The influence of psychological safety on feedback conversations in general practice training.

INTRODUCTION: Fostering trainee psychological safety is increasingly being recognised as necessary for effective feedback conversations. Emerging literature has explored psychological safety in peer learning, formal feedback and simulation debrief. Yet, the conditions required for psychologically safe feedback conversations in clinical contexts, and the subsequent effects on feedback, have not been explored. METHODS: We conducted a qualitative study using interviews and longitudinal audio-diaries with 12 rural general practice trainees. The data were analysed using framework thematic analysis to identify factors across the data and as individual participant case studies with illustrative vignettes of dynamic interleaving of factors in judgements about feedback conversations. FINDINGS: Findings identify the influence of intrapersonal (e.g. confidence and comfort to seek help), interpersonal (e.g. trust and relationship) and sociocultural factors (e.g. living and working in a rural community) that contribute to psychological safety in the context of everyday feedback conversations. Multiple factors interplayed in feedback conversations where registrars could feel safe and unsafe within one location and even at the one time. DISCUSSION: Participants felt psychologically safe to engage their educators in sanctioned systems of conversation related to the immediate care of the patient and yet unsafe to engage in less patient related performance conversations despite the presence of multiple positive interpersonal factors. The concept of a safe 'container' (contained space) is perhaps idealised when it comes to feedback conversations about performance in the informal and emergent spaces of postgraduate training. More research is needed into understanding how clinical environments can sanction feedback conversations in clinical environments.

A systematic review of the approaches to multi-level learning in the general practice context, using a realist synthesis approach: BEME Guide No. 55.

Background: Recent global increases in medical student numbers and shifts in medical education from teaching hospitals to community settings call for effective strategies to meet the demand for general practice teaching placements. It has been proposed that "multi-level learning" (MLL), in which learning and teaching are shared across different levels of learners, may provide teaching efficiencies and valuable experiences for learners and teachers. Aims: To identify, evaluate and synthesize the evidence related to the types, benefits, challenges, and facilitators of MLL in community-based general practice, and the underlying mechanisms and associated contexts to explain the reported outcomes. Method: A realist synthesis approach guided the systematic review. Results: Fifteen papers were identified, providing primary evaluation data predominantly from interviews with or surveys of key stakeholders. Generally, all levels of learners reported overall satisfaction with their MLL experiences. Medical students appreciated learning from prevocational doctors and registrars due to social and cognitive congruence. Mechanisms and contexts that supported our hypotheses regarding successful MLL outcomes were identified, with "a strong teaching culture" being a major mechanism. Conclusions: The findings can help inform practices considering the implementation or enhancement of MLL initiatives in general practice. Further research should include measuring defined learning outcomes.

Medical students, early general practice placements and positive supervisor experiences.

Introduction Community-based longitudinal clinical placements for medical students are becoming more common globally. The perspective of supervising clinicians about their experiences and processes involved in maximising these training experiences has received less attention than that of students. Aims This paper explores the general practitioner (GP) supervisor perspective of positive training experiences with medical students undertaking urban community-based, longitudinal clinical placements in the early years of medical training. Methods Year 2 medical students spent a half-day per week in general practice for either 13 or 26 weeks. Transcribed semi-structured interviews from a convenience sample of participating GPs were thematically analysed by two researchers, using a general inductive approach. Results Identified themes related to the attributes of participating persons and organisations: GPs, students, patients, practices and their supporting institution; GPs' perceptions of student development; and triggers enhancing the experience. A model was developed to reflect these themes. Conclusions Training experiences were enhanced for GPs supervising medical students in early longitudinal clinical placements by the synergy of motivated students and keen teachers with support from patients, practice staff and academic institutions. We developed an explanatory model to better understand the mechanism of positive experiences. Understanding the interaction of factors enhancing teaching satisfaction is important for clinical disciplines wishing to maintain sustainable, high quality teaching.

A review of longitudinal community and hospital placements in medical education: BEME Guide No. 26.

BACKGROUND: Traditionally, clinical learning for medical students consists of short-term and opportunistic encounters with primarily acute-care patients, supervised by an array of clinician preceptors. In response to educational concerns, some medical schools have developed longitudinal placements rather than short-term rotations. Many of these longitudinal placements are also integrated across the core clinical disciplines, are commonly termed longitudinal integrated clerkships (LICs) and often situated in rural locations. This review aimed to explore, analyse and synthesise evidence relating to the effectiveness of longitudinal placements, for medical students in particular to determine which aspects are most critical to successful outcomes. METHOD: Extensive search of the literature resulted in 1679 papers and abstracts being considered, with 53 papers ultimately being included for review. The review group coded these 53 papers according to standard BEME review guidelines. Specific information extracted included: data relating to effectiveness, the location of the study, number of students involved, format, length and description of placement, the learning outcomes, research design, the impact level for evaluation and the main evaluation methods and findings. We applied a realist approach to consider what works well for whom and under what circumstances. FINDINGS: The early LICs were all community-based immersion programs, situated in general practice and predominantly in rural settings. More recent LIC innovations were situated in tertiary-level specialist ambulatory care in urban settings. Not all placements were integrated across medical disciplines but were longitudinal in relation to location, patient base and/or supervision. Twenty-four papers focussed on one of four programs from different viewpoints. Most evaluations were student opinion (survey, interview, focus group) and/or student assessment results. Placements varied from one half day per week for six months through to full time immersion for more than 12 months. The predominant mechanism relating to factors influencing effectiveness was continuity of one or more of: patient care, supervision and mentorship, peer group and location. The success of LICs and participation satisfaction depended on the preparation of both students and clinical supervisors, and the level of support each received from their academic institutions. CONCLUSION: Longitudinal placements, including longitudinal integrated placements, are gaining in popularity as an alternative to traditional block rotations. Although relatively few established LICs currently exist, medical schools may look for ways to incorporate some of the principles of LICs more generally in their clinical education programmes. Further research is required to ascertain the optimum length of time for placements depending on the defined learning outcomes and timing within the programme, which students are most likely to benefit and the effects of context such as location and type of integration.

Analysing clinical reasoning characteristics using a combined methods approach.

BACKGROUND: Despite a major research focus on clinical reasoning over the last several decades, a method of evaluating the clinical reasoning process that is both objective and comprehensive is yet to be developed.The aim of this study was to test whether a dual approach, using two measures of clinical reasoning, the Clinical Reasoning Problem (CRP) and the Script Concordance Test (SCT), provides a valid, reliable and targeted analysis of clinical reasoning characteristics to facilitate the development of diagnostic thinking in medical students. METHODS: Three groups of participants, general practitioners, and third and fourth (final) year medical students completed 20 on-line clinical scenarios -10 in CRP and 10 in SCT format. Scores for each format were analysed for reliability, correlation between the two formats and differences between subject-groups. RESULTS: Cronbach's alpha coefficient ranged from 0.36 for SCT 1 to 0.61 for CRP 2, Statistically significant correlations were found between the mean f-score of the CRP 2 and total SCT 2 score (0.69); and between the mean f-score for all CRPs and all mean SCT scores (0.57 and 0.47 respectively). The pass/fail rates of the SCT and CRP f-score are in keeping with the findings from the correlation analysis (i.e. 31% of students (11/35) passed both, 26% failed both, and 43% (15/35) of students passed one but not the other test), and suggest that the two formats measure overlapping but not identical characteristics. One-way ANOVA showed consistent differences in scores between levels of expertise with these differences being significant or approaching significance for the CRPs. CONCLUSION: SCTs and CRPs are overlapping and complementary measures of clinical reasoning. Whilst SCTs are more efficient to administer, the use of both measures provides a more comprehensive appraisal of clinical skills than either single measure alone, and as such could potentially facilitate the customised teaching of clinical reasoning for individuals. The modest reliability of SCTs and CRPs in this study suggests the need for an increased number of items for testing. Further work is needed to determine the suitability of a combined approach for assessment purposes.

Workplace bullying--what's it got to do with general practice?

BACKGROUND: Workplace bullying is repeated systematic, interpersonal abusive behaviours that negatively affect the targeted individual and the organisation in which they work. It is generally the result of actual or perceived power imbalances between perpetrator and victim, and includes behaviours that intimidate, offend, degrade or humiliate a worker. It is illegal, and bullied employees can take legal action against their employers for a breach of implied duty of trust and confidence. Despite this, workplace bullying occurs in many Australian workplaces, including Australian general practices. OBJECTIVE: This article explores the issue of workplace bullying with particular reference to bullying within general practice and provides a framework for managing these situations. DISCUSSION: All general practices need organisation-wide anti-bullying policies that are endorsed by senior management, clearly define workplace bullying, and provide a safe procedure for reporting bullying behaviours. General practitioners should investigate whether workplace issues are a potential contributor to patients who present with depression and/or anxiety and assess the mental health of patients who do disclose that they are victims of workplace bullying, Importantly, the GP should reassure their patient that bullying is unacceptable and illegal, and that everyone has the right to a safe workplace free from violence, harassment and bullying. The time has come for all workplaces to acknowledge that workplace bullying is unacceptable and intolerable.

Bullying in the Australian medical workforce: cross-sectional data from an Australian e-Cohort study.

OBJECTIVE: This study aimed to describe the prevalence of perceived workplace bullying in the Australian medical workforce, and investigate the relationship between workplace bullying and job satisfaction, health status, and current and planned medical workforce participation. METHODS: An electronic cross-sectional survey of doctors currently in the paid workforce, conducted between April 2008 and October 2009, was nested within a longitudinal cohort study investigating factors affecting the recruitment and retention of the Australian medical workforce. To address the specific aims of this study, a subset of questions in the survey investigated the prevalence of self-reported bullying; physical and mental health; workforce participation patterns; job satisfaction; and job stressors. RESULTS: Seven hundred and forty-seven participants responded to the bullying question and were included in this analysis. Twenty-five percent of participants reported being bullied in the last 12 months. There were no differences in the reported rates of bullying across age groups, sex and country of medical qualification. Bullied doctors were least satisfied with their jobs (P<0.001), had taken more sick leave in the last 12 months (P<0.001), and were more likely to be planning to decrease the number of hours worked in medicine in the next 12 months (P=0.01) or ceasing direct patient care in the next 5 years (independent of their age or the number of hours currently worked in patient care) (P=0.006). CONCLUSIONS: Our findings suggest that Australian doctors, independent of age or sex, have experienced workplace bullying, and although no conclusions can be made about causal pathways, there were strong associations between this exposure and poorer health and wellbeing, and on remaining in the medical workforce.

The COVID-19-forced transformation of general practitioner training from face-to-face to online delivery: A qualitative study of participants' experiences.

BACKGROUND AND OBJECTIVES: Outside the clinical space, face-to-face education essentially stopped when the COVID-19 pandemic started, largely substituted by online education. This provided an opportunity to explore general practice registrar and educator views about the benefits, challenges and enablers of both types of educational delivery. METHOD: This qualitative study included 45 registrars and medical educators from across Queensland, Australia. Transcripts of five focus groups and 22 semi-structured interviews were analysed thematically using the Framework Method. RESULTS: Major themes focused on social connection, learning engagement, content delivery, and time and space in relation to education. Other themes included technology, unplanned learning, learning safety and pastoral care. Face-to-face education was viewed more positively than online education, but many suggested ways to enhance online education. DISCUSSION: The importance of social connection dominated and underpinned many other themes identified as central to achieving safe and effective vocational general practitioner education.

Rewards, costs and challenges: the general practitioner's experience of teaching medical students.

CONTEXT: Medical student attachments in general practices play an important role in undergraduate medical education internationally. The recruitment by universities of new teaching practices or an increase in the teaching commitment of existing practices will be necessary to address rising medical student numbers. General practitioners (GPs) are likely to weigh the perceived rewards of practice-based teaching against the perceived costs and challenges in deciding whether to accept a student placement and how to teach. These aspects of the 'lived experience' of the GP-teacher have not been adequately investigated. OBJECTIVES: This study aims to enhance understanding of the GP clinical teacher experience in order to inform strategies for the recruitment, retention, training and support of teaching general practices. METHODS: Sixty GP clinical teachers in Brisbane-based urban teaching general practices were interviewed individually face-to-face by the principal investigator, using a semi-structured interview plan. Representativeness was ensured through quota sampling. The interview data were analysed thematically by two of the investigators independently, following member checking of interview transcripts. RESULTS: The results demonstrate a number of key inter-related perceived rewards, costs and challenges of teaching, including intellectual stimulation, cognitive fatigue and student characteristics. CONCLUSIONS: The findings extend reports in the previous literature by offering a richer description of current GP-teacher experience. Participants identified teaching rewards in a manner largely consistent with previous research, with the exception of enhanced practice morale and teamwork. Findings confirm that reduced productivity and increased time pressures remain key perceived negative impacts of teaching, but also reveal a number of other important costs and challenges. They emphasise the diversity of GP experience and practice cultures, and the need for teaching to enhance both GP and patient perceptions of consultation quality without increasing the load on the GP-teacher. Recruitment and retention strategies should promote the rewards of teaching, and teacher training should respond to the costs and challenges of practice-based teaching, and facilitate the growth of GPs in their role as clinical educators.

Incomplete pregnancy and risk of ovarian cancer: results from two Australian case-control studies and systematic review.

Although full-term pregnancies reduce the risk of ovarian cancer, it has not been conclusively established whether incomplete pregnancies also influence risk. We investigated the relationship between a history of incomplete pregnancy and incident epithelial ovarian cancer among over 4,500 women who participated in two large Australian population-based case-control studies in 1990-1993 and 2002-2005. They provided responses to detailed questions about their reproductive histories and other personal factors. Summary odds ratios (OR) and confidence intervals (CI) derived for each study using the same covariates were aggregated. We found no significant associations between the number of incomplete pregnancies and ovarian cancer, for parous (OR = 0.98, 95% CI: 0.89, 1.08) or nulliparous (OR = 1.06, 95% CI: 0.75, 1.48) women, nor for the number of spontaneous or induced abortions and ovarian cancer for parous women (OR = 0.95, 95% CI 0.82, 1.09; OR = 1.08, 95% CI: 0.86, 1.36) or nulliparous women (OR = 1.2, 95% CI: 0.6, 2.4; OR = 0.8, 95% CI: 0.47, 1.38), respectively. A systematic review of 37 previous studies of the topic confirmed our findings that a history of incomplete pregnancy does not influence a woman's risk of epithelial ovarian cancer.

Chronic pelvic pain in women: assessment and management.

BACKGROUND: Chronic pelvic pain (CPP) is a common condition that poses diagnostic and management challenges for doctors and their patients. OBJECTIVE: This article outlines an approach to the diagnosis and management of CPP in women, lists a range of possible aetiologies, and provides additional information on three conditions commonly associated with CPP: endometriosis, pelvic inflammatory disease, and irritable bowel syndrome. DISCUSSION: Chronic pelvic pain may be due to one or several aetiologies, while in some women no specific cause is identified. All women should be advised that even though limited medical knowledge sometimes precludes the assignation of a definite cause and cure, the pain can be managed, and psychological support can be provided. A multidisciplinary approach can be beneficial.

Psychological and psychiatric causes of fatigue. Assessment and management.

BACKGROUND: Fatigue is a common presentation in general practice and its diagnosis and management can be a source of frustration to both doctor and patient. Although it may exist independently of other diagnoses, and in conjunction with physical disorders, fatigue is strongly associated with psychological disorders. OBJECTIVE: We propose an approach to the diagnosis and management of the psychological and psychiatric causes of fatigue, and present two clinical cases to highlight some of the discriminating features. DISCUSSION: Psychological causes should be considered in all patients with fatigue. Awareness of the range of causes of fatigue, experience in using readily available screening tests to detect psychological disorders, and knowledge of the recommended management regimens will facilitate the delivery of quality care to patients and the reduction of the morbidity associated with the underlying conditions.

Haemochromatosis--a future focus for continuing education in general practice.

INTRODUCTION: This study aimed to assess the educational needs of general practitioners with regards to the diagnosis and management of hereditary haemochromatosis. METHODS: A questionnaire was mailed to all 216 GPs in a suburban division of general practice, with a response rate of 91 (42.1%). The survey covered GPs knowledge of the symptoms, signs, diagnosis, management and prognosis of haemochromatosis; attitudes toward management; beliefs regarding the prevalence of haemochromatosis and its relationship to other conditions; and management practices. RESULTS: The relative prevalence, symptoms, signs, diagnostic requirements and prognostic factors associated with haemochromatosis were generally well recognised. The specifics of management is an area of educational need; in particular, venesection goals, dietary recommendations and the role of liver biopsy in diagnosis. Respondents were generally not comfortable managing haemochromatosis without specialist support, most commonly from a gastroenterologist. Of 80% of GPs who reported having patients with haemochromatosis, 41% primarily managed the condition. DISCUSSION: The management of haemochromatosis in general practice could be improved by an educational campaign targeting GPs and the referral of uncomplicated patients back to their GPs from specialist services.

GPs' perceived competence and comfort in managing medical emergencies in southeast Queensland.

INTRODUCTION: Little is known about general practitioners' confidence and competence in managing medical emergencies, yet these qualities are vital to maximise patients' chances of survival. AIM: To document the distribution and determinants of GPs' self reported levels of comfort and competence in managing medical emergencies, and GPs' interest in attending an emergency skills update course. METHODS: We conducted a random sample survey of 900 GPs in current clinical practice in southeast Queensland. RESULTS: Five hundred and twelve (57%) GPs responded to the questionnaire. An association between perceived levels of competence and the amount of training GPs received was demonstrated (P < 00.05 for 14 of 16 listed emergency skills), as was an association between level of comfort in managing emergencies and the frequency with which such emergency types are encountered in practice (P < 0.05 for 8 of 18 listed emergencies). Sixty-nine percent of GPs expressed interest in attending a specifically designed emergency medicine update course. CONCLUSION: Postgraduate training in and experience with medical emergencies is important for GPs' confidence and competence in dealing with such emergencies. A proposed update course designed specifically for GPs was strongly supported.

Increasing access to consumer health organisations among patients with chronic disease - a randomised trial of a print-based intervention.

AIM: To assess whether a print-based intervention led to increased contact with consumer health organisations (CHOs) by general practice patients with chronic disease. BACKGROUND: CHOs can enhance people's capacity to manage chronic illness by providing information, education and psychosocial support. However, these organisations appear to be grossly under-utilised by patients and clinicians. METHODS: A total of 276 patients completed a computer-assisted telephone interview before randomisation to an intervention (n = 141) or control (n = 135) group. The intervention consisted of mailed printed materials designed to encourage contact with a CHO relevant to the patient's main diagnosed chronic condition. Follow-up interviews were conducted 4 and 12 months later. FINDINGS: Patients with conditions other than diabetes who received the intervention were twice as likely as those in the control group to contact a consumer health organisation during the 12-month study period: 41% versus 21% (P < 0.001). No such effect was found for diabetes patients, probably because of pre-existing high levels of contact with diabetes organisations. The intervention package received strong patient endorsement. Low-intensity interventions may be effective in improving access to CHOs for patients with chronic disease.

Consumer health organisations for people with diabetes and arthritis: who contacts them and why?

As health systems worldwide confront a growing prevalence of chronic disease, attention has focused on self-management as a strategy for delivering better outcomes for individuals and the health system. Consumer health organisations (CHOs) offer an existing, but under-utilised, resource for supporting self-management. This paper reports on a study designed to investigate the use of CHOs among people with diabetes and arthritis. A cross-sectional computer-assisted telephone interview survey was completed by 279 people who had made contact with one of four CHOs in Queensland, Australia, between July and August 2006. Self-reported data were collected on the participants' socio-demographic and health-related characteristics, pathways to, use and benefits of CHO contact and subsequent health actions. People contacted CHOs primarily to obtain further information about their condition or to access services or products. Most believed CHOs offered useful information relevant to their health and better ways to manage health problems. Almost half reported that they had started exercising or changed diet following contact. More than two-thirds of diabetes contacts had been directed to the organisation by a health professional, compared with less than one-third of those with arthritis. Correspondingly, people with diabetes reported shorter periods between diagnosis and contact and more prior contact with the organisation and were less likely to wish they had made contact earlier. The study concludes that people who contact CHOs report benefits and health actions conducive to better self-management. The integration of CHOs within the wider health system, as in the case of the diabetes CHO in this study, is likely to facilitate contact. Further attention to the role of these organisations as part of a comprehensive approach to chronic illness care is warranted.

Vertical Integration in Teaching And Learning (VITAL): an approach to medical education in general practice.

There is increasing demand to provide clinical and teaching experiences in the general practice setting. Vertical integration in teaching and learning, whereby teaching and learning roles are shared across all learner stages, has the potential to decrease time demands and stress on general practitioners, to provide teaching skills and experience to GP registrars, and to improve the learning experience for medical students, and may also help meet the increased demand for teaching in general practice. We consider potential advantages and barriers to vertical integration of teaching in general practice, and provide results of focus group discussions with general practice principals and registrars about vertical integration. We recommend further research into the feasibility of using vertical integration to enhance the capacity to teach medical students in general practice.

Teaching and learning population and preventive health: challenges for modern medical curricula.

OBJECTIVES: This study aimed to formally identify medical students' attitudes towards population and preventive health issues addressed in the University of Queensland's Bachelor of Medicine, Bachelor of Surgery (MBBS) programme, in response to informal student reports that population and preventive health issues were largely just matters of "common sense". METHODS: Year 2 medical students were surveyed in 1999 and 2000 using a custom-designed instrument incorporating Likert scales and requests for qualitative responses. A sample of students participated in semistructured interviews. RESULTS: A total of 341 students (71%) responded to the survey. Students' attitudes towards general population health issues were overwhelmingly positive, and more than 60% of students reported having a more positive attitude towards psychosocial and preventive health issues than they had when they commenced the MBBS programme. Just over half of the students, however, considered population and preventive health issues to be matters of common sense. Students reported poor role modelling by the faculty in relation to population and preventive health issues, with only 41% of students indicating they perceived a positive attitude towards psychosocial and preventive health issues in the School of Medicine. Qualitative data indicated that some students fear that the opportunity cost of dedicating study time to population and preventive health issues might endanger their future clinical knowledge, skills and management of patients. CONCLUSIONS: These findings have important implications for modern medical curricula. The challenge in teaching population health issues is to balance students' needs to understand and apply the principles of population and preventive health and the biopsychosocial model of patient care, with the need for them to be confident they will be able to practise safely if they do so.

General practitioners with special interests: risk of a good thing becoming bad?

There is a long tradition of some general practitioners developing areas of special interest within their mainstream generalist practice. General practice is now becoming increasingly fragmented, with core components being delivered as separate and standalone services (eg, travel medicine, skin cancer, women's health). Although this fragmentation seems to meet a need for some patients and doctors, potential problems need careful consideration and response. These include loss of generalist skills among GPs, fewer practitioners working in less well-remunerated areas, such as nursing home visits, and issues related to standards of care and training.