Continuing professional development of occupational medicine practitioners: a needs assessment

OBJECTIVE: The aim of this study was to identify elements of occupational medicine practice used on a frequent basis which are considered to be of high priority for continuing professional development (CPD). METHODS: A postal questionnaire covering 28 areas of knowledge or practice was sent to all members of the Society of Occupational Medicine in September 2000. Respondents were asked to allocate scores to the 28 items for both CPD priority and frequency of use. RESULTS: The return rate for questionnaires was 29.5%. There was reasonable agreement between frequency of use and CPD priority ratings for the elements covered in the questionnaire. CONCLUSIONS: Despite the low return rate for questionnaires, this survey has helped identify themes which are important to physicians practising occupational medicine and has also highlighted those which are less important for inclusion in a CPD programme. Some differences in responses were identified between accredited specialists, specialist registrars and non-specialist practitioners of occupational medicine. The findings from this survey should be useful to providers of continuing medical education in planning courses, study days and electronic or distance learning educational packages.     

Occupational health in general practice in an industrial area of Singapore

The aim of this study was to estimate the caseload with regard to the proportion of work-related medical cases in factory workers and to survey knowledge of and attitudes to occupational medicine among doctors in an industrial area in Singapore. To this end, a self-administered questionnaire was given to 74 general practitioners in the industrial district of Jurong in Singapore. Overall, there was an 89.2% response rate. Thirty-three of the 66 respondents were males. Mean age was 40.8 years (range 27-64 years). Twenty-four (36%) had some postgraduate training in occupational medicine (GP-OM) while the rest did not (GP). The caseload for all doctors was similar with regard to the number of adult patients and, more specifically, the number of factory workers seen per day. The majority of doctors (76.6%) felt that <10% of factory workers seen had work-related problems. Most (70%) felt confident in dealing with the occupational problems that arose. However, a large percentage (78% of GPs, 45.8% of GP-OMs) felt that training in occupational medicine was inadequate. This is reflected in the knowledge questions, where GPs did not score as well as GP-OMs. It was concluded that GPs working in this industrial area see a good proportion of factory workers, in a fair number of cases for work-related problems. However, only a third of the GPs are qualified in occupational medicine. These factors highlight the need for more emphasis on occupational medicine training among general practitioners, especially those working in industrial areas.     

Medical students and congenital colour vision deficiency: unnoticed problems and the case for screening.

The results are given of a questionnaire study to determine the range of difficulties that doctors notice in their work due to congenital colour vision deficiency (CCVD). The study is primarily qualitative. A questionnaire was sent to 40 self-selected doctors, 35 of whom were general practitioners (GPs). All were administered a number of colour vision tests to assess the type and severity of their deficiency. Many difficulties and some ways of overcoming them were reported. Those with a mild deficiency reported fewer difficulties and this relationship was significant. Twenty-three of the doctors also reported difficulties as medical students and their answers are given verbatim. The results are discussed in relation to other studies and data on colour vision. The reasons for and against screening medical students for this deficiency are considered and it is concluded that there is a strong case for screening.     

A comparison of the attitudes shown by general practitioners, hospital doctors and medical students towards alternative medicine.

The aim of this study was to compare and contrast the views of general practitioners (GPs), hospital doctors and medical students to alternative medicine. A questionnaire was sent to a random sample of 100 GPs and 100 hospital doctors in the South West Thames Regional Health Authority (SWTRHA). A convenience sample of 237 pre-clinical medical students at St George's Hospital Medical School was also given a questionnaire. Eighty-seven GPs and 81 hospital doctors replied. Five therapies were investigated: acupuncture; chiropractice; homeopathy; naturopathy; and osteopathy. All respondents were asked about their attitude towards and knowledge of these therapies. Doctors were asked how often they referred patients for such treatment and whether they practised it themselves. GPs and hospital doctors had similar levels of knowledge of the therapies. Medical students were the least informed but the most enthusiastic respondents. Seventy per cent of hospital doctors and 93% of GPs had, on at least one occasion, suggested a referral for alternative treatment. GPs were making these referrals more frequently and earlier. Twelve per cent of hospital doctors and 20% of GPs were practising alternative medicine. The majority of the respondents felt that alternative medicine should be available on the National Health Service (NHS) and that medical students should receive some tuition about alternative therapies. A considerable proportion of those doctors referring patients to alternative practitioners were ignorant of their official qualifications.     

Communication between an occupational physician and other medical practitioners--an audit

Four hundred and seventy-two consecutive referral episodes relatingto 386 patients attending the Occupational Health Departmentof a general teaching hospital were analyzed to evaluate thefrequency, content and effect on management of communicationsbetween the occupational physician and other doctors. In all,250 episodes (53%) were associated with such a communication.The likelihood of a communication was strongly influenced byreason for referral, particularly in respect of long or shortterm sickness absence; univariate odds ratios (OR)=10.58, 95%Cl=8.13–27.08) and 2.65, 95% Cl=1.55–4.60) respectively;a medical diagnosis of psychiatric illness (OR=3.17, 95% Cl=1.69–5.97));and by number of consultations. Communication was also morelikely when the occupational outcome was ill health retirement,rehabilitation in work or modified work. Ninety-eight per centof specific requests for information or an opinion eliciteda reply. Information received from other doctors influencedthe occupational health physician's management in 52 referralepisodes (20%). Specific action by GPs as a result of communicationwas documented in 54 and by specialists in 37 episodes. Theimportance of communication between occupational health physicianand other doctors in the occupational health process is confirmed.     

A new comprehensive model for Continuous Professional Development

Background: It is generally agreed that continuing professional development (CPD) for GPs is important for quality of care. Internationally, however, different approaches to identify the learning objectives and the CPD content have been chosen.

Objectives: To improve GPs’ CPD in Denmark we explore how general practitioners’ (GPs) self-experienced learning needs can be combined with learning needs experienced from a societal perspective and still make sense for GPs.

Methods: We performed a multi-dimensional learning needs analysis with a modified Delphi method in a participatory action research set-up. Twenty practice-based small learning groups and a group appointed by the Danish public health service were asked to identify learning needs with the Danish family medicine curriculum as reference. Then we asked a group of GP researchers and hospital consultants, a group of GPs with interests in narrative, person-centred medicine and a group of GP educators, and administrative staff, to triangulate the initial findings.

Results: We identified educational themes through a defined collaborative consensus oriented process. Examples of themes are the diagnostic challenge, care for patients with multi-morbidity, elderly patients and children. Due to variation in requested learning objectives, the identified themes do not cover all relevant areas for CPD training. The identified themes will only make sense if seen as supplementary to other CPD activities based on GPs individual needs analyses.

Conclusion: It is possible to identify prioritized educational themes for GPs through a process involving the majority of stakeholders. Nevertheless, CPD should also include activities based on individual needs analysis.

KEY MESSAGES

• When developing a continuing professional development programme for GPs, educational themes can be identified by a multi-dimensional needs analysis involving different stakeholders.

• GPs might benefit from activities based on a consensus-based curriculum combined with an individual needs analysis, thus exposing individual GPs to both recognized and non-recognized relevant learning needs.

     

The perceptions of occupational health in primary care

AIM: A random sample of general practitioners (GPs), practice nurses (PNs) and practice managers (PMs) in Sheffield and Manchester was recruited into a study to evaluate the perceptions of occupational health (OH) in primary care. METHODS: Qualitative data were collected using focus groups with three groups of primary care sector professionals. Quantitative data were collected nationally from 295 GPs using a postal questionnaire. RESULTS: GPs and PNs had minimal OH training, and 60% of GPs reported constraints in addressing OH matters with patients. The lack of referral routes (63 and 67%, respectively) was also seen as a barrier. OH was regarded as a speciality, and primary care professionals preferred to refer patients with OH problems to specialist centres because they perceived barriers to their dealing with the issues. A total of 74% of GPs surveyed thought that speedier access to secondary care would help them to address OH problems. CONCLUSIONS: This study has identified some of the problems associated with delivering OH through primary care. It also demonstrated a need for greater emphasis on OH education in medical and nurse training, and a need for better advice for GPs, PNs and PMs regarding support services for OH.     

Teaching of occupational medicine to undergraduates in UK schools of medicine

OBJECTIVES: To assess any recent change in the commitment to occupational medicine teaching in UK undergraduate medical curricula. DESIGN: A questionnaire survey of the teaching of occupational medicine to undergraduates in all medical schools listed in the UK Universities and Colleges Admissions Service prospectus for 1999-2000 (n = 24). RESULTS: Nineteen UK schools medical schools returned a completed questionnaire, giving a response rate of 79%. A comparison of results from this survey with previous surveys of teaching of occupational medicine to undergraduates in the UK shows that fewer schools now provide lectures, project work or ward-based tuition in the subject. Workplace visits were not undertaken by any institution. Only two of the schools setting an examination question also had a syllabus. CONCLUSION: Despite the prominence given to issues related to occupational health in recent UK government policy, this study suggests a declining commitment to occupational medicine on the part of UK medical schools. Urgent action needs to be taken to address the lack of training in occupational medicine in UK medical schools.     

Preference of distance learning methods among post-graduate occupational physicians and hygienists

BACKGROUND: The Centre for Occupational and Environmental Health at the University of Manchester has successfully run distance-learning courses for a number of decades. These are based on hundreds of pages of (paper-based) written text, specially commissioned, packaged and distributed in eight binders. Converting printed text to an online format has the potential to improve learning through the benefits of information and communication technology as well as to save printing and distribution costs. AIM: To determine which distance learning method is preferred by postgraduate occupational health students: paper-based text, or online text with embedded interactive questions and separate practical exercises. METHODS: From approximately 50 paper-based textual course sub-units, one was converted to an online format, incorporating a variety of interactive text and supplemental practical exercises. Occupational medicine and hygiene students were provided with both the paper-based and online versions and asked, via anonymous postal questionnaire, a series of questions, including their preference for future course sub-units. RESULTS: Sixty-two replies were received from 91 registered students (68% response). Apart from one student who had never tried the internet, all others described themselves as 'frequent' or 'occasional' internet users, with 78% having access both at home and work. Opinion was overwhelmingly positive with regard to ease of navigation, quality of the interactive exercises and online photo quality. Students tended to prefer multiple-choice questions and photo exercises and disliked interactive functions asking for words to complete paragraphs. Regarding preference for future teaching sub-units, the majority of students answering this question (67%) expressed a desire for mostly paper-based text supplemented with interactive online exercises. CONCLUSION: Currently enrolled students prefer core teaching materials to remain in the printed medium, with the addition of online practical exercises to supplement learning.     

Specialist competencies in occupational medicine: appraisal of the peer-reviewed literature

BACKGROUND: A re-assessment of competencies and therefore learning outcomes for higher specialist training in occupational medicine (OM) is being undertaken. Although peer-reviewed literature on the subject exists, it is limited and needs appraisal. AIMS: To search, and critically appraise the peer-reviewed literature on specialist competencies in OM. METHODS: Systematic search of a range of databases of peer-reviewed literature, followed by criterion based appraisal and categorization of the findings. RESULTS: Two hundred and thirty five papers were found of which only 20 were left after application of the grading and exclusion criteria. These addressed competencies from four perspectives: peer consensus, client, educational and legal. CONCLUSIONS: Limited evidence can be obtained from the peer-reviewed literature on specialist competencies in OM. However, it suggests the main paradigms for deriving these competencies as well as indicating gaps and the manner in which these might be filled.     

A survey of eye trauma and diseases at a teaching hospital: implications for training in occupational ophthalmology in Nigeria

This study explores the amount of occupational ophthalmology that it is possible to encounter within an existing teaching hospital system, as this offers the primary training facilities for resident doctors who expect to specialize in occupational medicine. The study was based on an analysis of ophthalmology patient records available at the University College Hospital, Ibadan, which is Nigeria's largest teaching hospital. One thousand, three hundred and thirty-four patients with eye disease were seen during the 1-year study. Of these, 1052 (78.9%) did not have their occupations recorded. Accidents were the only occupational diagnoses recorded, and this occurred in 75 (5.6%) of cases. The findings indicate that doctors who train in this specialty should gain experience in industries that have sizeable occupational health services, in addition to their formal ophthalmology training, in order to acquire experience in primary and occupational eye care. It is suggested that greater emphasis be placed on occupational ophthalmology in teaching hospitals and that there is a general improvement in completing patients' records: in particular, a patient's occupation should be recorded.     

The general practitioners' view

General practitioners have patients on their lists who work in a variety of occupations, but the doctor is most unlikely to have had any training in occupational medicine. As a result, occupational causes for illness are rarely considered by GPs. Little contact occurs between occupational health physicians and GPs leading to a lack of understanding of the occupational physician's role. These two factors, when combined, may lead to patients receiving sub-optimal treatment. This could be remedied by better undergraduate and postgraduate training, and by greater professional contact.     

Evaluation of an occupational health service for general practitioners and their staff in a primary care trust

BACKGROUND: An occupational health service was set up in 2002 for general practitioners (GPs) and their staff in a London primary care trust (PCT). The service was based on a needs assessment undertaken in the locality in 1998. AIMS: To evaluate awareness, usage and perceived helpfulness of the service amongst GPs and practice managers, and to ascertain current perceived priorities for what to include in the service. METHODS: Questionnaire survey sent postally and electronically to 199 named GPs and 69 practice managers in 78 practices in the PCT. RESULTS: Overall 119/268 (44%) responses were received from 54/78 practices (69%). Awareness of the existence of the service was high (76%), and although uptake had been poor, this was not related to a perception that the service was unlikely to be helpful. Almost all those who had used the service had found it helpful. Nineteen (16%) respondents asked for more information about the service. Advice on health and safety law and fitness for work assessments were the highest priorities and hepatitis B immunization lowest, as in the 1998 needs assessment. However, a discrepancy between GPs and practice managers with regard to the perceived relative importance of pre-employment health screening and counselling/stress management emerged. CONCLUSIONS: The service is valued by users but could be developed by exploring new ways to disseminate information about the service and deliver it.     

Is there value in routinely obtaining a report from the general practitioner as part of pre-entry health screening of students for nursing studies?

BACKGROUND: Reports from general practitioners (GPs) are requested on applicants for nurse training, but there is no published evidence of the merit of this practice. AIMS: To assess the benefit of GP report in health assessments of student nurse applicants. METHODS: An audit was made of information obtained by health declaration form (HDF), nurse's assessment, GP report and, when performed, a physician's assessment for each applicant. Agreement between the health questionnaire and GP report was analysed by kappa statistics. RESULTS: Of 254 applicants, 246 (97%) were declared 'fit to work', four (1.6%) were deemed 'fit with restrictions' and four (1.6%) were considered 'unfit to work'. The most common problems declared were psychiatric and skin problems. The agreement between health declaration and the information provided by GPs was classed as almost perfect for diabetes and only fair to moderate for all other measures. The reports provided additional information on problems not declared by applicants, but all of these were passive problems. The four unfit candidates all had psychiatric illness, but in all cases the occupational health assessment was sufficient to make this decision or to request further information. In the 'fit with restrictions' category, three of the four GP reports (75%) helped in correctly assigning the applicants to this category. In one of these eight cases a passive problem had not been declared. CONCLUSIONS: The additional information in GP reports does not affect the conclusion regarding fitness for training in most cases and does not provide sufficient information to merit it being sought routinely.     

Public health physicians' knowledge of core skills and current policy: clinical audit by questionnaire.

BACKGROUND: The aim of this study was to facilitate the assessment of the knowledge of general public health physicians on a range of topics relating to everyday areas of work and core skills, and to encourage learning in the process, by means of an educational clinical audit exercise. METHODS: A group of experts in different aspects of public health were asked to contribute multiple-choice questions. These were developed into a questionnaire that could be marked by computer. The questionnaire was circulated to all members of the Faculty registered for Continuing Professional Development (CPD) and to specialist registrar members, but participation was voluntary. The experts marked answers according to a marking scheme against model answers agreed. RESULTS: A total of 499 public health doctors returned answer sheets. There was no 'pass mark' as this was a learning exercise, not an examination. However, although the negative marking system meant that the possible range of scores was -100 per cent to 100 per cent, no one had a negative score. The median uncorrected result was 44 out of 80. Questions on communicable disease and critical appraisal had the highest scores, and one on Primary Care Trusts the lowest. Participants thought the most interesting questions were those on epidemiology and evidence-based medicine, whereas the most unpopular was on Personal Medical Services pilots. Most comments were favourable to the approach but several commented that the whole exercise was too general and questions outside their current area of specialization were irrelevant. CONCLUSION: The general public health physicians who took part in this audit appeared to be mainly competent in their knowledge of core skills and up to date with current health policy issues. However, the audit raises a debate about what 'core' knowledge is required in the post-training period. The place of UK-wide CPD initiatives over national or regional, or local approaches needs consideration, as do potential regional or national variations in CPD. This will receive further impetus because of revalidation and the need to demonstrate valid CPD activities in public health medicine.     

Improved communication between doctors and with managers would benefit professional integrity and reduce the occupational medicine workload

BACKGROUND: Professional expectations for communication skills are explicit. These skills are needed for professional integrity and personal morale. Nevertheless, occupational physicians see doctors as patients for whom communication among between doctors and with their managers are the principal cause of their presenting health problems. AIM: To describe the frameworks of professionalism in medicine and the duty to care for good communication; present issues surrounding competency in communication skills; identify health problems among doctors associated with poor communication; and consider roles of economic appraisal and preventive strategies. METHOD: A literature review identified key publications of professional expectations and requirements of doctors for their communication skills. Health problems among doctors associated with poor communication and presenting at least twice in a National Health Service (NHS) occupational health (OH) department during January-December 2002, were sought by manual retrieval of all doctor-patient records. The categories of communication difficulty were agreed in the focus group discussion of the presenting problems with occupational physicians. RESULTS: Nine categories of communication difficulties among doctors resulting in their presentation in OH departments with health problems were identified. CONCLUSIONS: Personal health problems caused by poor communication involve considerable time and potential litigation costs. Doctors need to be reminded of their responsibilities. Opportunity cost studies would help to strengthen an evidence base for the need of doctors to adhere to the professional requirements of good communication skills.     

The interaction between general practitioners and occupational health professionals in relation to rehabilitation for work: a Delphi study

BACKGROUND: Anecdotally, communication between general practitioners (GPs) and occupational health professionals is poor and acts as a barrier to successful rehabilitation for work. It is not known how widely this view is held by the many stakeholders in rehabilitation for work, or how important the observation is in its effect. METHODS: A Delphi study was conducted by initial semi-structured telephone interview, followed by a three-round collation and feedback of opinion by e-mail. The 25 participants were identified by suggestion within the study process for their position as key informants within a wide range of stakeholders. RESULTS: The process generated a consensus statement which identifies the extremely important nature of rehabilitation for work, the crucial role by GPs, the central role of occupational health professionals in case management and the barrier represented by the often very poor communication between them. CONCLUSION: The way forward is to improve communication by mutual education and understanding and a team approach to rehabilitation strategy. This may be facilitated by the GPs who work in occupational health and disability assessment and the involvement of other health professionals to great benefit for all stakeholders.     

Occupational and environmental medicine: sustainable development?

Occupational medicine is evolving to meet the needs of the 21st century. There is a need to define the remit of occupational and environmental medicine in order to facilitate the development and maintenance of requisite competencies, the establishment of educational goals for practitioners and production of a professional product for the global market place. The delivery of occupational health services will be underpinned by quality assurance systems.     

Management of hepatitis B immunizations and blood exposure incidents in primary care

AIM: To investigate how well primary care health care workers, with no access to an occupational health service (OHS), have managed their hepatitis B immunizations and blood exposure incidents, compared with National Health Service Trust staff, with access to an OHS. METHOD: A questionnaire was sent to 78 general practitioners (GPs), 93 general practice nurses, 81 NHS Trust consultants and 88 NHS Trust community nurses, in the Airedale area of West Yorkshire in June 2001. RESULTS: The response rate was 80%. GPs were significantly less likely than consultants to have received a hepatitis B booster vaccination after their primary course (57 versus 80%, P < 0.009) and significantly less likely to have had their blood anti-HBs test checked after their last vaccination (74 versus 94%, P < 0.011). General practice nurses were significantly less likely to fill in a blood exposure incident form after an injury than community nurses (56 versus 91%, P < 0.006). Overall, the group with access to an OHS was significantly more likely to have received a hepatitis B booster (P < 0.036), have had a blood anti-HBs test after last vaccination (P < 0.010) and to have filled in a blood exposure incident form after last blood exposure (P < 0.033), than the group without access to an OHS. CONCLUSION: Any future OHS with responsibility for primary care, should consider calling in all GPs and general practice nurses for a review of their hepatitis immunity and for education regarding the management of blood exposure incidents.     

Acceptability and educational impact of a peer feedback model for significant event analysis

Context A model of independent, external review of significant event analysis by trained peers was introduced by NHS Scotland in 1998 to support the learning needs of general practitioners (GPs). Engagement with this feedback model has increased over time, but participants’ views and experiences are largely unknown and there is limited evidence of its educational impact. This is important if external feedback is to play a potential role in appraisal and future revalidation. Objective The study aimed to explore aspects of the acceptability and educational impact of this external feedback model with participating GPs. Methods Semi‐structured interviews were carried out with nine GPs. Participants were sampled to reflect their level of learning need (low, moderate or high) to gain a range of views and experiences. Transcribed interviews were analysed for content. Results This system of external peer feedback is generally acceptable to participants. It complemented and enhanced the appraisal process. External feedback had positive educational outcomes, particularly in imparting technical knowledge on how to analyse significant events. Training issues for peer reviewers were suggested that would further enhance the educational gain from participation. There was disagreement over whether this type of feedback could or should be used as supporting evidence of the quality of doctors’ work to educational and regulatory authorities. Conclusions The findings add to the evidence for the acceptability and educational impact of external review by trained peers. Aligning such a model with the current national appraisal system may provide GPs with a more robust demonstration of participation in reflective learning.