Improving communication: a practical programme for teaching trainees about communication issues in the general practice consultation

This paper describes a teaching programme, for use in general practice vocational training, which provides a theoretical and practical framework for exploring key aspects of the consultation with trainees. A particular emphasis is on the educational or 'cognitive' outcomes of the consultation and skills for improving them. The five stages of the programme are described and an example of experience of each stage is given. The paper concludes with an evaluation of the programme by the trainers, trainees and social scientist involved.     

Audit: trainers' and trainees' attitudes and experiences

Little is known about the audit activity taking place among general practitioners as part of their vocational training. All 155 trainers and their trainees in the West of Scotland were asked about their attitudes to and their experiences of audit. Two hundred and thirty-five replies were received from 310 questionnaires sent, giving an 85% response from trainers and 67% from trainees. Both trainers and trainees had positive attitudes to audit with regard to its use: for assessing work (87% of trainers, 97% trainees); as an appropriate use of resources (92% of trainers, 78% of trainees); as an appropriate use of time (91% trainers, 76% trainees); in improving patient care (96% of trainers, 76% of trainees). Most trainers (90%) and 52% of trainees had started collecting data with a view to starting an audit, 56% of trainers and 23% of trainees had personally set a standard and 54% of trainers but only 12% of trainees had completed a cycle of audit. Despite very positive attitudes to audit there is a problem completing a cycle of audit, particularly among trainees. They will thus be denied the benefit of negotiating and evaluating change as part of their training, skills which will be necessary to ensure a lifelong awareness of the quality of care they are providing.     

Educational assessment of general practice experience for psychiatric trainees

Eighteen psychiatric trainees spent 6 months each as general practice trainees. The educational impact of the experience was assessed by a self-assessment questionnaire, a semi-structured interview and a videotaped interview with a psychiatric patient. Each assessment was conducted at baseline and after 12 months. A control group of 14 trainees was recruited from the same rotation. On the self-assessment questionnaire, the study registrars rated their abilities to solve general medical problems significantly improved compared to controls. They had also acquired greater understanding of the limitations of their knowledge and their legal responsibilities towards their patients. The semi-structured interview failed to distinguish between the two groups. Videotapes for rating at baseline and follow-up were available for only 17 of the trainees. Assessment of the tapes used the Maguire Scale and the Interview Behaviour Scale. Neither scale demonstrated any intervention effect. The interviews were all characterized by a preponderance of 'closed psychological' and 'checking-out' questions. It appears that psychiatric trainees' interviewing styles had not been influenced by the experience. This study suggests that psychiatric trainees gain greater confidence in their role as a doctor and greater understanding of the scope and nature of general practice by such an attachment. It is unclear whether or not supplementary interviewing skills had been acquired which were not utilized in the taped interview, which conforms very much to traditional psychiatric examination behaviour. Trainees were reassured that they had increased their knowledge without losing any of their specific professional skills.     

Improving the psychiatric skills of established general practitioners: evaluation of group teaching

Ten established general practitioners, eight of whom were also trainers, took part in a course designed to improve their psychiatric interviewing skills. Participants were instructed in the problem-based model with audiotape and videotape feedback of real consultations in a group setting. Although those attending were experienced practitioners with a particular interest in the management of psychological problems, evaluation demonstrated a significant improvement in their skills after training. It is suggested that trainers could be trained to provide a similar teaching experience for their own trainees.     

Recent changes in the workload and clinical experience of pre-registration house officers: experiences over four years in south-west England

We aimed to measure changes in the training and workload of pre-registration house officers using a postal questionnaire. Two hundred and six pre-registration house officers in the south-western region of England were surveyed and asked to report on the education, training and workload of their posts. Results were compared with a survey conducted four years earlier. Since the previous survey, the number of hours on duty had reduced from a median of 80 h week-1 in 1992/3 to 72 h week-1 in 1996/7 (P < 0.0001). There were no statistically significant changes in the number of patients admitted or clerked in an average week, but house officers' clinical experience had fallen. All but five of 26 marker conditions showed a decline, which was statistically significant in seven cases. House officers were keener to include four months of general practice in the pre-registration year and were less adverse to extending the pre-registration year to two years. The reduction in hours of work for house officers has been accompanied by a decline in their clinical exposure to common medical and surgical emergencies. The long-term effects of these changes are unknown.     

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

OBJECTIVES: These were: to describe the implementation of a scheme to extend the general practice registrar component of vocational training to 18 months in Scotland; to determine the effect of the additional attachment on registrars' confidence and skill deficits, and compare changes in these parameters with a control group of registrars who did not extend their training, and to determine whether trainers required a different training style for experienced registrars. SUBJECTS: 35 registrars extending their training, their trainers, and 39 controls who did not extend their training. SETTING: Scottish training practices. METHODS: Pre-attachment and post-attachment questionnaires for registrars, triangulated by semistructured telephone interviews, and post-attachment questionnaires for trainers. RESULTS: Extended attachments were popular with registrars and with trainers, who felt they should be a normal part of training. Registrars with extended training declared themselves to have increased in confidence and addressed skill deficits better than controls. Projects completed were assessed as being of high quality. Trainers found 10% of registrars to have a remediable, important deficit in their skills. CONCLUSION: Extended attachments appear to improve registrar confidence and to address knowledge deficits. However, only a minority of registrars had important remediable knowledge deficits and while such attachments may be desirable they may not be essential for most registrars. Overall the outcome appears to have been positive, and supports those who have argued for a change in the proportion of time spent in general practice training, but the scheme is expensive and it is difficult to set a value on what has been gained. Future schemes should have clear training objectives and be tailored towards these.     

Audit and summative assessment: two years' pilot experience

An audit project has been submitted by all trainees in the West of Scotland since 1992 as part of a pilot process for summative assessment. The impact of 2 consecutive years of audit was assessed on 117 trainees in May 1994. A response rate of 89% was achieved. For 82 trainees (79%) this was their first practical experience of audit and as a result of it 85% felt more confident in introducing change to their next practice. Protected time was still a problem for the majority (53%) and one-third wanted more help from their trainer. Thirty trainees (29%) had attended four or fewer formal practice meetings in their 10 months of training, with 10% never having attended one. The previous trainee's audit project was rarely or never discussed with 70 trainees (87%) and only 12 trainees were evaluating changes recommended. An audit project as part of summative assessment may be encouraging trainees to think about change after they leave their training practices. Few, however, are evaluating change and protected time and support are still required. The marking of the summative assessment audit project may need to address this.     

Consulting skills training and medical students' interviewing efficiency

In more traditional medical education, medical students took a patient's medical history by asking a series of sequenced, routine questions, covering presenting medical problem(s); medical history; social and personal history; systems review; and physical examination. Following this process, the student then attempted to derive the patient's medical problems. This inductive problem-solving paradigm may not assist students to prepare for their future interviewing needs, given doctors use a hypothetico-deductive, problem-solving approach when interviewing patients and numerous researchers have developed specialized communication skills training programmes designed to enhance students' interviewing skills. Students given specific consulting skills training have tended to show significantly greater interpersonal effectiveness and improved interview behaviours compared with students who experience traditional patient clerking training. These improvements in interviewing tend to persist over the period of students' medical training. The aim of the present study was to determine whether specialized communication skills training helped students elicit greater quantity and quality of information from patients and if so, whether such information assisted students in improving their diagnostic skills. Videotaped history-taking interviews conducted by students trained in communication skills and untrained (control) students were rated for their interview efficiency. A comparison of ratings given by experimentally naive, independent observers revealed that trained students were more efficient, but took no longer than their control group counterparts to elicit fuller, more relevant information. However, the student groups did not differ in the accuracy or scope of their medical diagnoses. It is argued that students' lack of medical knowledge in this early phase of their clinical training militated against their being able to use their interviewing competence to derive more potentially accurate medical diagnoses.     

Developing an education and assessment framework for the Foundation Programme

AIM: To develop an education and assessment framework for the second year of the Foundation Programme (F2). METHODS: A total of 23 PRHOs were recruited to the F2 pilot in August 2003. The training posts included a variety of specialties at 2 hospital trusts plus primary care. Trainee expectations and satisfaction were evaluated using questionnaires administered before and at the end of the pilot. At the end of the pilot, 10 trainees participated in a focus group and 19 trainers participated in a semistructured telephone interview. RESULTS: The majority of trainees (78%) felt that their expectations of the F2 pilot were met and all felt that they had improved their generic skills. Attendance at the generic education programme was 95%. The majority of trainees found the assessment framework useful. The percentage of undecided trainees in terms of career aspirations dropped from 48% to 13%. Trainees valued the breadth of experience provide by the year and the support provided by the programme directors and each other. A need for better communication, administrative support and time for assessment was highlighted by the trainers. CONCLUSIONS: Early, focused education on generic skills will benefit both doctors and their patients. More varied career experience will help to ensure that doctors make appropriate and timely career decisions. Pilots are identifying good practice and areas that need improvement.     

Professionalism in general practice: development of an instrument to assess professional behaviour in general practitioner trainees

INTRODUCTION: The aim of this study is to develop a new tool to assess professional behaviour in general practitioner (GP) trainees: the evaluation of professional behaviour in general practice (EPRO-GP) instrument. METHODS: Our study consisted of 4 phases: (1) development of a model of professionalism in general practice based on a literature review on professionalism, competency models of general practice and the overall educational objectives of postgraduate training for general practice; (2) development of the EPRO-GP instrument in collaboration with a sounding board; (3) establishing the content validity of the EPRO-GP instrument using a nominal group technique; and (4) establishing the feasibility of the EPRO-GP instrument in 12 general practice trainees and their general practice trainers. RESULTS: The model of professionalism in general practice encompassed 4 themes within professionalism: (a) professionalism towards the patient; (b) professionalism towards other professionals; (c) professionalism towards the public; and (d) professionalism towards oneself. These 4 themes covered 26 elements of professionalism. This model provided the framework of the EPRO-GP instrument, which we developed further by operationalising the 26 elements in 127 behavioural items. The expert ratings confirmed the content validity of the instrument with one exception: the element "altruism" was removed as a stand-alone category but it remained throughout the tool in items giving primacy to patient welfare. The results on the feasibility of the EPRO-GP instrument were very encouraging. All tutorials yielded professional behaviour learning points. DISCUSSION: Our results support the content validity of the EPRO-GP instrument as well as its feasibility as a tool to educate for professionalism in general practice.     

Peer-assisted learning: a novel approach to clinical skills learning for medical students

OBJECTIVE: This study aimed to determine whether peer-assisted learning (PAL) can enhance clinical examination skills training. METHODS: Three student trainers studied small-group theory and clinical examination and provided PAL as extra tuition for 86 trainees. Trainees watched an examination video, were videotaped practising the examination and, after constructive feedback, repeated the examination. Responses to PAL were evaluated to attain an overview of trainee and trainer performance using visual analogue and Likert scale analyses. Year-group review was undertaken using questionnaires. RESULTS: Trainees evaluated all aspects of PAL highly, including their post-training confidence in examination skills (mean > 7.7 on a 10-cm scale), indicating that the PAL was effective. Written comments confirmed the students perceived the sessions as well structured and of high quality. Compared with trainees in the first groups, those from later groups gave all parameters similar or higher gradings. Those for interest (P = 0.03) and appropriateness (P = 0.01) were significantly higher, suggesting that trainers may improve their technique with time. Students with previous degrees gave similar or lower gradings than standard entry students, with answers about post-training confidence and recommendation to friends being statistically lower (P < 0.006). Six months later, year-group analysis showed that 90% of trainees rated PAL highly, and 86% wished to become trainers. Of the trainers' year group, 79% perceived that PAL training could improve examination skills. CONCLUSIONS: In the context of clinical skills training, PAL was highly evaluated across many parameters, including confidence after training. Student interest and enthusiasm supports suggestions that PAL could be a useful adjunct to clinical skills training.     

Preferred antibiotics,dosages and length of treatments in general practice: A comparison between ten European countries

This paper describes the learning experience when pairs of UK trainers and their GP registrars (trainees) cooperated in running a general practice trainers' workshop in Jutland, Denmark.     

Quality assessment in general practice trainers

INTRODUCTION: General practice trainers hold a key position in general practice training, especially through their provision of a role model. Their own competence in general practice care is important in this regard. The purpose of the study was to evaluate whether a quality assessment programme could identify the strengths and weaknesses of GP trainers in four main domains of general practice care. METHODS: The quality assessment programme comprised validated tests on four domains of general practice: general medical knowledge, knowledge of medical-technical skills, consultation skills and practice management. The criterion for the identification of relative strengths and weaknesses of GP trainers was a variation in the scores of trainers indicating higher and lower scores (strengths and weaknesses) within each domain. RESULTS: GP trainers (n=105) were invited to participate in the study and 90% (n=94) did so. The variation in scores allowed the indication of strengths and weaknesses. Main strengths were: general medical knowledge of the digestive system; knowledge of medical skills relating to the skin; consultation skills concerning empathy; practice management with regard to accessibility. Main weaknesses were: general medical knowledge of the neurological system; knowledge of the medical/technical skills relating to the endocrine metabolic and nutritional system; consultation skills regarding shared decision making; practice management involving cooperation with staff and other care providers. DISCUSSION: This first systematic evaluation of GP trainers identified their strengths and weaknesses. The weaknesses identified will be used in the improvement process as topics for collective improvement in the GP trainers' general curriculum and in individual learning plans.     

Pelvic manikins as learning aids

The use of pelvic trainers in undergraduate teaching was evaluated, using a questionnaire based on examination findings of a series of four pelvic trainers by 20 medical students and 34 gynaecologists. The main outcome measures were the ability to correctly identify pelvic findings in the trainers, and the numbers of false positive findings. There were two adnexal masses in two of the trainers. One was correctly identified by 33 (14 (70%) medical students and 19 (56%) doctors) in one trainer, whereas the other was missed by 52 of 54 examiners. Prolapse was missed by 41 of 54. The normal pelvis was correctly identified by 30 (16 (80%) medical students and 20 (59%) doctors. There were 15 false positive identifications of adnexal masses (6 by medical students and 9 by doctors) and 22 false positive identification of uterine enlargements (5 by medical students and 17 by doctors). The pelvic trainers were of value in demonstrating the process of pelvic and speculum examination. Some of the clinical conditions emulated were missed by most of the gynaecologists, suggesting that they were not suitable for training students in abnormal findings. Although the figures were not statistically significant, there was a trend for qualified doctors rather than medical students to make false positive findings.     

Teaching consultation skills: a survey of general practice trainers

BACKGROUND: Consultation skills are vitally important in general practice (GP), and now form part of the summative assessment of GP registrars in the UK. GP trainers need to be skilled in teaching consultation skills, and also need the time and resources to ensure that their registrars are competent in consultation skills. AIMS: To describe the teaching methods used by GP trainers in one deanery, the frequency of teaching of consultation skills, the problems encountered and the training that GP trainers have themselves received both in consultation skills and how to teach them. METHOD: Postal questionnaire survey of all the 164 trainers in the Yorkshire Deanery. RESULTS: Replies were received from 129 trainers (response rate 79%) of which 123 could be analysed. Of these trainers, 45 (37%) trainers taught consultation skills fewer than five times a year, 45 (37%) five to 10 times, and 14 (11%) more than 10 times a year. A total of 24 trainers reported problems with teaching consultation skills, most commonly lack of time, technical difficulties, and unreceptive registrars, and 97 (79%) trainers had had some postgraduate training in consultation skills with 112 (91%) reporting some form of teacher training. CONCLUSION: There is considerable variation in the reported frequency of teaching consultation skills, the models used, and the preparation of trainers for teaching, despite a systematic approach to teacher training in the Yorkshire Deanery.     

Portfolio learning in general practice vocational training – does it work?

Reflective learning has been widely addressed as an important learning mechanism in the educational literature. The creation of portfolios has been seen as a mechanism to promote this, though there has been little exploration of the place of a portfolio in general practice training. This study examined the introduction of a model of a portfolio learning strategy into one training region. The model had been developed by previous pilot work. The study explored the model in terms of its usefulness in general practice training and its relationship to reflective learning. An educational facilitator was used to support this introduction. Workshops and written material were developed to disseminate and refine ideas generated in the pilot study. This was followed by visits to trainer/general practice registrar (GPR) pairs over a 2-year period. These visits included semistructured interviews, which were tape-recorded and analysed using qualitative methods. Additional written resources, video and audio material as well as new workshops were designed with the researched participants in order to promote the development of the concepts of portfolio learning. Sixty interviews were carried out over a 2-year period with 44 pairs of trainers and GPRs. This included a total of 27 trainers and 44 registrars. Eighteen pairs were interviewed twice. Two focus groups were used at the end of the project. Portfolios have a place to play in general practice vocational training. They act as a bridge between hospital and general practice. They can be used to develop a learner-centred curriculum, explore difficult emotive concerns and facilitate feedback. They do not suit all learning styles. Their use is determined by a cost–benefit analysis described in this study.     

Training in assessment and appraisal: who needs it?

The aim of this project was to develop a training programme to help consultants supervising postgraduate medical trainees to fulfil their role as Educational Supervisors. A training needs analysis was conducted which revealed that consultants did not appreciate the importance of some of their new duties. This was mainly because of the lack of clear perception of their new roles. Hence training needs to be provided.