Improving the skills of established general practitioners: the long-term benefits of group teaching

This study set out to determine the long-term benefits of teaching psychiatric interview skills. Nine established general practitioners, eight of whom were also trainers, took part some 18 months after attending a problem-based interviewing course. Interview skills were assessed by rating behaviour during 10-minute videorecorded simulated consultations with role-players, recorded before and after training and at follow-up. The finding of an earlier study that, in terms of the course model, training successfully modified the doctor's behaviour, was largely replicated. In addition, not only were acquired skills maintained but further change took place during the follow-up period, change that can be seen as improvement in terms of the course model.     

A communication skills course for preclinical students: evaluation of general practice based teaching using group methods

Summary. Teaching preclinical medical students about doctor-patient communication gives them an opportunity to develop their interviewing skills prior to their having to elicit lists of symptoms in their clinical years. General practitioners should be among the more efficient interviewers in clinical medicine and therefore able to make important contributions to the teaching of interviewing skills. This paper describes the aims, objectives and methods of the preclinical communications skills course at St George's Hospital Medical School. The contribution of the Division of General Practice and Primary Care to the teaching of interviewing skills in the preclinical course has been evaluated using rapid group methods. Students were asked to identify examples of specific interviewing behaviours in videotaped general practice consultations, and to judge whether the behaviours were helpful or unhelpful in eliciting relevant information from the patient. Students who had been given experience in interviewing patients in small groups led by general practitioners identified significantly more helpful and unhelpful interviewing behaviours in the taped consultations than students who had not received the small-group teaching. Students rated the teaching as relevant and effective in terms of giving insights into the interviewing skills they needed to develop. Group methods of evaluation such as these might prove useful to other medical schools with class sizes of 150 students or more.     

Continuing medical education and the education allowance: variation in credits obtained by general practitioners

The educational credits obtained by general practitioners for the postgraduate education allowance were examined. With over 3 months of the qualifying period remaining, 68.4% had reached the requirement. The educational day attainments show almost a normal distribution, with 4.2% of doctors completing more than double the requirement.     

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.     

Training general practitioners to teach psychiatric interviewing skills: an evaluation of group training

Group teaching in problem-based interviewing based on video and audiotape feedback of the doctor's own consultations significantly improved the ability of experienced general practitioners to teach psychiatric skills to their trainees. When the GPs were randomly allocated to one of three further training experiences--video feedback of their tutorial sessions, discussion about how to teach and no further teaching, there were very few differences between the groups. The greatest impact on improving teaching skills was brought about by watching their own consultations in a group feedback setting.     

Training of general practitioners in interpreting chest radiographs

Easily accessible chest and skeleton roentgen examinations are needed in primary health care. In Finland the health centres perform about a third of all roentgen examinations. Many of the films are interpreted by health centre doctors at least in the primary phase. About 40% of them are chest radiographs. In 2640 chest radiographs interpreted by general practitioners the final roentgen diagnosis was pathological in 54%. Pathological conditions were totally overlooked in 13%. Of normal cases 19% were interpreted falsely positive. The greatest need for general practitioners' training is in the common findings in the chest, for example cardiac insufficiency and inflammatory as well as atelectatic changes in the lungs. Pulmonary findings in children proved difficult to interpret and were proposed as a subject for training. The role of poor image quality in interpretation errors must be emphasized when less experienced doctors interpret chest films. If regular radiological consultation is not available, postgraduate training in diagnostics of chest radiographs should be considered in the training of specialists in general practice as well as in their supplementary training.     

Effects of the vocational training of general practice consultation skills and medical performance

The effects of the vocational training of general practitioners in the Netherlands on the consultation skills and medical performance of junior doctors were studied. Results obtained at a training institute providing systematic training in these skills (Nijmegen) were compared with those at an institute taking a problem-based learning approach (Groningen). Trainees (n = 63) audiotaped consultations and recorded their medical performance at the start and at completion of training. The skills were evaluated with the aid of validated criteria and medical 'protocols'. Data on 631 pre-training and 624 post-training consultations were compared. Changes in consultation skills and medical performance occurred at both institutes and proved more marked at the institute providing systematic training. Improved medical performance was found to be associated with improved consultation skills. Enhanced clinical knowledge was found to be related to improved medical performance and consultation skills. The most profound changes were found in junior doctors who had started at a lower level of consultation skills and medical performance.     

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.     

Teaching immediate cardiac care to general practitioners: a faculty-based approach

This paper describes the development, piloting and delivery of an immediate care cardiac course (ICCC) to Irish general practitioners. The course utilizes the continuing medical education network of the Irish College of General Practitioners. This has made the course locally accessible even for remote practitioners and has facilitated rapid dissemination. In its first year, 167 GPs (8% of the total number of Irish GPs) have completed the course. Participant feedback has been positive, especially regarding the small group- and skills-based components. The introduction of more formal assessment procedures is now being undertaken. We believe this model to be a possible template for the introduction of other skills courses both in Ireland and abroad.     

Interviewing skill: the effects of ultra-brief training for general practitioners. A preliminary report

Concepts of interviewing skill and of appropriate training and evaluation are briefly reviewed. It is hypothesized that if goals and skills relevant to a specific clinical interview can be identified and modelled in advance then even very brief training can improve outcome. An experiment is described in which three randomly selected general practitioners conducted, separately, test interviews with the same role played 'patient'. These interviews were repeated after a 'goal focusing' exercise and again after a modelling and instruction exercise. All interviews were telerecorded and subsequently blindly rated for impact on the 'patient'. The results suggest powerful training effects. The drawbacks of the study, such as lack of controls, are discussed. The similarity of evaluation raters who were 'behaviour' orientated and those who were 'psycho-dynamics' orientated is noted and it is suggested that agreed concepts of effective interviewing may be within reach.     

The contribution of general practice to medical education: expectations and fulfilment

The aim of this study was to discover what students expected to learn during their fourth-year general practice attachment, to compare this with their GP tutors' expectations and to determine the extent to which the students' expectations were fulfilled. Questionnaires were used to gather this information; students completed them on the first and last days of the 4-week attachment and tutors shortly after the attachment. Students and their tutors had the highest expectations of the course in helping to raise awareness of the psychological and social aspects of ill health and develop clinical decision-making and management skills. At the end of the course students thought that they had gained most in these areas. Both students and tutors had lower expectations of the course helping to develop physical examination and practical skills and to improve knowledge in certain clinical areas. These were also rated lowest in terms of fulfillment. This study was carried out at a time when it is being suggested that more undergraduate teaching should take place in general practice and that this could include the teaching of practical skills and clinical subjects traditionally associated with hospital-based teaching. The results suggest that the expectations of students and GP tutors would need to be modified, as well as extra resources provided, if there is to be a shift in teaching towards the community.     

Subjective and behavioural evaluation of the teaching of patient interview skills

Summary. One aim of the course in general practice and public health medicine during the final year at the University of Sheffield is to help students to develop further their interpersonal communication skills with particular reference to their skills in interviewing patients. During the course students meet twice in small groups with a tutor in order to review audiotape recordings of interviews with patients seen during their general practice attachments. The main activity during these tutorials is group discussion of the interviewer's behavioural options at significant points during the interview. Students also listen individually with a tutor to an interview that they have recorded, discuss this interview and assess it against a set of explicit criteria as part of their summative course assessment. In response to an anonymous end-of-course questionnaire, 85% of students felt that their interview skills had been improved by the teaching and 68% that listening to their own recordings had been the most helpful aspect. During interviews with simulated patients recorded at the end of the course, students asked more open questions, fewer questions referring to physical symptoms, more questions referring to feelings, beliefs or behaviour and fewer questions of a check-list type than during interviews recorded at the start. A number of students also requested examples of specific events during the end-of-course interviews although none had done so at the beginning of the course. All of these changes were statistically significant and were in directions that were consistent with the teaching in the small-group tutorials.     

Management of somatic presentations of psychiatric illness in general medical settings: evaluation of a new training course for general practitioners

An improved teaching package is described which aims to help general practice trainees manage somatized presentations of psychological distress. The package comprises a training videotape in which a reattribution model is demonstrated, with material for role-play of new skills and small-group video feedback of consultations. Eighteen general practice trainees attending an 8-week course in psychiatry participated fully in the somatization management teaching programme. The teaching package was evaluated by blind rating of general interview skills and model specific skills demonstrated by trainees during 10 to 15-minute clinical interviews with professional role-players. Ratings were made on pre-training and post-training videotaped interviews. A significant improvement was demonstrated in general interview skills. Improvements were also noted in specific reattribution skills post-training. The evaluation revealed that skills in the model can be effectively learned, and that improvements in the package have resulted in its improved efficacy.     

Training clinical teachers in psychiatry to teach interviewing skills to medical students

To study the feasibility of training all clinical teachers in psychiatry to teach interviewing skills to medical students, 24 (unselected clinicians were assigned to one of four different training methods. They received either experiential or didactic instruction, and their initial teaching sessions were either supervised or unsupervised. A total of 287 medical students subsequently received feedback training from these teachers. While all students showed significant increases in skill after training, those taught by experientially trained teachers showed the greatest gains. Neither supervision nor the teachers' own interviewing skills exerted significant effects on students' performance. It is concluded that with only brief training unselected clinicians can become effective teachers of essential interviewing skills. Feedback training in such skills can, therefore, be incorporated into existing curricula without major disruption of other requirements.     

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.     

Teaching behaviour therapy to psychiatrists with a structured learning format

A 5-day, in-service training in behaviour therapy, which was attended by six psychiatrists, is described. The course covered principles of behavioural assessment and therapy within a structured learning format. The results of this systematic approach are presented in terms of six measures, administered before and after training. Two of these assessed attitudes to treatment, one gauged knowledge of behavioural principles and the remaining three evaluated the psychiatrists' skills in some key areas of behaviour therapy. Statistically significant improvements were found on the knowledge questionnaire and on one skill measure. These results were compared to those obtained by a control group (n = 18) and a course-trained group (n = 65) of qualified psychiatric nurses. The main conclusion drawn was that the course succeeded as an efficient learning programme, developing understanding and skills of value both clinically and in terms of collaborative teamwork.     

Clinical tutor evaluation: a 5-year study by students on an in-patient service and residents in an ambulatory care clinic

Summary. Medical students on an in-patient service and residents working in an ambulatory care clinic have regularly evaluated their clinical tutors over the 5 years 1985-1989. Both groups of raters reliably and predictably evaluated their tutors and both emphasize between-tutor comparisons more than actual rating values for individual tutors. Tutors active in both contexts regularly receive higher ratings from the medical students than from the residents. Mid-course feedback to tutors in the medical course had no impact on end-of-course ratings. In neither context did tutor ratings improve from one evaluation to the next. Both groups reliably discriminate between the teaching skills and the personality traits of individual tutors.     

Chinese medical school exit objectives: a multiinstitutional survey of teacher opinion

This paper describes a collaborative survey of Chinese medical school teacher opinion concerning clinical behaviours and skills that Chinese students should be expected to demonstrate prior to graduation from medical school. Selected teachers from four Chinese medical schools indicated whether each of 77 objectives was: essential for every student to know or demonstrate prior to graduation; useful but not essential; or not applicable to their educational programmes. Results show teachers' expectations regarding some of the behaviours and skills Chinese medical school teachers consider to be important for students to learn. Forty-nine per cent of the exit objectives were regarded as essential by 75% or more of the teachers. The most essential objectives involved performing clinical procedures, collaborating and communicating with health care professionals, conducting organ system examinations, formulating hypotheses and defining problems. Other essential objectives were concerned with communicating with patients and their families, maintaining currency within the discipline, and recognition, evaluation and triage of patients with life-threatening or chronic conditions. Exit objectives related to health promotion and risk assessment were regarded as useful but not essential at the undergraduate level. Implications for Chinese medical education are discussed.     

Evaluating family counselling skills training for family practice

Educational programmes for family practice should develop family counselling skills of students to moderate levels of competence. Few specific training programmes are part of the regular curriculum and of these few are evaluated. Twenty-three residents enrolled in a 2-year family practice programme in Toronto, Canada participated in a non-randomized control intervention study to assess a specific training programme. Pre-training counselling skills, and ability were assessed using two types of generally recognized measurement instruments, the Carkhuff Stems of Communication Skills and the Carkhuff Discrimination Index. The treatment group entered the training programme which involved supervised family counselling 8 half-days each week for one month as part of their usual rotations. They completed a second set of instruments following this course to assess immediate within-group change and then both they and the control group completed a set about one year later to measure differences. Initial scores for all residents showed a less than 'minimally facilitative' level of counselling response on both empathy and warmth dimensions. Following the course, the treatment group scored above this level and significantly better than the control group. Furthermore, the former showed a 20% improvement in ability to discriminate between effective and ineffective helping responses which was sustained over one year, while the control group's scores became worse. Teaching of counselling skills can be effective.