CHIME-GP trial of online education for prescribing, pathology and imaging ordering in general practice - how did it bring about behaviour change?

BACKGROUND: There is a need for scalable clinician education in rational medication prescribing and rational ordering of pathology and imaging to help improve patient safety and enable more efficient utilisation of healthcare resources. Our wider study evaluated the effectiveness of a multifaceted education intervention for general practitioners (GPs) in rational prescribing and ordering of pathology and imaging tests, in the context of Australia's online patient-controlled health record system, My Health Record (MHR), and found evidence for measurable behaviour change in pathology ordering among participants who completed the educational activities. This current study explored the mechanisms of behaviour change brought about by the intervention, with a view to informing the development of similar interventions in the future. METHODS: This mixed methods investigation used self-reported questionnaires at baseline and post-education on MHR use and rational prescribing and test ordering. These were analysed using multi-level ordinal logistic regression models. Semi-structured interviews pre- and post-intervention were also conducted and were analysed thematically using the COM-B framework. RESULTS: Of the 106 GPs recruited into the study, 60 completed baseline and 37 completed post-education questionnaires. Nineteen participants were interviewed at baseline and completion. Analysis of questionnaires demonstrated a significant increase in confidence using MHR and in self-reported frequency of MHR use, post-education compared with baseline. There were also similar improvements in confidence across the cohort pre-post education in deprescribing, frequency of review of pathology ordering regimens and evidence-based imaging. The qualitative findings showed an increase in GPs' perceived capability with, and the use of MHR, at post-education compared with baseline. Participants saw the education as an opportunity for learning, for reinforcing what they already knew, and for motivating change of behaviour in increasing their utilisation of MHR, and ordering fewer unnecessary tests and prescriptions. CONCLUSIONS: Our education intervention appeared to provide its effects through providing opportunity, increasing capability and enhancing motivation to increase MHR knowledge and usage, as well as rational prescribing and test ordering behaviour. There were overlapping effects of skills acquisition and confidence across intervention arms, which may have contributed to wider changes in behaviour than the specific topic area addressed in the education. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12620000010998) (09/01/2020).

A realist evaluation of a London general practitioner trainer course.

Clinicians with teaching and training roles should be adequately trained and assessed. However, some debate exists as to what the nature of this training should be. Historically, a postgraduate certificate in education was a pre-requisite to becoming a GP trainer but this is changing with growing concern that such a pre-requisite might act as a deterrent to potential GP trainers. This research examines the impact of a scheme designed to provide an alternative, more practical and focused, pathway to becoming a GP trainer. We interviewed 26 course participants and stakeholders of the London GP Training Course (LGPTC), observed teaching sessions, and analysed course materials. We asked what elements of the course were and weren't effective, for whom, and under what circumstances. Here, we present a summary of our main findings - that GP trainers want to know practically, not theoretically, how to be a trainer; formative assessment boosts trainees' confidence in their own skills and abilities; short, practical GP training courses can help enhance the numbers of GP trainers; important questions remain about the role and value of educational theory in education faculty development.

Perspectives of general practitioners towards their supervisors over the past ten years in China.

OBJECTIVES: Doctors who wish to become general practitioners (GPs) in China are required to attend and complete general practice resident training. In the early stages of the standardized GP training system, GP training supervisors play important roles. This study aims to explore how GP residents perceive their GP supervisors, factors that affect GP residents' satisfaction level, as well as to offer suggestions based on the implications of this study. DESIGN: We conducted a mixed quantitative and qualitative study. Firstly, with respect to the quantitative research, we conducted a survey to investigate training satisfaction through questionnaires, then extracted and analyzed the factors that influence training satisfaction. In the qualitative study, we conducted in-depth, semistructured interviews using qualitative research criteria (COREQ)--a 32-item checklist for interviews. PARTICIPANTS: Participants in the quantitative survey included 1172 GPs whose training time wasbetween 2008 and 2017. Afterwards, 100 participants were selected from this sample , filtered by stratified random sampling and by having provided extreme answers on the quantitative survey (less than 5% of the total sample). They were chosen for the qualitative research to conduct a more detailed investigation., This stratified random sampling was based on residents' grades, regions, and training levels (city level or county level). Extreme answers were identified as answers of "extremely good" or "extremely bad" to questions from the initial comprehensive survey of 1172 participants. Consequently, 30 participants with extreme answers were found, while the remaining 70 participants in the interviews were selected by stratified random sampling. Ultimately, this sample of participants met our information collection and sample estimation requirements. RESULTS: The results show that satisfaction with GP theoretical training supervisors, GP hospital-based training supervisors, and GP community-based training supervisors differed. Considering long-term averages, the hierarchy of satisfaction is as follows: GP theoretical training supervisors > GP community-based training supervisors > GP hospital-based training supervisors. GP hospital-based training supervisors need to improve their conception of GPs, teaching methods and conscientiousness. GP community-based training supervisors need to improve their teaching methods, knowledge of clinical theory and practice ability. CONCLUSIONS: On the one hand, teams of GP supervisors in China have gradually been established over time. On the other hand,the satisfaction tendencies of residents with respect to their GP supervisors are quite different, and teams of GP supervisors must be promoted and improved.

Institutional influences on the supervision of GP trainees: a documentary analysis.

INTRODUCTION: The supervisory relationship is a key source of support for postgraduate GP trainees in the United Kingdom. This article focuses on the institutional influences on GP supervision through an analysis of training documentation. METHODS: Training documents were identified through a search of key sources of institutional influence: General Medical Council, Royal College of General Practitioners, Health Education West Midlands and a local university's supervisor-training material. Searches were run from September 2016 until February 2019, and 60 documents identified. Content analysis was undertaken, and documents were considered based on audience, context, language and purpose. RESULTS: Institutional expectations regarding the functions of trainees and supervisors were identified, and supervisory relationships appeared entangled within the broader contexts of the training practice, wider profession and political events. Collation of evidence, quality assurance and patient safety were prominent messages within the documents. The institutional hierarchy was accentuated through these messages, and through processes for trainees to raise concerns. Moving down this hierarchy, messages from within the profession changed in emphasis and content. CONCLUSION: With patient safety paramount, and high-quality training and supervision expected, the hierarchical system outlined by the documents is perhaps unsurprising. However, unintended messages may result: collation of evidence may be prized above quality and trainees may feel unable to raise legitimate concerns. Furthermore, conflicting messages from different institutions illustrate the tensions and complexities of GP supervision. For trainees and supervisors, these inconsistencies could lead to different perspectives and expectations as they interact within the supervisory relationship.

General Practitioners in US Medical Practice Compared With Family Physicians.

PURPOSE: General practitioners (GPs) are part of the US physician workforce, but little is known about who they are, what they do, and how they differ from family physicians (FPs). We describe self-identified GPs and compare them with board-certified FPs. METHODS: Analysis of data on 102,604 Doctor of Medicine and Doctor of Osteopathy physicians in direct patient care in the United States in 2016, who identify themselves as GPs or FPs. The study used linking databases (American Medical Association Masterfile, American Board of Family Medicine [ABFM], Area Health Resource File, Medicare Public Use File) to examine personal, professional, and practice characteristics. RESULTS: Of the physicians identified, 6,661 self-designated as GPs and 95,943 self-designated as FPs. Of the self-designated GPs, 116 had been ABFM certified and were excluded from the study. Of the remaining 102,488 physicians, those who self-designated as GPs but were never ABFM certified constituted the GP group (n = 6,545, 6%). Self-designated FPs that were ABFM certified made up the FP group (n = 79,449, 78%). The remaining self-designated FPs not ABFM certified constituted the uncertified group (n = 16,494, 16%). GPs differed from FPs in every characteristic examined. Compared with FPs, GPs are more likely to be older, male, Doctors of Osteopathy, graduates of non-US medical schools, and have no family medicine residency training. GPs practice location is similar to FPs, but GPs are less likely to participate in Medicare or to work in hospitals. CONCLUSIONS: GPs in the United States are a varied group that differ from FPs. Researchers, educators, and policy makers should not lump GPs together with FPs in data collection, analysis, and reporting.

Building general practice training capacity in rural and remote Australia with underserved primary care services: a qualitative investigation.

BACKGROUND: Australians living in rural and remote areas have access to considerably fewer doctors compared with populations in major cities. Despite plentiful, descriptive data about what attracts and retains doctors to rural practice, more evidence is needed which informs actions to address these issues, particularly in remote areas. This study aimed to explore the factors influencing General Practitioners (GPs), primary care doctors, and those training to become GPs (registrars) to work and train in remote underserved towns to inform the building of primary care training capacity in areas needing more primary care services (and GP training opportunities) to support their population's health needs. METHODS: A qualitative approach was adopted involving a series of 39 semi-structured interviews of a purposeful sample of 14 registrars, 12 supervisors, and 13 practice managers. Fifteen Australian Medical Graduates (AMG) and eleven International Medical Graduates (IMG), who did their basic medical training in another country, were among the interviewees. Data underwent thematic analysis. RESULTS: Four main themes were identified including 1) supervised learning in underserved communities, 2) impact of working in small, remote contexts, 3) work-life balance, and 4) fostering sustainable remote practice. Overall, the findings suggested that remote GP training provides extensive and safe registrar learning opportunities and supervision is generally of high quality. Supervisors also expressed a desire for more upskilling and professional development to support their retention in the community as they reach mid-career. Registrars enjoyed the challenge of remote medical practice with opportunities to work at the top of their scope of practice with excellent clinical role models, and in a setting where they can make a difference. Remote underserved communities contribute to attracting and retaining their GP workforce by integrating registrars and supervisors into the local community and ensuring sustainable work-life practice models for their doctors. CONCLUSIONS: This study provides important new evidence to support development of high-quality GP training and supervision in remote contexts where there is a need for more GPs to provide primary care services for the population.

UK longitudinal integrated clerkships: where are we now?

In this article, we discuss whether it is possible for UK institutions to influence the international longitudinal integrated clerkship (LIC) narrative, in the context of supplying future clinicians to a fragmented health service that is battling a General Practice recruitment crisis. Perhaps more importantly, we will discuss whether the 'LIC model' fits the UK undergraduate framework. We intend to present some emerging evidence of LICs in the UK, informed by a UK-wide survey and observations from a 2019 UK LIC think tank and then discuss whether the global CLIC definition applies to the UK context with possible ways forward.

Promoting excellence using a novel educational tool in the North of Scotland.

The General Medical Council (GMC) sets the standards and requirements for the delivery of all stages of medical education and training in the United Kingdom (UK). Using a novel educational tool (the 'Digital Carousel'), we set out to determine to what extent current systems and process sit alongside standards as set out in GMC document 'Promoting excellence' and establish key foci of work going forward to promote excellence in the Caledonian-Rural track (CRT) General Practice Specialty Training (GPST) educational programmes by engaging key stakeholders in the process. The 'Digital Carousel' allowed a large group of participants (including the Deanery team, GPSTs and ESs) to efficiently collaborate views on how our current GP training programme reflects guidance in 'Promoting excellence' and on areas for development. There was a sense of 'working together' in identifying key priorities of work for 'our' GP training programme. The tool may have value in a variety of medical educational settings.

Continuing education for general practitioners working in rural practice: a review of the literature.

Background Studies demonstrate that the CME/CPD (continuing medical education/continuing professional development) needs of rural general practitioners (GPs) are unique. Little research has focused specifically on the effectiveness of CME/CPD programmes for rural practice. Aims To review the literature on CME/CPD for GPs in rural areas, focussing on studies which examined impact on doctor performance or patient outcomes. Methods A search of peer-reviewed English language literature and relevant grey literature was conducted: identified literature was reviewed. Results Nineteen articles met the pre-specified inclusion criteria. Educational delivery approaches examined include regional CME/CPD small-group learning programmes, workshops and distance learning. Most articles report on participant experience or satisfaction while doctor performance and patient outcomes are seldom reported. Distance learning programmes found it difficult to recruit or engage doctors, two out of six studies found improvements in self-reported knowledge or performance, while none reported measurable changes in doctor performance/patient care.

E-learning in medical education: the potential environmental impact.

Introduction There is a growing interest in the use of e-learning in medical education. However until recently there has been little interest in the potential environmental benefits of e-learning. This paper models various environmental outcomes that might emerge from the use of an e-learning resource (BMJ Learning) in CPD. Methods We modeled the use of e-learning as a component of CPD and evaluated the potential impact of this use on the learner's carbon footprint. We looked at a number of models - all from the perspective of a General Practitioner (GP). We assumed that all GPs completed 50 h or credits of CPD per year. Results High users of e-learning can reduce their carbon footprint - mainly by reducing their travel to face-to-face events (reducing printing also has a small beneficial effect). A high user of e-learning can reduce the carbon footprint that relates to their CPD by 18.5 kg. Discussion As global warming continues to pose a risk to human and environmental health, we feel that doctors have a duty to consider learning activities (such as e-learning) that are associated with a lower carbon footprint.

Stepping up of MCQs' quality through a multi-stage reviewing process.

BACKGROUND: Assessment is a crucial and complex process. Thus quality assurance of assessment Methods is essential when assessment is used for the purposes of certification. AIM: To evaluate the effect of continuous well-structured process of the question bank revision, enlightened by item analysis, in improving the quality of Multiple-Choice Questions (MCQs). SETTING: The Family Medicine (FM) training certification exam for the Egyptian Board accredited for International Membership of the Royal College of General Practitioners (MRCGP[INT]). METHOD: The results of the item analysis of Applied Knowledge Tests (AKTs) of two academic years (2009, 2013) were included in the study. The AKT test consisted of two papers, each of 100 MCQS, and blue printed against the FM training curriculum. A total of 226 candidates sat for the two exams; 102 in 2009 and 124 in 2013. RESULTS: There were more MCQs with moderate difficulty and higher discrimination in 2013. Significant improvement was found in the discrimination index (DI) values in 2013 (p < 0.001). and questions with a high facility and classified as easy decreased from 40.5 to 28.7%. The average number of functioning distractors per item increased from 1.99 in 2009 to 2.19 in 2013 (p = 0.015). CONCLUSION: Revision of well-constructed MCQs on a regular basis, and in a structured manner, improved the quality of the MCQs and consequently improved the validity of the examination.

Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems.

Participation in projects to improve patient safety is a key component of general practice (GP) specialty training, appraisal and revalidation. Patient safety training priorities for GPs at all career stages are described in the Royal College of General Practitioners' curriculum. Current methods that are taught and employed to improve safety often use a 'find-and-fix' approach to identify components of a system (including humans) where performance could be improved. However, the complex interactions and inter-dependence between components in healthcare systems mean that cause and effect are not always linked in a predictable manner. The Safety-II approach has been proposed as a new way to understand how safety is achieved in complex systems that may improve quality and safety initiatives and enhance GP and trainee curriculum coverage. Safety-II aims to maximise the number of events with a successful outcome by exploring everyday work. Work-as-done often differs from work-as-imagined in protocols and guidelines and various ways to achieve success, dependent on work conditions, may be possible. Traditional approaches to improve the quality and safety of care often aim to constrain variability but understanding and managing variability may be a more beneficial approach. The application of a Safety-II approach to incident investigation, quality improvement projects, prospective analysis of risk in systems and performance indicators may offer improved insight into system performance leading to more effective change. The way forward may be to combine the Safety-II approach with 'traditional' methods to enhance patient safety training, outcomes and curriculum coverage.

Quality assessment and improvement of post graduate family medicine training in the USA.

BACKGROUND: In 2013, the World Organisation of Family Doctors published training standards for post-graduate medical education (GME) in Family Medicine/General Practice (FP/GP). GME quality has not been well-defined, other than meeting accreditation standards. In 2009, the Association of Family Medicine Residency Directors (AFMRD) developed a tool that would aid in raising the quality of family medicine residency training in the USA. OBJECTIVE: We describe the development of this quality improvement tool, which we called the residency performance index (RPI), and its first three years of use by US family medicine residency (FMR) programmes. The RPI uses metrics specific to family medicine training in the USA to help programmes identify strengths and areas for improvement in their educational activities. Our review of three years of experience with the RPI revealed difficulties with collecting data, and lack of information on graduates' scope of practice. It also showed the potential usefulness of the tool as a programme improvement mechanism. CONCLUSIONS: The RPI is a nationwide, standardised, programme quality improvement tool for family medicine residency programmes in the USA, which was successfully launched as part of AFMRD's strategic plan. Although some initial challenges need to be addressed, it has the promise to aid family medicine residencies in their internal improvement efforts. This model could be adapted in other post-graduate training settings in FM/GP around the world.

For the general internist: a review of relevant 2013 innovations in medical education.

We conducted a review of articles published in 2013 to identify high-quality research in medical education that was relevant to general medicine education practice. Our review team consisted of six general internists with expertise in medical education of varying ranks, as well as a professional medical librarian. We manually searched 15 journals in pairs, and performed an online search using the PubMed search engine for all original research articles in medical education published in 2013. From the total 4,181 citations identified, we selected 65 articles considered most relevant to general medicine educational practice. Each team member then independently reviewed and rated the quality of each selected article using the modified Medical Education Research Study Quality Instrument. We then reviewed the quality and relevance of each selected study and grouped them into categories of propensity for inclusion. Nineteen studies were felt to be of adequate quality and were of moderate to high propensity for inclusion. Team members then independently voted for studies they felt to be of the highest relevance and quality within the 19 selected studies. The ten articles with the greatest number of votes were included in the review. We categorized the studies into five general themes: Improving Clinical Skills in UME, Inpatient Clinical Teaching Methods, Advancements in Continuity Clinic, Handoffs/Transitions in Care, and Trainee Assessment. Most studies in our review of the 2013 literature in general medical education were limited to single institutions and non-randomized study designs; we identified significant limitations of each study. Selected articles may inform future research and practice of medical educators.

[MODERN EDUCATIONAL TECHNOLOGY MASTERING PRACTICAL SKILLS OF GENERAL PRACTITIONERS].

The article presents the experience of postgraduate training of general practitioners--family medicine. Identified current trends, forms and methods of pedagogical innovations that enhance the quality of learning and mastering the practical skills of primary professionals providing care.

Measuring the effectiveness of an intensive IPV training program offered to Greek general practitioners and residents of general practice.

BACKGROUND: The need for effective training of primary care physicians in the prevention, detection and handling of intimate partner violence (IPV) has been widely acknowledged, given its frequency in daily practice. The current intervention study aimed to measure changes in the actual IPV knowledge, perceived knowledge, perceived preparedness and detection ability of practicing general practitioners (GPs) and general practice residents, following an intensive IPV training program. METHODS: A pre/post-test design with a control group was employed to compare changes in baseline measures of IPV at the post intervention stage and at 12 months. A total of 40 participants provided full data; 25 GPs (11 in the intervention and 14 in the control) and 15 residents (intervention only). Three scales of the PREMIS survey were used to draw information on the study outcomes. RESULTS: The training program met high acceptance by both groups of participants and high practicality in clinical practice. The GPs in the intervention group performed better than the GPs in the control group on "Perceived preparedness" and "Perceived knowledge" in both the post-intervention (p= .012, r= .50 and p= .001, r= .68) and the 12-month follow-up (p= .024, r= .45 and p= .007, r= .54) as well as better than the residents in "Perceived preparedness" at post-intervention level (p= .037, r= .41). Residents on the other hand, performed better than the GPs in the intervention group on "Actual knowledge" at the 12-month follow-up (p= .012, r= .49). No significant improvements or between group differences were found in terms of the self-reported detection of IPV cases. CONCLUSION: Further studies are needed to decide whether residency training could serve as an early intervention stage for IPV training.