT, UK.
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Affiliation(s)
- Robert K McKinley
- Clinical Consultation Research and Development Unit, Department of Health Sciences (General Practive and Primary Health Care), University of Leicester, Leicester General Hospital, UK.
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Abstract
OBJECTIVE To develop a valid and reliable questionnaire for measuring patient trust in an emergency department (ED) that can be administered by phone, direct interview, or mail. METHODS This was a survey conducted at a Level 1 urban trauma center with an annual census of 52,000 visits. Literature review, focus group discussions, and direct patient interviews identified potential items for pilot surveys. Fifteen ED nurses, residents, and faculty scored the items on a 1-10 scale, rephrasing or removing ambiguous items to ensure face and content validity. A telephone survey with responses recorded on a five-point Likert scale was conducted. Reliability and internal consistency of items were tested using SPSS software. Factor analyses were performed using principal components analysis and Varimax rotation with Eigen values set at 1.0. RESULTS A total of 383 patients seen in the ED were surveyed. Using two pilot surveys, 18 of 42 potential items were extracted among five factors identified as important to the development of trust. Internal consistency for the final 18 items was calculated, and a Cronbach's alpha of 0.88 was obtained for all items. Test-retest reliability was calculated by telephoning 38 patients twice, two weeks apart, and correlation coefficients of >0.748 were obtained for all items. CONCLUSIONS This questionnaire can be used for telephone or direct interview to survey patients' trust in EDs.
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Affiliation(s)
- John J Kelly
- DO, Department of Emergency Medicine, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141, USA.
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Lwin AM, McKinley RK. Management of COPD in primary care in Leicestershire. Prim Care Respir J 2004; 14:38-41. [PMID: 16701691 PMCID: PMC6743548 DOI: 10.1016/j.pcrj.2004.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2004] [Accepted: 06/18/2004] [Indexed: 10/26/2022]
Abstract
AIM To determine the proportion of general practices in Leicestershire, UK, with the resources to provide high quality COPD care. METHODS A postal survey of all 147 Leicestershire practices with postal and telephone follow up. RESULTS The response rate was 65%. 45 practices (47%) had COPD registers, 44 practices (46%) had COPD protocols and eight practices (8%) had COPD clinics. 52 practices (54%) owned one or more spirometers and 13 (15%) had at least one person with current (within the last two years) approved/formal training in performing spirometry. Four practices (4%) had COPD protocols, registers and clinics and trained operators with current training. DISCUSSION Very few practices have the resources to provide high quality care of COPD in the practice. Maintenance of current approved training for spirometry operators is likely to be a major and continuing barrier to providing such care. This may be best provided at locality level by intermediate care.
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Affiliation(s)
- Aye Ma Lwin
- Division of General Practice and Primary Health Care, Department of Health Sciences, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK
| | - Robert K. McKinley
- Division of General Practice and Primary Health Care, Department of Health Sciences, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK
- Tel.: +44 116 258 4367; fax: +44 116 258 4982. E-mail address:
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McKinley RK, Stokes T, Exley C, Field D. Care of people dying with malignant and cardiorespiratory disease in general practice. Br J Gen Pract 2004; 54:909-13. [PMID: 15588535 PMCID: PMC1326108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND Provision of palliative care for people dying with malignant disease is a well-characterised aspect of general practice workload. The nature of end-of-life care of people with non-malignant disease is less well described. AIM To compare the general practice care provided in the last year of life to people who died with malignant and with cardiorespiratory disease. DESIGN Case record review. SETTING Two Leicestershire general practices: one inner-city, one semi-rural; total practice population 26,000 people. METHOD General practice review of the records of all people registered with the practices who died with malignant or cardiorespiratory disease between 1 August 2000 and 31 July 2002 to determine: cause and place of death, recorded comorbidity, palliative medication prescribed, number of consultations and continuity of care, receipt and duration of palliative care. RESULTS When compared with people who died with cardiorespiratory disease, those who died with malignant disease were more likely to have had a terminal phase of their illness identified and to have been prescribed more palliative drugs. Both groups consulted a similar number of times, experienced similar continuity of care, had similar comorbidity, and were equally likely to die at home. CONCLUSION People who died with cardiorespiratory disease were less likely to be in receipt of formally identified terminal care and were likely to have had fewer drugs prescribed for palliation than people with malignant disease, yet they make similar demands of practices. They are likely to have unmet needs with respect to palliation of symptoms.
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Affiliation(s)
- Robert K McKinley
- Clinical Consultation Research and Development Unit, Department of Health Sciences, University of Leicester, Leicester General Hospital, Leicester.
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Abstract
BACKGROUND The doctor-patient relationship in general practice is often viewed by practitioner and patient alike as a long-term 'personal' relationship. Little, however, is known about how such relationships are ended in general practice. METHODS This paper uses theoretical insights obtained from the sociology and social psychology of social relationships, together with the authors' own empirical work on the removal of patients from GPs' lists, to develop a theoretical model of ending the doctor-patient relationship in general practice. RESULTS Ending the relationship involves 'breakdown' and 'termination'. 'Breakdown' in the relationship occurs when one party decides that the other has acted in such a way as to threaten that party's identity as a 'good' patient or doctor. 'Termination' may be patient initiated, doctor initiated or by mutual consent. CONCLUSIONS It is proposed that further research is needed to delineate the rules and rituals governing entry into and maintenance of the doctor-patient relationship in general practice as well as those that govern its ending.
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Affiliation(s)
- Tim Stokes
- Division of General Practice and Primary Health Care, Department of Health Sciences, University of Leicester, Leicester General Hospital, Leicester LE54PW
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McKinley RK, Fraser RC, Baker RH, Riley RD. The relationship between measures of patient satisfaction and enablement and professional assessments of consultation competence. Med Teach 2004; 26:223-228. [PMID: 15203498 DOI: 10.1080/01421590410001683186] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The authors examined the extent of the relationship between a Consultation satisfaction questionnaire and Patient enablement instrument scores and professionally assessed consultation competence scores of senior medical students. Three analyses were performed: (i) linear regression with mean overall competence score as response variable; (ii) sensitivity and specificity calculations using patient scores to classify competence; (iii) a repeated measures model with consultation-specific competence score as response variable. One hundred and nineteen students and 388 patients took part. Consultation satisfaction and enablement scores were weakly correlated with overall and consultation specific competence scores (correlation coefficient 0.16 to 0.44). 'Satisfaction with professional care' had a sensitivity of 0.68, specificity of 0.72 and positive and negative predictive values of 0.32 and 0.92 respectively. It is concluded that patient and professional assessments may complement, but do not replace, each other. Levels of patient satisfaction should not be used as proxy measures of the quality of consultation competence.
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Affiliation(s)
- R K McKinley
- Department of Health Sciences, University of Leicester, Leicester General Hospital, UK
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Abstract
OBJECTIVE The aim of this study was to understand why GPs choose to end their relationship with patients by removing them from their lists. METHODS Semi-structured interviews were carried out with 25 GPs from 22 general practices in Leicestershire. Qualitative analysis was performed using the constant comparative method. The main outcome measures were participants' accounts of removing patients from their lists. RESULTS GPs use removal as a means of ending their professional relationships with problematic patients. All of the doctors indicated that they wished to retain the right to remove patients and stressed that removal is a rare event which they only use as a "last resort". There are two distinct but overlapping types of patients who are most likely to become eligible for removal: "bad" patients, who break the rules of the doctor-patient or practice-patient relationship, and "difficult" patients, with whom the doctor-patient relationship is so strained that doctors feel they can no longer care for them. The doctors may choose to remove a patient without warning or else to write a short letter giving "relationship breakdown" as the reason. They find it hard to confront the patient openly about the difficulties in the relationship. CONCLUSIONS The ability to remove patients is a right that GPs value. They report that it is rare for them to seek to end their relationships with patients and, when they do, it is for reasons that are important in the maintenance of professional boundaries or fulfilling professional responsibilities.
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Affiliation(s)
- Tim Stokes
- Department of General Practice and Primary Health Care, University of Leicester, Leicester General Hospital, Leicester LE5 4PW, UK.
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Abstract
OBJECTIVE To explore patients' accounts of being removed from a general practitioner's list. DESIGN Qualitative analysis of semistructured interviews. SETTING Patients' homes in Leicestershire. PARTICIPANTS 28 patients who had recently been removed from a general practitioner's list. RESULTS The removed patients gave an account of themselves as having genuine illnesses needing medical care. In putting their case that their removal was unjustified, patients were concerned to show that they were "good" patients who complied with the rules that they understood to govern the doctor-patient relationship: they tried to cope with their illness and follow medical advice, used general practice services "appropriately," were uncomplaining, and were polite with doctors. Removed patients also used their accounts to characterise the removing general practitioner as one who broke the lay rules of the doctor-patient relationship. These "bad" general practitioners were rude, impersonal, uncaring, and clinically incompetent and lied to patients. Patients felt very threatened by being removed from their general practitioner's list; they experienced removal as an attack on their right to be an NHS patient, as deeply distressing, and as stigmatising. CONCLUSIONS Removal is an overwhelmingly negative and distressing experience for patients. Many of the problems encountered by removed patients may be remediable through general practices having an explicit policy on removal and procedures in place to help with "difficult" patients.
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Affiliation(s)
- Tim Stokes
- Department of General Practice and Primary Health Care, University of Leicester, Leicester General Hospital, Leicester LE5 4PW.
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