'They say': medical students' perceptions of General Practice, experiences informing these perceptions, and their impact on career intention-a qualitative study among medical students in England.

OBJECTIVES: The number of UK graduates choosing General Practice training remains significantly lower than the current numbers required to meet the demands of the service. This work aims to explore medical students' perceptions of General Practice, experiences which lead to the development of these perceptions, and the ultimate impact of these on career intention. DESIGN: This mixed-methods, qualitative study used focus groups, semistructured interviews, longitudinal audio diary data and debrief interviews to explore and capture the experiences and perceptions of students in their first and penultimate years of university. SETTING: Three English medical schools. PARTICIPANTS: Twenty students were recruited to focus groups from first and fourth/fifth year of study. All students in these years of study were invited to attend. Six students were recruited into the longitudinal diary study to further explore their experiences. RESULTS: This work identified that external factors, internal driving force and the 'they say' phenomenon were all influential on the development of perceptions and ultimately career intention. External factors may be split into human or non-human influences, for example, aspirational/inspirational seniors, family, peers (human), placements and 'the push' of GP promotion (non-human). Driving force refers to internal factors, to which the student compares their experiences in an ongoing process of reflection, to understand if they feel General Practice is a career they wish to pursue. The 'they say' phenomenon refers to a passive and pervasive perception, without a known source, whereby usually negative perceptions circulate around the undergraduate community. CONCLUSION: Future strategies to recruit graduates to General Practice need to consider factors at an undergraduate level. Positive placement experiences should be maximised, while avoiding overtly 'pushing' GP onto students.

Chest pain symptoms during myocardial infarction in patients with and without diabetes: a systematic review and meta-analysis.

OBJECTIVE: Chest pain (CP) is key in diagnosing myocardial infarction (MI). Patients with diabetes mellitus (DM) are at increased risk of an MI but may experience less CP, leading to delayed treatment and worse outcomes. We compared the prevalence of CP in those with and without DM who had an MI. METHODS: The study population was people with MI presenting to healthcare services. The outcome measure was the absence of CP during MI, comparing those with and without DM. Medline and Embase databases were searched to 18 October 2021, identifying 9272 records. After initial independent screening, 87 reports were assessed for eligibility against the inclusion criteria, quality and risk of bias assessment (Strengthening the Reporting of Observational Studies in Epidemiology and Newcastle-Ottawa criteria), leaving 22 studies. The meta-analysis followed Meta-analysis Of Observational Studies in Epidemiology criteria and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled ORs, weights and 95% CIs were calculated using a random-effects model. RESULTS: This meta-analysis included 232 519 participants from 22 studies and showed an increased likelihood of no CP during an MI for those with DM, compared with those without. This was 43% higher in patients with DM in the cohort and cross-sectional studies (OR: 1.43; 95% CI: 1.26 to 1.62), and 44% higher in case-control studies (OR: 1.44; 95% CI: 1.11 to 1.87). CONCLUSION: In patients with an MI, patients with DM are less likely than those without to have presentations with CP recorded. Clinicians should consider an MI diagnosis when patients with DM present with atypical symptoms and treatment protocols should reflect this, alongside an increased patient awareness on this issue. PROSPERO REGISTRATION NUMBER: CRD42017058223.

Can a training hub deliver undergraduate medical education with patient educators?

BACKGROUND: Medical schools may find it difficult to coordinate GP practices to support undergraduate medical education in primary care. In England, every Integrated Care System area now has a funded training hub to plan and upskill the primary care and community health workforce. We evaluated whether a training hub could help deliver undergraduate medical education, co-facilitated by patient educators. No published research has evaluated this model before. METHODS: We used before and after surveys (617 students), interviews (28) and focus groups (20 people) with undergraduate medical students, patient educators and training hub and medical school team members. FINDINGS: It was feasible for a training hub to develop and co-deliver a workshop with patient educators. 61% of Year 4 undergraduate students (first clinical year) took part, a high attendance rate during the COVID-19 pandemic. 80% of students said they learnt a lot about managing conditions in primary care and the community as a result. They particularly valued engaging with patient educators and seeing interprofessional working between GPs and pharmacists, which were cornerstones of the training hub approach. The hub was able to recruit and retain patient educators more effectively than the medical school alone. Patient educators said they felt valued and developed new skills. CONCLUSIONS: Working with training hubs may be part of the solution to issues medical schools face when organising undergraduate education about primary care. This small evaluation suggests that this model could be tested further.

An evaluation of a student-led career profiling project to support the exploration of a career in general practice and other specialties.

BACKGROUND: Choosing medical careers is complex but the undergraduate period is formative. St George's University of London (SGUL) students called for greater careers information. AIM: To develop and evaluate students' careers resources. DESIGN & SETTING: A quality improvement student-staff project at SGUL, UK. METHOD: A 'Plan-Do-Study-Act' (PDSA) cycle was completed. For the 'Plan' element, students' career intentions and information preferences were surveyed. For the 'Do' element, video interviews with clinicians and infographic posters were produced and published on SGUL's virtual learning environment. For the 'Study' element, feedback questionnaires were thematically analysed using Kirkpatrick's framework. For the 'Act' element, the model was rolled out across SGUL programmes. RESULTS: In the 'Plan' stage, 79 students ranked interest in specialties, with general practice being the second most popular. Students were unconfident in how to pursue careers and wanted more information. For the 'Do' element, 13 careers videos and infographics were created for 10 specialties. The 'Study' questionnaire showed changes across three of the four levels in Kirkpatrick's model of evaluation of training. Level 1 (Response): students found resources helpful and accessible. Level 2 (Learning): students reported increased understanding of careers. Level 3 (Transfer): students planned using checklists and made career comparisons by specialty. Level 4 (Results): students' career choices were not demonstrated, but there were tentative proxy measures such as copying and modelling career routes and choices. 'Act' involved rolling out and regularly updating resources. CONCLUSION: This PDSA model enabled development of resources by students mapped to students' needs. Changes were demonstrated in relation to students' response, learning, and transfer, with tentative suggestions of impact on career choice.

Undergraduate medical teaching with remote consultations in general practice: a realist evaluation.

BACKGROUND: Supervisors historically educated students in primary care in face-to-face contexts; as a result of COVID-19, students now experience patient consultations predominantly remotely. There is a paucity of evidence regarding the facilitators and barriers to supervising students for excellent educational impact in the remote consultation environment. AIM: To understand the facilitators and barriers to educating medical students using remote consultations in primary care, and the consequences for students in terms of educational impact. DESIGN & SETTING: A realist evaluation methodology was adopted to identify causal chains of contexts, mechanisms, and outcomes, describing how the teaching and learning functioned on a sample of medical students and GP tutors from two medical schools in London, UK. METHOD: An initial programme theory was developed from the literature and a scoping exercise informed the data collection tools. Qualitative data were collected through online questionnaires (49 students, 19 tutors) and/or a semi-structured interview (eight students, two tutors). The data were coded to generate context-mechanisms-outcome configurations outlining how the teaching and learning operated. RESULTS: The results demonstrated a sequential style of supervision can positively impact student engagement and confidence, and highlighted a need to address student preparation for remote patient examinations. Students found passive observation of remote patient encounters disengaging, and, in addition, reported isolation that impacted negatively on their experiences and perceptions of primary care. CONCLUSION: Student and tutor experiences may improve through considering the supervision style adopted by tutors, and through interventions to reduce student isolation and disengagement when using remote patient consultations in primary care.

Medical students' experience of the hidden curriculum around primary care careers: a qualitative exploration of reflective diaries.

OBJECTIVES: Primary healthcare internationally is facing a workforce crisis with fewer junior doctors choosing general practice (GP) as a career. In the UK, a national report on GP careers highlighted adverse influences during medical school on students' career choices. The authors explored these influences in two urban UK medical schools, both with relatively low numbers of students entering GP training. DESIGN: Using a phenomenological approach, the authors thematically analysed the reflective diaries of four medical students who were recruited as 'participant researchers' over a period of 10 months. These students made regular reflexive notes about their experiences related to GP career perceptions in their academic and personal environments, aiming to capture both positive and negative perceptions of GP careers. The research team discussed emerging data and iteratively explored and developed themes. SETTING: Two UK medical schools PARTICIPANTS: Undergraduate medical students RESULTS: Seven key themes were identified: the lack of visibility and physicality of GP work, the lack of aspirational GP role models, students' perceptions of a GP career as default, the performativity of student career choice with the perceptions of success linked to specialism, societal perceptions of GP careers, gender stereotyping of career choices and the student perception of life as a GP. CONCLUSIONS: Students overwhelmingly reflected on negative cues to GP careers, particularly through their experience of the hidden curriculum. Three recommendations are made: the need for increased representation of GP role models in clinical curricula content delivery and senior leadership; ensuring GP clerkships involve an active and authentic student role with patients, enabling students to experience GP's 'work' including managing complexity, uncertainty and risk. Finally, institutions need to consider students' experiences of the hidden curriculum and the effect this can have on students' perception of careers, alongside the challenges of rankings and perceived hierarchical positioning of disciplines.

GP registrars teaching medical students- an untapped resource?

BACKGROUND: General practice placements are fundamental to undergraduate medical education but there are difficulties in recruiting teaching practices. Developing "near peer teaching" may help. Health Education England & UCL run a programme in general practice (GP) training schemes with Innovative Training Posts in medical education. AIM: To evaluate GP innovative training posts in undergraduate medical education. DESIGN AND SETTING: Focus groups and interviews with GP specialty trainees ("trainees"), medical students & educational stakeholders in London. METHOD: A qualitative study exploring stakeholders' perspectives of this initiative. Transcribed interviews were analysed thematically. RESULTS: We interviewed 26 stakeholders. Students valued trainees' generalist expertise and making explicit areas of medicine. Trainees adopted student-centred approaches, addressing students' assessment agendas, in contrast to senior doctors. Trainees also provided career guidance. Trainees expressed benefits to their development; their identity as learners & educators, and clinical knowledge. Teaching & learning for trainees were inter related; as identified by "to teach something well is to understand it well". Educational leaders were supportive but had to champion such initiatives. CONCLUSION: Near peer teaching in general practice is relatively novel. There are strong educational benefits for learners & teachers clearly influenced by the social context of learning. Positive career roles are modelled by trainees.

Effect of weather on GP home visits: a cross-sectional study.

BACKGROUND: GPs in the UK conduct >13 million home visits each year. The visits, which are resource intensive, are usually to the frailest patients who are least resilient to adverse weather. AIM: To explore the relationship between meteorological variables (temperature, rainfall, sunshine) and temporal variables (day of the week, season) with GP home visits (HVs). DESIGN AND SETTING: A cross-sectional study using data provided by Herts Urgent Care for its GP acute in-hours visiting service and UK Meteorological (Met) Office weather data for the Herts & South East region of the UK. METHOD: The association between the number of GP HVs and weather and temporal variables was explored using univariable and multivariable negative binomial regression. RESULTS: There was a significant 0.4% decrease in HVs per degrees Celsius increase in minimum temperature (incidence rate ratio [IRR] 0.996, 95% confidence interval [CI] = 0.993 to 0.999), and a 0.4% decrease per hour increase in sunshine (IRR 0.996, 95% CI = 0.992 to 1.000), as well as significant decreases in weekday HVs compared with Mondays (Thursday IRR 0.824, 95% CI = 0.790 to 0.859). There were 6.2% fewer HVs in summer compared with winter (IRR 0.938, 95% CI = 0.902 to 0.975). Multivariable negative binomial regression showed non-significant relationships between meteorological variables and HVs, but a significant day-of-the-week relationship. CONCLUSION: GP HVs increased on cold days and fell on sunnier days. The effect sizes were small so it is unlikely that there is any clinically significant effect of weather on HVs in this acute GP visit setting. A tentative conclusion might also be that GPs in this system can deliver care to frail housebound patients in most weather conditions.

Socio-economic inequalities in life expectancy of older adults with and without multimorbidity: a record linkage study of 1.1 million people in England.

BACKGROUND: Age of onset of multimorbidity and its prevalence are well documented. However, its contribution to inequalities in life expectancy has yet to be quantified. METHODS: A cohort of 1.1 million English people aged 45 and older were followed up from 2001 to 2010. Multimorbidity was defined as having 2 or more of 30 major chronic diseases. Multi-state models were used to estimate years spent healthy and with multimorbidity, stratified by sex, smoking status and quintiles of small-area deprivation. RESULTS: Unequal rates of multimorbidity onset and subsequent survival contributed to higher life expectancy at age 65 for the least (Q1) compared with most (Q5) deprived: there was a 2-year gap in healthy life expectancy for men [Q1: 7.7 years (95% confidence interval: 6.4-8.5) vs Q5: 5.4 (4.4-6.0)] and a 3-year gap for women [Q1: 8.6 (7.5-9.4) vs Q5: 5.9 (4.8-6.4)]; a 1-year gap in life expectancy with multimorbidity for men [Q1: 10.4 (9.9-11.2) vs Q5: 9.1 (8.7-9.6)] but none for women [Q1: 11.6 (11.1-12.4) vs Q5: 11.5 (11.1-12.2)]. Inequalities were attenuated but not fully attributable to socio-economic differences in smoking prevalence: multimorbidity onset was latest for never smokers and subsequent survival was longer for never and ex smokers. CONCLUSIONS: The association between social disadvantage and multimorbidity is complex. By quantifying socio-demographic and smoking-related contributions to multimorbidity onset and subsequent survival, we provide evidence for more equitable allocation of prevention and health-care resources to meet local needs.

Is there a role for GPs in teaching neurology to medical students? A qualitative evaluation.

INTRODUCTION: The purpose of this study was to evaluate whether GPs can support medical students in learning basic neurology in the context of a traditional hospital neurology attachment. METHOD: This was a qualitative evaluation using routinely collected data from stakeholders, consisting of qualitative data in the form of student evaluation questionnaires, course documentation and correspondence from faculty staff. RESULTS: The addition of GP teaching to the programme increased availability of patients with neurological problems accessible to students and provided a safe, supportive environment for students to learn their fundamental clinical skills. Students gained valuable insights into the impact of neurological disease from the perspective of patients, their families and carers. GP teaching of neurology was well regarded by students. Some GP tutors felt they lacked adequate experience to teach more technical aspects of neurology, and some students shared this concern. Concepts of professional boundaries between generalists and specialists were not observed, but GP teaching was perceived to be 'other' or outside normal medical school activity. CONCLUSIONS: General practitioners can successfully facilitate students' access to patients with neurological disease and employ their generalist to enhance neurological learning. Some GPs were initially uncomfortable with teaching skills such as detailed neurological physical examination.

Universities and primary care organisations working together to recruit GPs: a qualitative evaluation of the Enfield clinical teaching fellow programme.

BACKGROUND: General practice recruitment is in difficulty in the UK as many experienced GPs retire or reduce their commitment. The numbers of junior doctors choosing to specialise in the discipline is also falling, leading to primary care workforce issues particularly in 'hard to serve' areas. AIM: To evaluate an academic service collaboration on GP recruitment between a primary care organisation (PCO), Enfield CCG, and a university, University College London (UCL). DESIGN & SETTING: Evaluation of an academic service collaboration in the Enfield CCG area of north east London. METHOD: An action research method utilising qualitative methodology was used to evaluate a local service intervention, undertaken by the participants themselves. The qualitative data were analysed by one researcher but themes were agreed by the whole team. Enfield CCG, an NHS PCO, funded a collaboration with UCL to employ five GPs as clinical teaching fellows to work in Enfield, to increase patients' access, to provide input to CCG development projects, and to provide undergraduate medical student teaching in practice. RESULTS: Five teaching fellows were employed for ≤2 years and provided 18 266 extra appointments, engaged with development projects, and delivered local undergraduate teaching. The themes identified by stakeholders were the challenges of these organisations working together, recruiting GPs to an underserved area, and perceptions of the model's value for money. CONCLUSION: The evaluation showed that the collaboration of an NHS PCO and a higher education institution can work, and the prestige of being associated with a universty and clinical variety ensured GP recruitment in an area that had previously struggled. However, the project's costs were high, which affected perceptions of its value.

Do primary care placements influence career choice: What is the evidence?

BACKGROUND: The NHS is struggling with GP recruitment. The Health Education England (HEE) Wass Report (By Choice not by Chance), among its recommendations to boost GP numbers, highlighted undergraduate (UG) GP placement experience as an important influence on future career choice. Aim To explore the UG influences on GP career choice. METHODS: Two junior doctors produced a pragmatic rapid appraisal of the literature on the UG influences on GP career choice for the Wass Report. The search strategy was supported by librarians and focused on rapidly accessing and summarising relevant literature. Databases searched, including Medline, EMBASE, HMIC & grey literature, revealed 294 items. Data extraction and synthesis was pragmatic. RESULTS: The international evidence suggests that UG GP experience can positively influence students towards a primary care career. Longitudinal placements are more influential than traditional blocks. UK literature is limited, but there are consistencies with the international evidence. The relevant studies identified are observational with risk of bias, but this is unavoidable within this research context. DISCUSSION: The implications of these results for medical school curricula are discussed with particular reference to Government plans to expand medical student numbers and establish new medical schools with explicit aims to produce more GPs.

'Just like a normal pain', what do people with diabetes mellitus experience when having a myocardial infarction: a qualitative study recruited from UK hospitals.

OBJECTIVE: The objective of the study was to investigate the symptoms people with diabetes experience when having a myocardial infarction (MI), their illness narrative and how they present their symptoms to the health service. SETTING: Three London (UK) hospitals (coronary care units and medical wards). PARTICIPANTS: Patients were recruited with diabetes mellitus (DM) (types 1 and 2) with a clinical presentation of MI (ST elevated MI (STEMI), non-ST elevated MI (NSTEMI), acute MI unspecified and cardiac arrest). A total of 43 participants were recruited, and 39 interviews met the study criteria and were analysed. They were predominantly male (n=30), aged 40-90 years and white British (18/39), and just over a half were from other ethnic groups. The majority had type 2 DM (n=35), 24 had an NSTEMI, 10 had an STEMI and five had other cardiac events. DEFINITIONS OF SELECTION/EXCLUSION CRITERIA: A diagnosis of MI and DM and the ability to communicate enough English to complete the interview. Ward staff made a clinical judgement that the participant was post-treatment, clinically stable and well enough to participate. METHODS: A qualitative study using taped and transcribed interviews analysed using a thematic analysis. RESULTS: While most participants did experience chest pain, it was often not their most striking symptom. As their chest pain did not match their expectations of what a 'heart attack' should be, participants developed narratives to explain these symptoms, including the symptoms being effects of their DM ('hypos'), side effects of medication (oral hypoglycaemics) or symptoms (such as breathlessness and indigestion) related to other comorbidities, often leading to delays in seeking care. CONCLUSIONS: While truly absent chest pain during MI among people with DM was rare in this study, patients' attenuated symptoms often led to delay in seeking attention, and this may result in delays in receiving treatment.

Patient participation in general practice based undergraduate teaching: a focus group study of patient perspectives.

BACKGROUND: Patients make a crucial contribution to undergraduate medical education. Although a national resource is available for patients participating in research, none is as yet available for education. AIM: This study aimed to explore what information patients would like about participation in general practice based undergraduate medical education, and how they would like to obtain this information. DESIGN AND SETTING: Two focus groups were conducted in London-based practices involved in both undergraduate and postgraduate teaching. METHOD: Patients both with and without teaching experience were recruited using leaflets, posters, and patient participation groups. An open-ended topic guide explored three areas: perceived barriers that participants anticipated or had experienced; patient roles in medical education; and what help would support participation. Focus groups were audiorecorded, transcribed, and analysed thematically. RESULTS: Patients suggested ways of professionalising the teaching process. These were: making information available to patients about confidentiality, iterative consent, and normalising teaching in the practice. Patients highlighted the importance of relationships, making information available about their GPs' involvement in teaching, and initiating student-patient interactions. Participants emphasised educational principles to maximise exchange of information, including active participation of students, patient identification of student learner needs, and exchange of feedback. CONCLUSION: This study will inform development of patient information resources to support their participation in teaching and access to information both before and during general practice based teaching encounters.