Psychiatric training for family doctors: what do GP registrars want and can a brief course provide this?

CONTEXT: About 40% of British General Practitioners (GPs) train formally in a psychiatric post as part of their general practice training, but such training may not fully meet the needs of future GPs. A specific course in psychiatry for family doctors has run in Manchester for more than a decade. METHOD: Semi-structured interviews conducted with GP registrars before attending the Manchester course in psychiatry with questionnaire follow-up afterwards to ascertain (a) the training 'wants' of GP registrars and (b) whether the course was providing them. RESULTS: GP registrars most frequently wanted training in communication skills, how to access the resources that are available to GPs, the detection of psychiatric illness, drug treatment and the management of aggression. The course was successful in satisfying the first three but failed in the last two. There was trend for those who attended Manchester Medical School, which scored significantly higher on number of topics covered at undergraduate level, to perceive a greater need for training than those who attended other medical schools. However, there was no evidence to link self-perception of greater need with having already worked in general practice during postgraduate training. CONCLUSIONS: More attention needs to be paid to how to address the specific mental health skills training requirements of GP registrars both within the attachment in psychiatry and during the practice year. Preliminary research is required to devise teaching packages before they are entirely satisfactory for GP education.     

Effective teaching of communication skills for medical practice: selecting an appropriate clinical context

Increasingly, courses in communication skills are being incorporated into medical training. In order for communication skills to be effectively maintained in post-training medical practice, they must be taught within an appropriate clinical context. The present paper describes and provides rationale for seven criteria by which to select clinical issues which are appropriate foci for communication skills courses. The criteria are : (1) the issue must be one which is encountered frequently in clinical practice; (2) the issue must be associated with a high burden of illness; (3) there must be evidence that practitioners need to improve skills for dealing with the issue; (4) there must be an intervention, of which communication skills are an integral component, that is demonstrably effective for dealing with the clinical issue; (5) the intervention must represent a cost-effective means of dealing with the issue; (6) the intervention must be acceptable to doctors and be able to be incorporated into routine medical practice; (7) the intervention must be acceptable to patients. Examples of clinical issues which fit these criteria are given in the paper and include smoking, hazardous alcohol consumption, non-adherence to treatment instructions, overdue cervical screening, inappropriate diet, recovery from medical interventions, and breaking bad news to patients.     

Effect of a short skills training course on competence and performance in general practice

OBJECTIVES: Evaluation of the efficacy of a short course of technical clinical skills to change performance in general practice. DESIGN: Subjects were self-selected general practitioners (n=59) who were unaware of the study design. They were assigned to the intervention group (n=31) or control group (n=28) according to their preference for course date. The course covered four different technical clinical skills (shoulder injection technique, PAP-smear, laboratory examination of vaginal discharge, ophthalmoscopic control in diabetes mellitus). Main outcome measures used were pre- and post-training scores on a knowledge test of skills (60 multiple choice items), and pre- and post-training performance of procedures in practice using a log-diary covering 20 days. SETTING: University of Maastricht, The Netherlands. SUBJECTS: Self-selected general practitioners. RESULTS: Competence, as measured by the knowledge test of skills, improved significantly as a result of the training and skills test scores were satisfactory after training. A significant effect on performance in practice was found for PAP-smear and shoulder injection technique, whereas no effect could be demonstrated for examination of vaginal discharge and ophthalmoscopic control in diabetes mellitus. CONCLUSIONS: A good degree of competence is a necessary but not always sufficient condition for a physician to change his performance in practice. While some skills training seems adequate to bring about desired changes, for other skills more complex interventions are probably needed.     

The clinical and educational experiences of pre-registration house officers in general practice

AIMS: To describe aspects of the clinical experience and educational supervision gained by pre-registration house officers (PRHOs) in general practice, and to relate these to the current General Medical Council (GMC) aims for general clinical training in general practice. DESIGN: Qualitative evaluation, part of which involved semistructured interviews with 12 PRHOs who were experiencing a general practice rotation. Interviews were conducted at the beginning and the end of the pre-registration year, and following return to hospital work after completion of the general practice placement. SETTINGS: Three teaching hospitals, two district general hospitals and six general practices in south-east England. PARTICIPANTS: 12 PRHOs who were involved in rotations incorporating a general practice placement. RESULTS: To varying degrees, the GMC aims for training in general practice were met for all the participants. All PRHOs recognized the value of the clinical experience and educational supervision they received in general practice. They particularly valued aspects such as having an individual training programme based on their own needs, and the interlinking of theory and practice, which aided learning. Most felt that having responsibility for their own patients acted as an important incentive for learning, and in general, PRHOs appreciated having the time to learn which general practice allowed. CONCLUSIONS: For the majority of PRHOs, the time spent in general practice was seen as a positive clinical and educational experience. In a variety of ways, the general practice placement encouraged PRHOs to develop the self-directed learning skills seen as essential to the lifelong learning advocated by the GMC. A number of recommendations are made to help improve the integration of the hospital and general practice components of these rotations.     

Assessing the ability of medical students to apply evidence in practice: the potential of the OSCE

OBJECTIVES: Critical analysis and application of evidence-based practice are key skills for students to master. Assessment of these skills can be undertaken by written examination. Regardless of how knowledge of the appraisal process may be assessed, written examinations ignore assimilation of that evidence into everyday practice. DESIGN: A combined clinical and communication skills station was used in an objective structured clinical examination where the ability to appraise evidence critically was assessed along with the application of that evidence in managing a common clinical problem. SETTING: University of Liverpool. SUBJECTS: Undergraduate medical students. RESULTS: The results from 156 undergraduate medical students demonstrated that it is possible to assess the application of evidence in practice, both in terms of outcome and patient assessment of the encounter. CONCLUSIONS: Assessment is a powerful tool in promoting learning and adoption of such assessment strategies may help to address concerns surrounding apparent poor effect of critical appraisal training.     

The doctor-patient relationship: from undergraduate assumptions to pre-registration reality

OBJECTIVES: To describe the ways in which the doctor-patient relationship experienced by newly qualified pre-registration house officers (PRHOs) differed from their undergraduate expectations. DESIGN: Qualitative study in which in-depth semistructured interviews were carried out with each PRHO within 4-6 weeks of the start of their first job. SETTING: Three teaching hospitals, three district general hospitals and four general practices in south-east England. PARTICIPANTS: 24 newly qualified PRHOs. RESULTS: A number of differences were identified by PRHOs. These were caused in part by the impact of factors such as the shortage of time, which could lead to emotional 'blunting'. Some PRHOs were changing their ideas about what constitutes a 'good' doctor, and were redefining the meaning of a 'professional' relationship. The relationships of PRHOs with patients were also affected by the attitudes of their senior colleagues. For example, where PRHOs tried to maintain a patient-centred relationship, they could be identified by colleagues as working too slowly. PRHOs working in general practice were able to utilize and improve their communication skills with patients, but found it difficult to transfer these skills back into the hospital setting. CONCLUSIONS: Despite receiving substantial undergraduate education on how best to communicate with patients, a variety of factors conspired to prevent hospital-based PRHOs from utilizing this information. Building on these findings, a number of recommendations are made to help improve practice.     

CeMENT: evaluation of a regional development programme integrating hospital and general practice clinical teaching for medical undergraduates. The Community-Based Medical Education in North Thames

OBJECTIVES: To determine the feasibility and effectiveness of shared hospital and general practice clinical teaching for medical undergraduates. DESIGN: A multifaceted approach employing quantitative and qualitative techniques. SETTING: All medical schools in North Thames Region. SUBJECTS: Students, GP tutors and hospital specialists. RESULTS: The model was successfully adopted in a broad range of clinical specialties in all of the participating medical schools, resulting in a doubling of the involvement of general practice in clinical teaching. Participating students provided an overwhelmingly positive evaluation of the attachments and there was a clear perception of benefit amongst the participating GPs. However, the views of the participating hospital clinicians were less positive and the true nature and extent of the educational impact proved difficult to assess. CONCLUSIONS: This model of collaborative clinical teaching between hospital and general practice can be implemented in accordance with the project's key aims, but the enthusiastic involvement of hospital clinicians may be difficult to secure.     

Developing senior doctors as mentors: a form of continuing professional development. Report Of an initiative to develop a network of senior doctors as mentors: 1994-99

BACKGROUND: Senior doctors report that mentoring skills are transferable to everyday medical practice and managing juniors. An analysis of views from consultants and general practitioners, who had trained together on a regional mentoring scheme, reveals significant potential for personal and professional development in such networks. CONTEXT: The Northern and Yorkshire Region Doctors' Development and Mentoring Network was set up in 1994. Since then there have been six programmes with 116 senior doctors participating. In 1997 there was an evaluation of the first four programmes. METHOD: Focus groups and postal questionnaire. RESULTS: There were responses from 71 senior doctors, giving a response rate of 86%, and responses from 78 professional stakeholders in 49 NHS organizations, a response rate of 54%. Results indicate that the programmes were highly valued by the participants, particularly with regard to: being part of a network of senior doctors; developing mentoring skills, and engaging in personal and professional development. The most difficult part of the programme was setting up mentoring networks for junior doctors, and reasons included: personal factors, such as levels of confidence in providing mentoring; cultural factors, such as juniors not wishing to be seen to need help, and organizational factors, such as lack of time allocated for mentoring. RECOMMENDATIONS AND ISSUES FOR FURTHER DEBATE: The positive benefits from the scheme raise questions about how to develop mentoring training for senior doctors. Issues include: developing mentors; who needs mentoring; mentoring and the organization; transferability of mentoring skills, and widening the network.     

Teaching clinically experienced physicians communication skills. A review of evaluation studies

CONTEXT: Interest in the teaching of communication skills in medical schools has increased since the early seventies but, despite this growing interest, relatively limited curricular time is spent on the teaching of communication skills. The limited attention to the teaching of these skills applies even more to the physicians' clinical years, when attention becomes highly focused on biomedical and technical competence. Continuing training after medical school is necessary to refresh knowledge and skills, to prohibit decline of performance and to establish further improvements. OBJECTIVE: This review provides an overview of evaluation studies of communication skills training programmes for clinically experienced physicians who have finished their undergraduate medical education. The review focuses on the training objectives, the applied educational methods, the evaluation methodology and instruments, and training results. METHODS: CD-ROM searches were performed on MedLine and Psychlit, with a focus on effect-studies dating from 1985. RESULTS: Fifteen papers on 14 evaluation studies were located. There appears to be some consistency in the aims and methods of the training programmes. Course effect measurements include physician self-ratings, independent behavioural observations and patient outcomes. Most of the studies used inadequate research designs. Overall, positive training effects on the physicians' communication behaviour are found on half or less of the observed behaviours. Studies with the most adequate designs report the fewest positive training effects. CONCLUSION: Several reasons are discussed to explain the limited findings. Future research may benefit from research methods which focus on factors that inhibit and facilitate the physicians' implementation of skills into actual behaviours in daily practice.     

Impact of patient feedback on the interpersonal skills of general practice registrars: results of a longitudinal study

CONTEXT: A general practice vocational training program. OBJECTIVES: To examine the impacts and implications of different models of systematic patient feedback on the development of general practice (GP) registrars' interpersonal skills as they progressed through a GP vocational training program. DESIGN: A longitudinal study in which GP registrars were randomly assigned to three models of patient feedback: a control group and two intervention groups. The major source of data gathering was through the Doctors' Interpersonal Skills Questionnaire (DISQ) which was administered to patients immediately after their consultation. SUBJECTS: 210 GP registrars, 104 GP supervisors and 28 156 patients. RESULTS: Multivariate analysis techniques (including repeated-measures analysis) tested the effectiveness of the interventions. Findings showed that systematic patient feedback at regular intervals throughout GP training resulted in sustained levels of interpersonal skills. The most significant gains in interpersonal skills for both intervention groups occurred in the earlier stages of general practice training. Most registrars found the experience of patient feedback useful for gaining a better understanding of their interpersonal skills and for identifying areas in which they needed to improve. GP supervisors valued the opportunity to receive patient feedback themselves and found the activity a useful adjunct to their preceptor role. CONCLUSIONS: Patients, by providing feedback on doctors' interpersonal skills, have been able to contribute to improving the quality of the patient-doctor interaction. GP registrars and their supervisors value highly the role of patient feedback in interpersonal skill development.     

Acquisition of communication skills in postgraduate training for general practice

PURPOSE: The evidence suggests that a longitudinal training of communication skills embedded in a rich clinical context is most effective. In this study we evaluated the acquisition of communication skills under such conditions. METHODS: In a longitudinal design the communication skills of a randomly selected sample of 25 trainees of a three-year postgraduate training programme for general practice were assessed at the start and at the end of training. Eight videotaped real life consultations were rated per measurement and per trainee, using the MAAS-Global scoring list. The results were compared with each other and with those of a reference group of 94 experienced GPs. RESULTS: The mean score of the MAAS-Global was slightly increased at the end of training (2.4) compared with the start (2.2). No significant difference was found between the final results of the trainees and the reference group. According to the criteria of the rating scale the performance of both trainees and GPs was unsatisfactory. CONCLUSION: The results of this study indicate that communication skills do not improve in a three-year postgraduate training comprising both a rich clinical context and a longitudinal training of communication skills, and that an unsatisfactory level still exists at the end of training. Moreover, GPs do not acquire communication skills during independent practice as they perform comparably to the trainees. Further research into the measurement of communication skills, the teaching procedures, the role of the GP-trainer as a model and the influence of rotations through hospitals and the like, is required.     

Teaching the teachers — a needs assessment of tutors for a new clinical skills course

There is an increasing trend in undergraduate education towards teaching clinical skills from a community base. A new clinical curriculum was introduced in Newcastle upon Tyne in 1995, beginning with an integrated clinical skills course. Although the attitudes and views of general practitioners (GPs) towards community-based clinical teaching have previously been reported, their perceived training needs have not been formally identified. The aims of this study were to identify the competencies needed by GPs for community-based clinical skills teaching, to compare and contrast these needs with their hospital colleagues, and to use the results to develop a teaching programme for the clinical tutors involved in the new course. In order of priority, the GPs and hospital tutors expressed similar needs: small-group teaching skills, assessing student needs, giving effective feedback and assessment of student performance, with a preference for the teaching to be organized within local teaching units. Most GPs and hospital tutors (73 and 69%, respectively) requested a distance-learning pack to complement the teaching. General practitioners rated resources for improving their individual clinical skills more highly than their hospital colleagues: for example, videotapes demonstrating examination techniques. Forty-six per cent of GP tutors had received some formal training in teaching methods compared to 29% of hospital tutors. The implications of the results for developing a 'Teaching the Teachers' course for clinical tutors are discussed.     

How do clinicians learn to request permission for autopsies?

A postal survey of 434 clinicians at four local hospitals was undertaken in order to identify the methods by which clinicians learn how to request permission for hospital autopsies and to assess the preferred techniques and timing of relevant communication skills training. The majority of 128 responding clinicians had learnt through personal experience with some assistance from senior colleagues and peers. Few clinicians appeared to have learnt through formal training. The preferred methods for the provision of communication skills training were training in small groups (such as seminars or tutorials) and observation of clinicians at work. The most desirable time for the provision of this training was considered to be between the beginning of the final undergraduate year and the end of the pre-registration house officer year. The communication skills training provided within medical education is in need of improvement. More emphasis should be given to clinical-task- or situation-specific applications such as requesting permission for autopsies.     

Developing a new line of patter: can doctors change their consultations for sore throat?

BACKGROUND AND OBJECTIVES: Doctors report pressure from peers to reduce prescribing of antibiotics for minor respiratory illnesses, and from patients to do the opposite. It has been suggested that doctors adopt a more patient-centred consulting style in order to encourage patient satisfaction and shared decision-making. No evidence exists that such changes are achievable. We developed a new, on-site method for training postgraduates and used this for teaching patient-centred intervention. Here, we examine whether this training method is associated with changes in consulting patterns in consultations for sore throat with children, among doctors from a single group practice. METHODS: Audiotaped consultations (simulated and real) conducted before and after training were analysed and interviews were carried out with participants about the impact of training. SETTING: A general practice in South Wales. PARTICIPANTS: Four general practitioners who consulted with 25 real and simulated patients participated in the study. MAIN OUTCOME MEASURES: Four patient-centred skills used by doctors and 2 patient behaviours measured before and after training were identified. RESULTS: Three out of 4 practitioners produced clear evidence of changes in patient-centred consulting skills. These changes were evident in simulated and real consultations 2 and 4 weeks later, respectively. Prior to training the doctors produced only five examples of patient-centred skills in 10 consultations. After training they produced 39 examples in 15 consultations. CONCLUSIONS: Evidence from both consultations and interviews indicated that the intervention and training were well received and had been put into practice.     

Single-handed practices – their contribution to an undergraduate teaching network in the first year of the new curriculum

OBJECTIVES: The new curriculum at King's College School of Medicine and Dentistry, which commenced in September 1996, requires all medical undergraduates to have a general practice placement throughout the 5 years of their medical education. DESIGN: This paper discusses recruitment, training and support of teaching practices for the new curriculum, reviews the distribution of single-handed general practices in the network and, via a selection of monitoring and evaluation procedures, discusses the implications of a policy which is inclusive of single-handed practices. The findings relate to the experience of the first semester of the first year of the new curriculum. It also examines the contributions that single-handed practices have made to the teaching network and the kind of support needed, if single-handed practices are to continue to contribute to the King's teaching network. SETTING: King's College School of Medicine and Dentistry. SUBJECTS: Medical undergraduates. RESULTS: The findings of this paper revealed that over a third of general practice provision is via single-handed practices in South-east London. Within the undergraduate teaching network, 10% of practices are single-handed. Students are welcomed and receive a learning experience comparable to those students in larger practices. Attendance at training events has proved difficult for some of these tutors, but the extra input from the department, in order to address this deficit, has not been onerous. Indeed, single-handed practices have not been unique with regard to difficulties in attendance at training events. CONCLUSIONS: The study concludes that single-handed practices can make satisfactory provision for undergraduates in the new curriculum and there is no evidence from this study to suggest otherwise.     

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.     

The Open University pack on coronary heart disease: reactions of Welsh general practitioners

The introduction of the new Open University distance learning pack on coronary heart disease to a selected group of Welsh general practitioners has been evaluated. The most commonly perceived disadvantages were the amount of time required to study the pack, the cost of buying it and the work involved in implementing its study in a practice by the whole primary-care team. Despite a relatively high level of awareness among the group, only 17% declared a positive intention to introduce the pack and another 17% thought they 'probably' would. Contact with primary care facilitators and informal feedback from colleagues appeared to distinguish those general practitioners who were motivated to try innovative postgraduate learning methods in their practices from the rest of the sample. The implications of trying to disseminate novel kinds of teaching material to general practitioners are considered.     

" 'Just think of TB and Asians', that's all I ever hear": medical learners' views about training to work in an ethnically diverse society

The case for being able to respond effectively to cultural and ethnic diversity in health care is attracting increasing debate in medical education. However research exploring the perspectives of learners is lacking. AIMS: We sought medical learners' perceptions and their perceived training needs in relation to cultural and ethnic diversity in health care. METHODS: A series of nine focus group interviews was conducted with 55 medical learners, including undergraduate students in a UK medical school and a group of postgraduate general practitioners in training. Interview data were analysed using qualitative methods. RESULTS: Participants had a broad but superficial awareness of multicultural issues. This focused upon "difference" with students emphasizing their need to acquire knowledge of different beliefs and practices. Current teaching was perceived as inadequate and limited largely to ethnic patterns of disease. Most felt a need for greater training. They regarded development of particular communication skills, such as working with interpreters as helpful. Beyond avoiding stereotyping, learners rarely identified reflecting upon their attitudes or the issue of racism as important. Students anticipated a range of potential problems for further training, but sought learning that was relevant, practically oriented and stimulating. CONCLUSIONS: The study points to learners' experience of inadequate training but suggests a willingness to learn more. The possible predominance of a "difference" perspective might drive a narrow focus upon learning cultural knowledge at the expense of promoting a balance with self-reflection upon attitudes and developing generic skills. Educators might heed learners' views about how they should be taught successfully.     

Journeys and pathways: exploring the role of professional development advice and educational guidance for practitioners expressing interest in research

BACKGROUND: Recent policy reports highlight the need to increase the number of primary care practitioners with academic experience, research skills and higher level qualifications. Various courses, training schemes and awards are available but it is not clear what advice and support might best assist practitioners to access and successfully pursue such opportunities. AIM: To understand and document the professional development support needs of primary care practitioners who wish to develop their own paths forward in research. METHOD: A research adviser based in the Unit of General Practice, University of Cambridge invited enquiries on any aspect of research activity from practitioners. Summaries of contacts, enquiries and other relevant issues were prepared on a monthly basis. Through the process of offering help and through reflexive engagement with the summaries we sought to understand and document practitioner support needs. FINDINGS: Many enquiries from practitioners concerned professional development. Practitioners requested help before embarking on a new course of action and during the course of their progress along a chosen track. The advice required went beyond the provision of information about the opportunities which existed and often evolved into a mentoring relationship. The impact of the advice offered can be viewed in terms of contribution to the journey of the individual practitioner and contribution to nationally recognized strategic aims. CONCLUSION: The need for professional development advice and educational guidance for those interested in research may be more widespread than appreciated. If this need is to be successfully addressed we should consider the skills and expertise required of advisers and the specific outcomes to be anticipated from their roles.