Effect of extension of postgraduate training in general practice on the acquisition of knowledge of trainees.

BACKGROUND: Postgraduate training in general practice aims to develop clinical competence. However, little is known about its effect on trainees' development of competence. OBJECTIVE: Our aim was to investigate whether 3 years of postgraduate training in general practice leads to a higher level of knowledge than 2 years training while maintaining the same structure and educational objectives. METHODS: This retrospective study had a mixed longitudinal design. Trainees of the Dutch postgraduate training in general practice participated. Knowledge was assessed by written progress testing of knowledge relevant to general practice embedded in real life situations. Test results were collected from 1992 to 1999. The results of trainees who received the 2-year and 3-year curriculum were compared. RESULTS: Both curricula started with the same entrance level and showed the largest acquisition of knowledge at the start and towards the end of training. Both curricula showed stagnation in growth at the end of the training period in which trainees rotate through hospitals, nursing homes and mental health institutions. The level of knowledge at the end of training was significantly higher for the 3-year curriculum. CONCLUSION: This study shows that postgraduate training contributes to an increase in knowledge and that a 3-year programme leads to a higher level of knowledge than a 2-year programme. The stagnation in growth found at the end of rotations through hospitals, nursing homes and mental health institutions questions the impact of these rotations on the development of competence and the efficacy of the training as a whole. Further study is needed to draw more firm conclusions.

Comparison of a rational and an empirical standard setting procedure for an OSCE. Objective structured clinical examinations.

PURPOSE: Earlier studies of absolute standard setting procedures for objective structured clinical examinations (OSCEs) show inconsistent results. This study compared a rational and an empirical standard setting procedure. Reliability and credibility were examined first. The impact of a reality check was then established. METHODS: The OSCE included 16 stations and was taken by trainees in their final year of postgraduate training in general practice and experienced general practitioners. A modified Angoff (independent judgements, no group discussion) with and without a reality check was used as a rational procedure. A method related to the borderline group procedure, the borderline regression (BR) method, was used as an empirical procedure. Reliability was assessed using generalisability theory. Credibility was assessed by comparing pass rates and by relating the passing scores to test difficulty. RESULTS: The passing scores were 73.4% for the Angoff procedure without reality check (Angoff I), 66.0% for the Angoff procedure with reality check (Angoff II) and 57.6% for the BR method. The reliabilities (expressed as root mean square errors) were 2.1% for Angoffs I and II, and 0.6% for the BR method. The pass rates of the trainees and GPs were 19% and 9% for Angoff I, 66% and 46% for Angoff II, and 95% and 80% for the BR method, respectively. The correlation between test difficulty and passing score was 0.69 for Angoff I, 0.88 for Angoff II and 0.86 for the BR method. CONCLUSION: The BR method provides a more credible and reliable standard for an OSCE than a modified Angoff procedure. A reality check improves the credibility of the Angoff procedure but does not improve its reliability.

Acquisition of clinical skills in postgraduate training for general practice.

BACKGROUND: Postgraduate training in general practice aims to develop clinical competence. However, little is known about its effect on trainees' development of clinical skills. AIM: To assess the acquisition of clinical skills during a 3-year training programme and to evaluate whether a satisfactory level is achieved towards the end of training. DESIGN OF STUDY: Cross-sectional design. SETTING: Dutch postgraduate training in general practice from 1995 to 1998. METHOD: Clinical skills were assessed using a written knowledge test of skills and by an Objective Structured Clinical Examination (OSCE). The written test was administered to trainees in all 3 years. Trainees at completion of their training took the OSCE. The results of both tests were compared with a standard of adequacy and to a reference group of general practitioner (GP) trainers. RESULTS: An increase in the level of clinical skills and pass rate was found throughout the training, being most prominent during the first 6 months. At completion of their training, trainees scored higher than the GPs on the written test (48% versus 39%) and on the OSCE (69% versus 63%). Eighty-eight per cent of the trainees would have passed the written test against 70% of the GPs and 94% would have passed the OSCE against 80% of the GPs. CONCLUSION: A 3-year postgraduate training period in general practice contributes to a satisfactory acquisition of clinical skills. Further research into when and where acquisition takes place, and the role of the GP trainer, is needed.

What influences the quality of educational encounters between trainer and trainee in vocational training for general practice?

This study of educational encounters between a trainer and a trainee in vocational training for general practice investigates the quality of the encounter. The study focuses on the relation between the quality of the encounter and elements such as presence of feedback, duration, use of media, etc. A quality measure based on the Gagné and Briggs model for the design of instructional events was developed. The quality score was correlated with other elements of the encounter as reported in a log diary completed by trainees. In the log diary 45 trainees registered 314 encounters. Quality predictors included duration of the encounter, the number of media (files of patients, professional guidelines) used, the number of follow-up activities and feedback by the trainer on the performance of the trainee. Several elements were identified as contributing to the educational quality of the encounter, such as presence of media, follow-up activities and positive feedback. The trainer can easily control these elements.