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.     

Teaching junior doctors to manage patients who somatise: is it possible in an afternoon?

CONTEXT: Many patients in primary care somatise psychological distress. Training general practitioners (GPs) to manage somatisation has been shown to lead to improvements in their management of these patients. However, the training has been intensive and conducted by psychiatrists, making it impractical for widespread use. The aim of this research was to determine the effectiveness of a teaching package in improving the ability of GP registrars to manage patients who somatise, when taught by GP vocational course tutors within the constraints of a general practice vocational training scheme. METHODS: This was a before-and-after training evaluation of GP registrars' skills. A total of 22 GP registrars and 6 GP course organisers were recruited from 3 GP vocational training schemes. The GP trainees had 2 videotaped consultations with trained actors role-playing patients with somatised depression, before and 1 month after training. RESULTS: There was a significant overall improvement in the ability of GP registrars to manage patients who somatise (mean scores on a 4-point Likert scale: pre-training 1.4 [standard deviation, SD, 0.6]; post-training 2.2 [SD 0.9]; P = 0.002). General practice registrars improved their ability to use a negotiating style of consultation (skill present in 8/22 pre-training, 16/22 post-training; P = 0.02) and also demonstrated more empathy during the 'consultation' after training (mean scores on a 5-point Likert scale: pre-training 2.3 [SD 1.0]; post-training 3.0 [SD 0.8]; P = 0.03). CONCLUSIONS: Using a structured training package, it is possible for GP vocational course tutors to successfully teach GP registrars to manage patients who somatise psychological distress. Given limited resources for teaching in terms of cost and time, this training package could have important implications for training medical staff.     

The effect of the general practice registrar year on perceived skills in palliative care in the West Midlands

OBJECTIVES: To ascertain the effect of 12 months spent as a GP registrar on perceived skills in palliative care. DESIGN: A previously validated questionnaire for use with medical undergraduates is modified and used to survey perceived skills in five aspects of providing palliative care in five different scenarios at two points during the 12-month period of general practice vocational training where no specific teaching intervention is conducted. SETTING: The West Midlands. PARTICIPANTS: 210 GP registrars. RESULTS: Perceived skill ratings were seen to significantly increase during the 12-month period, but anxiety in caring for the dying did not significantly decrease. Ratings of skills were lowest when caring for a child dying with leukaemia or a young adult dying with AIDS. In addition, other important variables which had a statistically significant influence were gender and age, but interestingly not the number of previous senior house officer (SHO) posts undertaken or whether the respondent had had formal teaching on the subject in the past. CONCLUSION: It might therefore be postulated that training as a GP registrar has an important impact on the development of perceived skills in palliative care.     

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.     

Assessing communication skills of GP registrars: a comparison of patient and GP examiner ratings

CONTEXT: General practice. OBJECTIVES: To compare ratings of GP registrars' communication skills by patients and GP examiners. DESIGN: A comparative study where the communication skills of GP registrars were assessed both by patients, using a validated tool called the Doctors' Interpersonal Skills Questionnaire (DISQ), and by GP examiners as part of the Fellowship examination of the Royal Australian College of General Practitioners (RACGP). PARTICIPANTS: These included 138 GP registrars, 6075 patients, and more than 70 GP examiners. RESULTS: Spearman rank correlations were used to test the strength of the relationship between Fellowship examination and DISQ scores. Findings showed that there were several communication skills areas with mild (but significant) correlations between patient and GP examiner ratings. These areas included warmth of greeting, listening skills, respect, and concern for the patient as a person. No significant correlations were detected for explanation skills. Interestingly, the correlations between GP examiner and patient ratings were stronger for female GP registrars. CONCLUSION: There is some evidence that patients' ratings of GP registrars' communication skills is aligned to ratings made by GP examiners as part of the summative RACGP Fellowship examination. However, further work is required to assess the strength of this alignment, given that patient-doctor communication is assessed more widely through new components of the examination.     

Consumers as educators: implementation of patient feedback in general practice training

There is growing interest in the adoption of patient-based assessments for the training of general practitioners. Consumers are in a unique position to comment on the quality of the doctor-patient interaction. Involving consumers as partners with general practice (GP) registrars and GP educators in the development of a patient feedback instrument enhances the relevance and acceptability of consumers as educators in GP training. It also demonstrates that social and medical agendas can be harmonized. Two patient feedback instruments on interpersonal skills were trialed in a training program for general practitioners in Australia. It was found that one of the instruments was more discriminating than the other because of its different response scale.     

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.     

Context-bound communication skills training: development of a new method

OBJECTIVES: To examine how communication skills training might be integrated into everyday clinical practice in a manner that is acceptable to clinicians. DESIGN: General practitioners from 3 group practices agreed to take part, in turn, in a study of how to manage difficult consultations about antibiotic prescribing for acute respiratory infections. This provided the opportunity to conduct communication skills training in which lessons learned from one practice were taken into the next. SETTING: United Kingdom general practices. SUBJECTS: Three groups of general practitioners. FINDINGS: Difficulties with the acceptability of a traditional off-site workshop approach, using role play as the main teaching method, led to the development of a new training method (context-bound training), which proved to be practical and acceptable to experienced clinicians. The main features of the method were the delivery of training in the clinicians' place of work, and the transformation of their reported difficult cases into scenarios which they then encountered with a standardized simulated patient before and after brief seminars. Everyday clinical experience was kept in the foreground and 'communication skills' in the background. CONCLUSIONS: The method is acceptable to clinicians and adaptable to a range of clinical situations. It offers potential for improving the communication skills of clinicians both in hospital and primary care settings.     

What is effective supervision and how does it happen? A critical incident study

OBJECTIVES: To identify the key features of supervision from the perspectives of educational supervisors and specialist registrars. DESIGN: Critical incident study. Telephone interviews were conducted with selected informants representing a range of specialties. The sample comprised educational supervisors with an identified interest in supervision, specialist registrars and GP trainees in the Yorkshire region. RESULTS: Educational supervisors and specialist registrars were generally agreed on what constitutes effective supervision: direct supervision was seen as very important. Educational supervisors and specialist registrars had very different concerns in relation to ineffective supervision: specialist registrars were concerned with inadequate supervision whilst educational supervisors were concerned with failures in direct supervision and poorly performing trainees. Supervision practices varied between specialties; in this study there seemed to be particular problems in anaesthesia, medicine and paediatrics. CONCLUSIONS: Direct supervision and the quality of the supervisory relationship are key to effective supervision. There is a need for clear guidance on supervision and the establishment of appropriate procedures and mechanisms to resolve difficulties relating to inadequate supervision for trainees and performing trainees. Insufficient numbers of supervisors have received training in supervision.     

Learning to consult with computers

OBJECTIVE: To develop and evaluate a strategy to teach skills and issues associated with computers in the consultation. INTERVENTION: An overview lecture plus a workshop before and a workshop after practice placements, during the 10-week general practice (GP) term in the 5th year of the University of Melbourne medical course. DESIGN: Pre- and post-intervention study using a mix of qualitative and quantitative methods within a strategic evaluation framework. OUTCOME MEASURES: Self-reported attitudes and skills with clinical applications before, during and after the intervention. RESULTS: Most students had significant general computer experience but little in the medical area. They found the workshops relevant, interesting and easy to follow. The role-play approach facilitated students' learning of relevant communication and consulting skills and an appreciation of issues associated with using the information technology tools in simulated clinical situations to augment and complement their consulting skills. The workshops and exposure to GP systems were associated with an increase in the use of clinical software, more realistic expectations of existing clinical and medical record software and an understanding of the barriers to the use of computers in the consultation. CONCLUSIONS: The educational intervention assisted students to develop and express an understanding of the importance of consulting and communication skills in teaching and learning about medical informatics tools, hardware and software design, workplace issues and the impact of clinical computer systems on the consultation and patient care.     

Improving the psychiatric skills of the general practice trainee: an evaluation of a group training course

Fourteen general practice trainees took part in a course specifically designed to improve their psychiatric interviewing skills. The trainees were instructed in the problem-based model and were taught in a group setting with the use of videotape feedback. A significant improvement was demonstrated in the trainees' ability to identify psychiatric illness accurately, and there were significant changes in their interview behaviours after training. Those who were below average before training showed the greatest improvement. The implications of these findings are discussed. Group video feedback training is as effective as one-to-one video feedback training in improving the psychiatric interviewing skills of GP trainees, and could be more widely employed in general practice vocational training.     

Impact of supervision and self-assessment on doctor-patient communication in rural Mexico.

OBJECTIVE: To determine whether supervision and self-assessment activities can improve doctor-patient communication. SETTING AND PARTICIPANTS: Six supervisors, 60 doctors in their last year of training, and 232 primary health care patients at rural health clinics in Michoacan, Mexico. DESIGN: The main evaluation compared post-intervention measures in control and intervention groups. A small panel study also examined changes from baseline to post-intervention rounds in both groups. INTERVENTION: Over a 4-month period, specially trained supervisors added 1 hour of supervision on interpersonal communication and counseling (IPC/C) to regular site visits. Doctors, who had received prior IPC/C training, periodically audiotaped and assessed their own consultations. MAIN OUTCOME MEASURES: These comprised frequency of doctors' facilitative communication, doctors' biomedical information-giving, and patients' active communication. RESULTS: The performance of all doctors improved markedly over the study period, but gains in facilitative communication and information-giving were significantly greater in the intervention than the control group. No single component of the intervention was responsible for the improvement; it resulted from the combination of activities. The doctors appreciated the more supportive relationship with supervisors that resulted from the intervention and found listening to themselves on audiotape a powerful, although initially stressful, experience. CONCLUSION: Supportive supervision and self-assessment activities can reinforce IPC/C training, prompt reflection and learning, and help novice doctors improve their interpersonal communication skills.     

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.     

Real-patient evaluation of communication skills teaching for GP registrars

BACKGROUND: Five thousand eight hundred and eighty-five patient- completed questionnaires were used to evaluate the effectiveness of an interpersonal skills module designed for a vocational training programme for GPs. OBJECTIVES: It was anticipated that patient-based assessments would detect a significant improvement in the interpersonal skills of GP Registrars who undertook the module. METHOD: A quasi- experimental design using an intervention and control group (comprising 68 GP Registrars) was used to monitor the outcomes of the interpersonal skills module. RESULTS: Patient ratings of interpersonal skills were significantly higher for those GP Registrars who participated in the interpersonal skills module. CONCLUSIONS: Patient-based assessments are a useful evaluation method for assessing the quality of the doctor- patient relationship.      

Feedback for general practice trainers: developing and testing a standardised instrument using the importance-quality-score method

INTRODUCTION: Although general practice vocational training has been mandatory in Germany since 1993, a service philosophy still prevails. To help general practice trainers develop their identity and skills as trainers we developed and tested a standardised instrument. The questionnaire is to be filled in by registrars after their attachment to a given practice and handed to the trainer as personal feedback on the training provided. METHODS: Items were collected by asking experts in the field to name content that should be covered. The resulting items were reduced using the importance-quality method derived from health-related quality of life research. Reliability was tested by registrars rating their training twice 3 weeks apart. They also provided free text comments that were coded and analysed to establish criterion validity. RESULTS: A total of 121 items were collected. Eighty registrars provided importance and quality ratings to reduce these to 43 items. Test-re-test reliability and criterion validity were also established. CONCLUSION: The importance-quality method proved to be useful for item reduction according to the objective of the questionnaire. Instruments evaluating the quality of vocational training must be context-sensitive.     

The curriculum of communication skills teaching at Maastricht Medical School

In the Skillslab at Maastricht Medical School students are prepared for their first encounters with patients. Students can focus on individual skills, separately mastering each skill in a controlled systematic manner. With this foundation students are better equipped to face the complex intellectual and emotional demands of real patients. A large proportion of training concerns communication skills. Features of Skillslab communication skills training programme are: (1) its continuity (once every 2 weeks, from year 1 to year 6); (2) a gradual increase of complexity in skills (basic interview skills, phases of interviews, entire interviews, problem patients); (3) a gradual increase of complexity in practice situations (apparatus, role-playing, simulated patients, real patients). Evaluation shows students' and teachers' satisfaction with the programme. Comparison with conditions required for interpersonal skills training shows that these are fully met. However, there are drawbacks, which are described.     

Are vocationally trained general practitioners better GPs? A review of research designs and outcomes

Implicit and explicit in reviews of and changes to vocational education for general practitioners in the 1990s is the challenge to defend the assumption that vocationally trained GPs are better GPs. This paper provides a review of the international literature which has reported on outcomes of general practice vocational training programmes. Through the review we identify both the types of research methodologies used (including a brief discussion of their strengths and limitations) and the outcomes reported of vocational training. Twenty-five studies on the outcomes of vocational training are reviewed. These studies used multiple data sources and one of four methodologies: pre- and post-training comparisons, analysis of learners' or teachers' accounts, audits of general practice or analysis of examination pass rates. When collated, the following range of outcomes from vocational training were identified: improved quality of patient care, increased knowledge, improved general practice skills, increased confidence and desirable GP attitudes and personality traits, increased adherence to practice guidelines and higher examination pass rates. The paper concludes with a summary of research and education issues which arise when we examine the question posed at the outset: are trained GPs better GPs?     

Making and sharing decisions about management with patients: the views and experiences of pre-registration house officers in general practice and hospital

OBJECTIVES: To explore the views and experiences of pre-registration house officers (PRHOs) in general practice and hospital settings regarding the concept of patient partnership and their experience of involving patients in management decisions. DESIGN: The 12 PRHOs who had graduated from British universities and who were working within the Yorkshire Deanery were interviewed towards the end of their four-month general practice attachments. The interviews were semi-structured and analysed qualitatively. RESULTS: Three major themes emerged. The PRHOs perceived differences in approach between consultations carried out in hospital and primary care settings, with general practitioners being more likely to share information and decisions with patients. As medical students, the PRHOs had little opportunity to practise sharing information and management decisions with patients, and variable experience of this after graduation. On the whole they were favourable to the concept of patient partnership. CONCLUSIONS: Medical students and PRHOs lack training and opportunities to decide on management and discuss this with patients and yet, particularly in general practice settings, they have to practise these skills. The PRHOs had begun to develop strategies to decide how much information to give to patients and to what extent to involve patients in management decisions. This is an area that needs further consideration when planning both undergraduate and postgraduate medical education.     

Much variety and little evidence: a description of guidelines for doctor-patient communication

AIM: To explore the quality of the content of communication skills training programmes, we analysed and assessed guidelines for doctor-patient communication used in communication programmes for general practitioner (GP) trainees. METHOD: Guidelines for doctor-patient communication were extracted from educational materials supplied by the 8 Dutch university centres for vocational training in general practice. Four themes guided the analysis of the guidelines: content, type of contact, format and structure and status. The quality of the guidelines was assessed with the Appraisal of Guidelines Research and Evaluation (AGREE) instrument, a validated measurement instrument for guideline quality. RESULTS: We identified 18 guidelines. Guideline content covered 64-100% of the GP qualification requirements. General consultations and specific situations were the subject of 9 guidelines each. Format and structure differed between guidelines. Guideline use seemed not to be obligatory. AGREE scores were low. CONCLUSIONS: Guidelines for doctor-patient communication are difficult to identify in materials of GP training courses. Guideline quality is low; guidelines are little evidence-based and little attention has been paid to applicability and involvement of users. GP qualification requirements are only partly covered. Guidelines differed substantially without clarity about the reasons behind different choices. Guideline status was low. RECOMMENDATIONS: When studying the factors that influence training effect, the quality of training content should be considered as well as teaching methods. Communication skills training programmes should be based on evidence-based guidelines that have been developed according to similar standards as for medical technical guidelines.