Patient outcomes in a Longitudinal Integrated Clerkship: A systematic literature review.

CONTEXT: Patient-student relationships are at the heart of Longitudinal Integrated Clerkships (LICs). Outcomes for students and preceptors are beneficial, but patient outcomes remain unclear. This systematic literature review explored the current evidence base of patient outcomes in an LIC. Patient outcomes were defined as issues related to patient safety, clinical effectiveness or patient experience. METHODS: Seven bibliographic databases were searched. A wider search strategy included a hand search of three medical education journals' previous issues and backward/forward citation searching of included studies and of a relevant systematic review. Included studies were quality appraised and assessed for their strength and level of evidence. A qualitative data synthesis was performed. RESULTS: Databases searches identified 7237 titles. Following the removal of duplicates, titles and abstracts were reviewed against the inclusion criteria. Forty-eight studies had a full-text review. Nineteen met the inclusion criteria. Seven studies were included from the wider search strategy. From the 26 included studies, two major themes were identified. (1) 'A trusting patient-student relationship' contains the sub-themes: 'care and compassion', 'patient education and empowerment' and 'the loss of the student as 'my' doctor'. (2) 'The student acts as an agent of change for the patient' contains the sub-themes: 'patient advocacy', 'supporting the patient to navigate the healthcare system', 'communication between patient and healthcare professional' and 'enhancement of preceptors' care, healthcare services and communities'. CONCLUSIONS: LICs provide educational continuity allowing the creation of a trusting patient-student relationship. This relationship leads to students becoming agents of change for patients by enhancing patient outcomes. This review provides further evidence on the benefits of having an LIC as part of the medical education curricula and implications for its successful delivery. Further research is needed to explore educationally induced benefits for patients and look at objective assessments of patient health outcomes.

Twelve tips for positive role modelling in medical education.

Role modelling has powerful impact in medical education, with the potential to shape the professional development, clinical skills and career choices of the medical workforce. In this article we provide twelve tips, some aimed at educators and some at curriculum leaders, to increase the positive potential of role modelling. Our tips are based on theory, evidence, our own research and experience. They include ensuring educators are conscious of their role modelling potential, providing role models to represent the diversity of learners, facilitating reflection in the role modelling process and supporting role modelling to improve recruitment to shortage specialties.

Students' and tutors' experiences of remote 'student-patient' consultations.

BACKGROUND: Remote consulting has become part of the medical student clinical experience in primary care, but little research exists regarding the impact on learning. AIM: To describe the experiences of General Practitioner (GP) educators and medical students in using student-led remote consultations as an educational tool. METHOD: A qualitative, explorative study conducted at four UK medical schools. GP educators and medical students were purposively sampled and interviewed. RESULTS: Nine themes arose: practical application, autonomy, heuristics, safety, triage of undifferentiated patients, clinical reasoning, patient inclusion in student education, student-patient interaction, and student-doctor interaction. DISCUSSION: Remote consulting has become part of the clinical placement experience. This has been found to expose students to a wider variety of clinical presentations. Verbal communication, history-taking, triage, and clinical reasoning skills were practised through remote consulting, but examination skills development was lacking. Students found building rapport more challenging, although this was mitigated by having more time with patients. Greater clinical risk was perceived in remote consulting, which had potential to negatively impact students' psychological safety. Frequent debriefs could ameliorate this risk and positively impact student-doctor relationships. Student autonomy and independence increased due to greater participation and responsibility. Pre-selection of patients could be helpful but had potential to expose students to lower complexity patients.[Box: see text].

How will the Covid-19 pandemic shape the future of primary care undergraduate teaching? Understanding modifications and developments deployed by UK academic units of primary care, and their implications for the future.

BACKGROUND: Primary care has been under-represented in its contribution to the academic literature base on Covid-19 developments. We sought to understand how teaching and learning was modified and developed by primary care academic leaders to support the continuation of primary care-orientated learning during the Covid-19 pandemic; and explore how these changes may shape future educational delivery in primary care. METHODS: We adopted a qualitative approach, using semi-structured interviews of seven General Practice Heads of Teaching (GP HoTs) from UK medical schools. We used mixed deductive and inductive coding to analyse interview transcripts. Modifications and developments were coded to four a priori themes (clinical off-site; clinical on-site; synchronous remote; asynchronous remote). We concurrently used inductive coding to identify developments that did not readily fit into these categories. To understand how participants perceived the developments may shape primary care teaching in the future, we carried out an inductive thematic analysis. RESULTS: A range of modifications and developments were described. Examples of developments include: GP practices being provided with increased flexibility to support ongoing provision of clinical placements (on-site clinical), examples of initiatives enabling students to consult remotely from their homes (off-site clinical), transfer of face-to-face teaching to remote formats (synchronous remote) and development of new, interactive on-line teaching materials (asynchronous remote). One additional theme arose inductively: collaboration and co-operation. For future implications, five themes arose: the evolution of flexible and hybrid clinical placement models; an increased role for telemedicine; increased networking and collaboration; increased active student involvement in patient care; and opportunities for community-based teaching afforded by the pandemic. CONCLUSION: This study highlights how teaching was modified to support the continuation of primary care-based learning during the Covid-19 pandemic, and implications for the future. Collaboration and placement flexibility were notable features in the response. Participants perceived that flexible placement models containing a mixture of clinical on-site with remote synchronous and asynchronous teaching and learning activities, may persist into the post-Covid era. Further research is required to understand which developments become routinely embedded into primary care teaching in the post-Covid era and explain how and why this occurs.

Cultural Attitudes towards General Practice within Medical Schools: Experiences of GP Curriculum Leaders.

INTRODUCTION: UK undergraduate medical curricula are under pressure to become more community-focused and generalist in approach to equip all future doctors with generalist skills and increase recruitment to generalist specialities like general practice. However, the amount of general practice teaching in UK undergraduate curricula is static or falling. Undervaluing, in the form of general practice denigration and undermining, is increasingly recognised from a student perspective. However, little is known about the perspectives of academics working within medical schools. AIM: To explore the cultural attitudes towards general practice within medical schools as experienced by general practice curriculum leaders. METHODS: A qualitative study using semi-structured interviews of eight general practice curriculum leaders in UK medical schools. Purposive sampling for diversity was used. Interviews were analysed using reflexive thematic analysis. FINDINGS: Seven themes were identified covering 'a kaleidoscope of attitudes towards general practice', 'overt everyday denigration of general practice', 'a hidden curriculum of undervaluing general practice', 'valuing general practice: representation, recognition and respect', 'relating to others, relating to oneself', 'power, empowerment and vulnerability', and 'the pandemic as an opportunity'. CONCLUSIONS: Cultural attitudes towards general practice were diverse: a spectrum varying from valuing general practice to overt denigration, with a 'hidden curriculum' of subtle undervaluing of general practice. Hierarchical, tense relationships between general practice and hospital were a recurring theme. Leadership was identified as important in setting the tone for cultural attitudes, as well as indicating general practice is valued when general practitioners are included within leadership. Recommendations include a shift in narrative from denigration to mutual speciality respect between all doctors.

Developing a career as a GP educationalist: contemporary challenges and workforce solutions.

GP educationalists are crucial in training the future medical workforce and in developing and advancing the field of primary care medical education, yet opportunities in the UK are patchy and varied. In this article, a group of GP educationalists summarise the challenges facing the sustainability of this particular group of clinical academics and outline opportunities available at each career stage, from medical students through to senior GP educationalists. Recommendations to support the growth of this workforce include the development of a nationally recognised framework for GP educationalist careers, collaboration with professional and educational bodies and taking steps to level out opportunities in order to reduce existing inequity.

How does the introduction of a new year three GP curriculum affect future commitment to teach? An evaluation using a realist approach.

In western countries, there is a trend towards increasing amounts of undergraduate medical education being delivered in General Practice (GP). However, many medical schools report difficulties with the recruitment and retainment of GP clinical teachers. Newcastle University recently introduced a new year three GP curriculum, involving an increased quantity of community-based teaching and changes to the responsibilities of GP clinical teachers. We sought to explore and explain how this curricular change affects the future teaching commitment of year three GP clinical teachers. We adopted a realist approach. We firstly developed a candidate theory of how the new curriculum may affect future teaching commitment. Data collection and analysis then involved interviews of 10 GP teachers to refine this theory and produce a final Programme Theory. The results suggest that different teachers are affected in different ways, influenced by practice and individual contexts. Some parts of the new curriculum tend to reduce future teaching commitment, whereas other aspects tend to increase commitment. Mechanisms include changes to autonomy and sense of value. The results allow medical schools to better understand how GP teacher retention can be facilitated during curricular change. We make numerous recommendations, including advocating a team-based approach to teaching, paying attention to teacher autonomy, and considering patient contact in relation to generalist, primary care-orientated medicine as a core component of GP teaching.

The impact of role modelling on the future general practitioner workforce: a systematic review.

Role modelling has been identified as an important phenomenon in medical education. Key reports have highlighted the ability of role modelling to support medical students towards careers in family medicine although the literature of specific relevance to role modelling in speciality has not been systematically explored. This systematic review aimed to fill this evidence gap by assimilating the worldwide literature on the impact of role modelling on the future general practitioner (GP) workforce. A systematic search was conducted in Medline, Embase, Scopus, Web of Science, Cochrane, ERIC and CINAHL, and all authors were involved in the article screening process. A review protocol determined those articles selected for inclusion, which were then quality assessed, coded and thematically analysed. Forty-six articles were included which generated four broad themes: the identity of role models in general practice, role modelling and becoming a doctor, the impact of role modelling on attitudes towards the speciality, and the subsequent influence on behaviours/career choice. Our systematic review confirmed that role modelling in both primary and secondary care has a crucial impact on the future GP workforce, with the potential to shape perceptions, to attract and deter individuals from the career, and to support their development as professionals. Role modelling must be consciously employed and supported as an educational strategy to facilitate the training of future GPs.

Real-time patients' perspectives about participating in teaching consultations in primary care: A questionnaire study.

INTRODUCTION: Patients presenting with undifferentiated illnesses provide valuable learning opportunities for medical students. Evidence detailing the factors that affect patient participation in undergraduate medical education is limited. This study examines how patients regard their participation in teaching consultations in primary care. METHODS: We conducted a cross-sectional questionnaire survey in four GP practices. We tested the relationship between variables of interest and willingness to participate, using hierarchical logistic regression. RESULTS: We analysed 525 questionnaires. 88% of respondents were willing to have students take part in their consultation, and 72% were willing to see a student alone before seeing the doctor. Older patients and those with less sensitive clinical problems were more likely to participate. Willingness to participate was also associated with patients' perceptions of certain costs and benefits of participation. Respondents had poor knowledge about medical education, and a sizeable minority perceived a lack of autonomy about the presence of students in their encounters. More than one-third of respondents expressed the presence of a clinician as a precondition for approval of students' performing some active roles. DISCUSSION: The findings have identified potential interventions to enhance patient involvement including patient education, respecting patient autonomy, and ensuring appropriate student supervision.

Longitudinal GP placements - inspiring tomorrow's doctors?

General practice worldwide is facing a severe recruitment crisis, with significantly fewer medical students choosing to pursue careers in primary care than are required to meet society's growing demands. The role of GP placements and GP tutors has been highlighted as having a significantly positive influence on medical students' perceptions of general practice. However, how students perceive these experiences to have influenced their subsequent career preferences remains poorly understood.We sought to explore how a longitudinal GP placement influences medical students' preferences regarding a career in general practice, in order to gain a deeper understanding of the significance of such placements. Semi-structured interviews were undertaken with five fourth-year medical students using Interpretive Phenomenological Analysis methodology.Four overarching concepts were identified, with nine superordinate themes, to describe how a longitudinal placement had influenced medical students' preference regarding a career in general practice. There appears to have been a matching process between an expanding knowledge of the realities of being a GP and an increasing understanding of self. The GP tutor and 'authentic' experiences to consult patients themselves developed a growing sense of self-efficacy within students, all of which resulted in a significant internal desire to become future GPs.

Focus on medical education research in primary care: an undergraduate medical education faculty's journey.

This paper provides a viewpoint on medical education research in primary care from undergraduate medical educators, discussing the issues and questions shared with other institutions, the role of medical education research in raising the profile of academic general practice, the challenges and opportunities faced and how education-based research can form an evidence-based approach to teaching.

The new cultural norm: reasons why UK foundation doctors are choosing not to go straight into speciality training.

BACKGROUND: The number of UK foundation doctors choosing to go straight into speciality training has fallen drastically over the last 10 years: We sought to explore and understand the reasons for this change. METHODS: We undertook semi-structured interviews with 16 foundation year two doctors, who had not applied to speciality training, from two regional foundation schools. Transcripts were thematically analysed. RESULTS: The reasons that foundation doctors are choosing not to go straight into speciality training centre around the themes of feeling undervalued, career uncertainty and a new cultural norm. They report major feelings of uncertainty regarding career choice at such an early stage of their profession and this challenge was magnified by a perceived lack of flexibility of training and the growing normality of taking time out from training. Trainees feel a lack of support in planning and undertaking an "FY3" year and being helped back into the workforce. Trainees overwhelmingly reported that they feel undervalued by their employers. Importantly, however, not going into training directly was not always a reflection of dissatisfaction with training. Many trainees spoke very positively about their planned activities and often saw a break in training as an excellent way to recharge, develop skills and prepare for the rest of their careers in medicine. CONCLUSIONS: Taking a year or more out of training after foundation years has become the new cultural norm for UK junior doctors and reasons for this include feeling undervalued, career uncertainty and the perception that this is now "normal". Exploring these factors with participants has generated a number of recommendations related to improving the workplace environment, allowing more flexibility in training and supporting those who chose to take an FY3.

Exploring educational integrated training posts in general practice: a phenomenological study of trainees' perspectives.

This study explores the experience of undertaking an educational integrated training post (ITP) in general practice. There are problems with General Practice (GP) recruitment and retention in the UK and worldwide. It is thought that integrated training programmes (ITPs) within GP training may offer a new and appealing way of training, which may address this problem. Health Education England North East (HEENE) has been running educational integrated training posts for over 5 years. Integrated training schemes such as this have been rarely studied and in particular the trainees' perspectives. In order to improve understanding of these posts and their potential for aiding GP recruitment, we undertook a qualitative study to explore trainees' perceptions of the experience of undertaking an educational ITP. The study takes an interpretive phenomenological approach using focus groups and one-to-one interviews which were audio-recorded, transcribed and thematically analysed. Emerging themes from the data captured participants' views of their experience of undertaking the posts, as well as the factors influencing their decisions to undertake the posts. The overarching theme found centred on identity formation. The study draws upon social learning theories to help understand and explain the themes identified and the influence on the individuals. For the interested stakeholder, this provides an insight into the individuals' experience and highlights important areas that could be targeted and utilised in the development of future general practice training models.

Promoting general practice in medical schools. Where are we now?

In November 2016, the Medical Schools Council and Health Education England published a joint report chaired by Professor Val Wass: 'By choice - not by chance' to raise the profile of general practice as a positive career choice for medical students. We sought to evaluate the impact of the report by firstly, asking the views of Heads of GP teaching at UK medical schools whether and how the report has supported them in raising the profile of general practice and secondly, describing the initiatives developed by medical schools in a national survey. There was a perception reported by heads of GP teaching that the report has been highly influential in facilitating the promotion of general practice as a career to medical students. We describe multiple specific initiatives developed in response to the report's recommendations. The national survey confirmed that whilst there is significant variation across medical schools in their response to the specific recommendations in the report, definite progress is being made. A number of areas that need particular consideration have been highlighted and we would recommend that future surveys are completed at appropriate time intervals to review further progress.

Facilitators and barriers to teaching undergraduate medical students in general practice.

CONTEXT: Globally, primary health care is facing workforce shortages. Longer and higher-quality placements in primary care increase the likelihood of medical students choosing this specialty. However, the recruitment and retention of community primary care teachers are challenging. Relevant research was predominantly carried out in the 1990s. We seek to understand contemporary facilitators and barriers to general practitioner (GP) engagement with undergraduate education. Communities of practice (CoP) theory offers a novel conceptualisation, which may be pertinent in other community-based teaching settings. METHODS: Semi-structured interviews were undertaken with 24 GP teachers at four UK medical schools. We purposively sampled GPs new to teaching, established GP teachers and GPs who had recently stopped teaching. We undertook NVivo-assisted deductive and inductive thematic analysis of transcripts. We used CoP theory to interpret data. RESULTS: Communities of practice theory illustrated that teachers negotiate membership of three CoPs: (i) clinical practice; (ii) the medical school, and (iii) teaching. The delivery of clinical care and teaching may be integrated or exist in tension. This can depend upon the positioning of the teaching and teacher as central or peripheral to the clinical CoP. Remuneration, workload, space and the expansion of GP trainee numbers impact on this. Teachers did not identify strongly as members of the medical school or a teaching community. Perceptions of membership were affected by medical school communication and support. The findings demonstrate gaps in medical school recruitment. CONCLUSIONS: This research demonstrates the marginalisation of primary care-based teaching and proposes a novel explanation rooted in CoP theory. Concepts including identity and membership may be pertinent to other community-based teaching settings. We recommend that medical schools review and broaden recruitment methods. Teacher retention may be improved by optimising the interface between medical schools and teachers, fostering a teaching community, increasing professional rewards for teaching involvement and altering medical school expectations of learning in primary care.

Barriers to involving GP Speciality Trainees in the teaching of medical students in primary care: the GP trainer perspective.

Involvement in teaching activities is a curriculum requirement for GP Speciality Trainees (GPSTs). There are numerous potential benefits to involving GPSTs in teaching, including mutual educational benefit for both GPST and learner. However, GPSTs on placement in primary care may be less involved in teaching activities than hospital-based trainees. The reasons for this are not fully understood. This multi-site study aimed to explore the perceptions of GP trainers of the barriers to involving GPSTs in teaching in primary care. Focus groups of General Practice (GP) trainers from four regional GP training programmes across Northern England were conducted. Data were analysed thematically. Trainers cited barriers relating to the trainee (e.g. capacity and capability), practice (e.g. capacity), and teaching (e.g. appropriateness of teaching methods). Underlying these barriers, there appeared to be a cultural attitude towards GPST involvement in teaching: trainers viewed teaching as an extraneous rather than integral part of GP training, considered teaching to represent a deviation from the norm and felt that the GPST was restricted to a learner role. Whilst attempts to address the practical barriers identified in this study are required, a cultural shift in which the role of the GPST as a teacher becomes normalised is urgently needed.

Near peer teaching in general practice: option or expectation?

General Practice (GP) trainees who teach medical students do so as near peers with established educational benefits for all concerned. Through teaching, GP trainees consolidate their own knowledge and skills whilst students value the experience of learning from teachers closer in age and stage. Importantly, involving GP trainees as teachers increases primary care teaching capacity and promotes GP as a potential career option for undergraduates. However, whilst junior doctors are often to be found teaching on hospital wards and in clinics, GP trainees based in primary care appear to have fewer opportunities to teach. This article encourages the promotion of near peer teaching in primary care on several levels. We make practical suggestions of potential benefit to the individual GP trainee, trainer and practice. We also discuss ways in which key stakeholders, including medical schools and those organising post-graduate primary care training programmes, may promote near peer teaching in GP. We propose that all medical students should have experience of being taught by GP trainees, and that all future general practitioners should have training and experience of teaching undergraduate medical students.

Twelve tips for the recruitment and retention of general practitioners as teachers of medical students.

BACKGROUND: Primary care physicians have become a fundamental aspect of teaching in modern medical school curricula worldwide with a significant proportion of undergraduate teaching taking place in primary care. There are calls for this to increase with more patient care occurring in the community but teaching capacity in primary care is a potential challenge. Medical schools, therefore, need strategies to be able to increase their primary care physician teaching workforce. METHODOLOGY: We asked all Heads of General Practice Teaching in UK medical schools to share their three top tips for recruiting and retaining GPs to teach undergraduate students. The majority (two-thirds) of medical schools responded and we have summarized the answers into the following twelve tips. RESULTS: Although the twelve tips are varied and comprehensive, including broad topics such as finances and training, one clear theme running through the majority of tips is good communication and relationships between education teams and GPs. CONCLUSIONS: The solutions to recruiting and retaining GPs to teach undergraduate medical students are clearly multifactorial and complex. We hope that by presenting suggestions from UK GP heads of teaching as these twelve tips provides some helpful, thought-provoking ideas and inspiration for both the UK and internationally.