How well do UK assistantships equip medical students for graduate practice? Think EPAs.

The goal of better medical student preparation for clinical practice drives curricular initiatives worldwide. Learning theory underpins Entrustable Professional Activities (EPAs) as a means of safe transition to independent practice. Regulators mandate senior assistantships to improve practice readiness. It is important to know whether meaningful EPAs occur in assistantships, and with what impact. Final year students at one UK medical school kept learning logs and audio-diaries for six one-week periods during a year-long assistantship. Further data were also obtained through interviewing participants when students and after three months as junior doctors. This was combined with data from new doctors from 17 other UK schools. Realist methods explored what worked for whom and why. 32 medical students and 70 junior doctors participated. All assistantship students reported engaging with EPAs but gaps in the types of EPAs undertaken exist, with level of entrustment and frequency of access depending on the context. Engagement is enhanced by integration into the team and shared understanding of what constitutes legitimate activities. Improving the shared understanding between student and supervisor of what constitutes important assistantship activity may result in an increase in the amount and/or quality of EPAs achieved.

Development and face validation of strategies for improving consultation skills.

While formative workplace based assessment can improve learners' skills, it often does not because the procedures used do not facilitate feedback which is sufficiently specific to scaffold improvement. Provision of pre-formulated strategies to address predicted learning needs has potential to improve the quality and automate the provision of written feedback. To systematically develop, validate and maximise the utility of a comprehensive list of strategies for improvement of consultation skills through a process involving both medical students and their clinical primary and secondary care tutors. Modified Delphi study with tutors, modified nominal group study with students with moderation of outputs by consensus round table discussion by the authors. 35 hospital and 21 GP tutors participated in the Delphi study and contributed 153 new or modified strategies. After review of these and the 205 original strategies, 265 strategies entered the nominal group study to which 46 year four and five students contributed, resulting in the final list of 249 validated strategies. We have developed a valid and comprehensive set of strategies which are considered useful by medical students. This list can be immediately applied by any school which uses the Calgary Cambridge Framework to inform the content of formative feedback on consultation skills. We consider that the list could also be mapped to alternative skills frameworks and so be utilised by schools which do not use the Calgary Cambridge Framework.

How do medical schools influence their students' career choices? A realist evaluation.

INTRODUCTION: The career choices of medical graduates vary widely between medical schools in the UK and elsewhere and are generally not well matched with societal needs. Research has found that experiences in medical school including formal, informal and hidden curricula are important influences. We conducted a realist evaluation of how and why these various social conditions in medical school influence career thinking. METHODS: We interviewed junior doctors at the point of applying for speciality training. We selected purposively for a range of career choices. Participants were asked to describe points during their medical training when they had considered career options and how their thinking had been influenced by their context. Interview transcripts were coded for context-mechanism-outcome (CMO) configurations to test initial theories of how career decisions are made. RESULTS: A total of 26 junior doctors from 12 UK medical schools participated. We found 14 recurring CMO configurations in the data which explained influences on career choice occurring during medical school. DISCUSSION: Our initial theories about career decision-making were refined as follows: It involves a process of testing for fit of potential careers. This process is asymmetric with multiple experiences needed before deciding a career fits ('easing in') but sometimes only a single negative experience needed for a choice to be ruled out. Developing a preference for a speciality aligns with Person-Environment-Fit decision theories. Ruling out a potential career can however be a less thought-through process than rationality-based decision theories would suggest. Testing for fit is facilitated by longer and more authentic undergraduate placements, allocation of and successful completion of tasks, being treated as part of the team and enthusiastic role models. Informal career guidance is more influential than formal. We suggest some implications for medical school programmes.

A rural undergraduate campus in England: virtue from opportunity and necessity.

The implementation of new curriculum at Keele University Medical School, UK has made heavy use of general practice as a locus for learning. This has necessitated a substantial expansion in the School's teaching network. The School's hinterland includes a large rural area with a number of excellent general practices and associated community hospitals that, to date, have been unable to teach undergraduates because of their inaccessibility. This article describes how the School and its partners articulated a vision to establish a rural campus with an associated rural accommodation hub, and the challenges involved in establishing and sustaining the campus.

Breathing exercises for asthma: a randomised controlled trial.

BACKGROUND: The effect of breathing modification techniques on asthma symptoms and objective disease control is uncertain. METHODS: A prospective, parallel group, single-blind, randomised controlled trial comparing breathing training with asthma education (to control for non-specific effects of clinician attention) was performed. Subjects with asthma with impaired health status managed in primary care were randomised to receive three sessions of either physiotherapist-supervised breathing training (n = 94) or asthma nurse-delivered asthma education (n = 89). The main outcome was Asthma Quality of Life Questionnaire (AQLQ) score, with secondary outcomes including spirometry, bronchial hyper-responsiveness, exhaled nitric oxide, induced sputum eosinophil count and Asthma Control Questionnaire (ACQ), Hospital Anxiety and Depression (HAD) and hyperventilation (Nijmegen) questionnaire scores. RESULTS: One month after the intervention there were similar improvements in AQLQ scores from baseline in both groups but at 6 months there was a significant between-group difference favouring breathing training (0.38 units, 95% CI 0.08 to 0.68). At the 6-month assessment there were significant between-group differences favouring breathing training in HAD anxiety (1.1, 95% CI 0.2 to 1.9), HAD depression (0.8, 95% CI 0.1 to 1.4) and Nijmegen (3.2, 95% CI 1.0 to 5.4) scores, with trends to improved ACQ (0.2, 95% CI 0.0 to 0.4). No significant between-group differences were seen at 1 month. Breathing training was not associated with significant changes in airways physiology, inflammation or hyper-responsiveness. CONCLUSION: Breathing training resulted in improvements in asthma-specific health status and other patient-centred measures but not in asthma pathophysiology. Such exercises may help patients whose quality of life is impaired by asthma, but they are unlikely to reduce the need for anti-inflammatory medication.

Measuring the quality of referral letters about patients with upper gastrointestinal symptoms.

BACKGROUND: General practitioners state the reason for referring patients in referral letters. The paucity of information in these letters has been the source of criticism from specialist colleagues. OBJECTIVE: To invite general practitioners to set standards for referral letters to gastroenterologists and to apply these standards to actual referral letters to one specialist gastroenterology unit. METHODS: A scoring schedule was designed based on the responses to a questionnaire survey of a large sample of all general practitioners in one locality. Altogether 350 consecutive letters to a district general hospital about patients referred for an upper gastrointestinal specialist opinion were subsequently scored using the schedule. RESULTS: 102 practitioners responded to the survey. Their responses imply that colleagues assess and record findings on 18 potential features of upper bowel disease. In practice most referral letters address fewer than six features of upper bowel disease. The mean number of positive features of upper gastrointestinal disease reported in each letter was one. CONCLUSIONS: This study reported a failure to meet "peer defined" standards for the content of referral letters set by colleagues in one locality. Referral letters serve many purposes, however, encouraging full documentation of specific clinical findings may serve to increase the pre-referral assessments performed in practice.

What do patients want from doctors? Content analysis of written patient agendas for the consultation.

BACKGROUND: Although much has been written about what patients want when they contact their general practitioner (GP), there are no published data from large cohort studies of what patients expect. AIM: To describe the expectations of a large group of patients who consulted with their GPs. METHOD: A GP and a social sciences graduate carried out a content analysis of written agenda forms completed by 819 patients who consulted 46 randomly selected GPs. Inter- and intra-rater reliabilities were confirmed. RESULTS: A total of 756 (92%) agenda forms were returned. Inter-rater reliability was satisfactory (kappa > 0.6 for all but two main themes). Almost all patients had requests they wished to make of their doctor, 60% had their own ideas about what was wrong, and 38% had considered explanations about why they were unwell. Forty-two per cent and 24% of patients had consulted because they had reached the limit of their anxiety or tolerance respectively. Seven per cent, 4%, and 2% had comments, which were usually negative, to make about previous management, communication with doctors, or time in the consultation. CONCLUSION: These data demonstrate that most patients come to the consultation with a particular agenda. Failure to address this agenda is likely to adversely affect the outcome of many consultations.

Consultation competence in general practice: establishing the face validity of prioritized criteria in the Leicester assessment package.

AIM: This study set out to test the face validity of prioritized criteria of consultation competence in general practice as contained in the Leicester assessment package. METHOD: A questionnaire was sent to a geographically stratified random sample of 100 members of the United Kingdom Association of Course Organisers to seek their views on the categories, components and weightings contained in the Leicester assessment package and to determine the proportion of respondents who rejected or suggested a new category, component or weighting or reallocated components to other categories or amended weightings. Their views were sought on a six-point scale (strongly approve, approve, tend to approve, tend to disapprove, disapprove and strongly disapprove). RESULTS: There was a 73% response rate. Of the respondents 99% either strongly approved or approved of the overall set of categories of consultation competence. Only two respondents (3%) expressed any disapproval of individual categories. Thirty five of the 39 suggested components of consultation competence were supported by more than 80% of respondents. There was minimal support for excluding any categories or components of consultation competence, for moving any components to different categories or for the inclusion of new categories or components. Eighty eight per cent of respondents were in favour of the need to identify priorities between any agreed categories of consultation competence and 79% expressed approval of the suggested weightings. Although 42% of respondents indicated a wish for some alteration in weightings, the mean values for all consultation categories suggested by all respondents were almost identical to the original weightings in the Leicester package. CONCLUSION: The face validity of the categories and components of consultation competence contained in the Leicester assessment package has been established, and the suggested weightings of consultation categories have been validated. Consequently, the criteria contained in the Leicester package can be adopted with confidence as measures against which performance can be judged in formative or summative assessment of consultation performance in general practice.

Consultation competence in general practice: testing the reliability of the Leicester assessment package.

BACKGROUND: An acceptable assessment must be both valid and reliable; the face validity of the Leicester assessment package has already been established. AIM: This study set out to test the reliability of the Leicester assessment package, and the factors influencing it, when used by multiple assessors to assess performance in general practice consultations. METHOD: Six randomly selected course organizer assessors simultaneously used the package to conduct independent assessments of the performance of five doctors of widely varying abilities in consultation with six simulated patients. The scores allocated were subjected to generalizability analysis. RESULTS: The mean scores allocated for consultation performance of individual doctors ranged from 51% to 70%, with the lower scores being allocated to the less experienced doctors. Scores of each assessor across the cases were examined for internal consistency and five of the six assessors consistently scored the doctors with an alpha coefficient of the minimum accepted level of 0.80 or greater. The other assessor had a consistency of only 0.22. Measurements of consistency within cases between markers indicated that the first case produced unreliable results (alpha coefficient 0.25) but all other cases were scored consistently. Two independent assessors scoring eight consultations are the requisite numbers to achieve acceptable levels of reliability in a formal assessment process; seven consultations produce the minimum acceptable generalizability coefficient of 0.80 plus the first 'non-counting' consultation. CONCLUSION: Required levels of reliability can be achieved when the package is used by multiple markers assessing the same consultations over a wide range of consultation performance. To achieve reliability only two hours of assessment time are required using the Leicester package compared with the previously regarded minimum of 32 hours. Although assessors can produce reliable scores with minimal training, intra-assessor reliability cannot be taken for granted and all assessors should be trained and calibrated before being sanctioned to conduct assessments, particularly for regulatory purposes. The Leicester assessment package has now been shown to be valid, reliable, feasible and easy to use in practice. It can, therefore, be recommended for use in both formative and summative assessment of consultation competence in general practice.

Undergraduate teaching in the community: can general practice deliver?

BACKGROUND: All UK medical schools are revising their curricula following the General Medical Council recommendations to increase general practice involvement in undergraduate education. However, workload in general practice has increased in recent years, raising questions about its ability to maintain, let alone extend, its educational activities. AIM: The aim of this study was examine whether recent changes in general practice have affected delivery of practice-based undergraduate education and to assess the extent to which practices will be able to increase their involvement in teaching. METHOD: A postal questionnaire survey was conducted of the lead clinical teachers and their partners in the practices to which students from Leicester Medical School had been attached in the last 2 years. RESULTS: The questionnaire was completed by 32 out of the 39 lead teachers and 134 of the 150 partners, an overall response rate of 88%. There was widespread support for departmental teaching requirements, but only 17 lead teachers (44%) felt that the suggested reduction by 25% of patients seen per session while teaching was feasible. A total of 14 lead teachers (47%) felt that the ability of their practice to deliver high-quality teaching had declined since 1990. Altogether, 113 (87%) of all doctors in teaching practices felt that time pressures had increased during this period, and 139 (88%) felt that present levels of remuneration were inadequate. The majority of these doctors felt that general practice was the preferred location for learning generic clinical skills and were interested in participating. Nevertheless, most were not prepared to increase their involvement in teaching under present arrangements. CONCLUSION: Practice-based teachers appreciate the need for quality teaching, remain enthusiastic about teaching and are, in principle, willing to take an increased teaching load. However, recent changes have made delivery of teaching more difficult, and if an expansion in practice-based teaching is to occur, more realistic levels of funding and support are a prerequisite.

Patient satisfaction with out of hours primary medical care.

OBJECTIVES: To describe the relationship between patient satisfaction with out of hours care provided by deputising and practice doctors in four urban areas in England and characteristics of the service provided and patients, the care given, and health outcomes. SETTING: -Fourteen general practices in four urban areas in England. PARTICIPANTS: People who requested out of hours care. DESIGN: Analysis of data from a study of out of hours care. Patients were interviewed within 5 days of their request for out of hours care. Data on the service provided were obtained from medical records and all other data were collected at interview. Satisfaction was measured using a valid reliable instrument. RESULTS: 2152 patients were recruited to the study and 1466 were interviewed. Satisfaction data were available on 1402 patients. "Overall satisfaction" was associated with age, doctor type, lack of access to a car at the time of the request, and health outcome. The relationships between satisfaction subscales and patient characteristics (age, sex, ethnicity, and access to a car at the time of the request), service characteristics (doctor type and delay between the request and visit), whether a prescription was given, and health outcome were variable. If an expected home visit was not received, "overall satisfaction" and satisfaction with "communication and management", "doctor's attitude", and "initial contact person" were reduced. CONCLUSION: Patient satisfaction is dependent on many factors. Mismatch between patient expectation and the service received is related to decreased satisfaction. This may increase as general practitioners delegate more out of hours care to cooperatives and deputising services.

Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey.

OBJECTIVES: To estimate the prevalence of dysfunctional breathing in adults with asthma treated in the community. DESIGN: Postal questionnaire survey using Nijmegen questionnaire. SETTING: One general practice with 7033 patients. PARTICIPANTS: All adult patients aged 17-65 with diagnosed asthma who were receiving treatment. MAIN OUTCOME MEASURE: Score >/=23 on Nijmegen questionnaire. RESULTS: 227/307 patients returned completed questionnaires; 219 (71.3%) questionnaires were suitable for analysis. 63 participants scored >/=23. Those scoring >/=23 were more likely to be female than male (46/132 (35%) v 17/87 (20%), P=0.016) and were younger (mean (SD) age 44.8 (14.7) v 49.0 (13.8, (P=0.05). Patients at different treatment steps of the British Thoracic Society asthma guidelines were affected equally. CONCLUSIONS: About a third of women and a fifth of men had scores suggestive of dysfunctional breathing. Although further studies are needed to confirm the validity of this screening tool and these findings, these prevalences suggest scope for therapeutic intervention and may explain the anecdotal success of the Buteyko method of treating asthma.

Reliability and validity of a new measure of patient satisfaction with out of hours primary medical care in the United Kingdom: development of a patient questionnaire.

OBJECTIVE: To develop a reliable, valid measure of patient satisfaction with out of hours care suitable for large scale service evaluation. DESIGN: Focus group meetings and semistructured interviews with patients to identify issues of importance to patients and possible questionnaire items; interviews and two pilot studies to test and identify new questionnaire items; modification or removal of items to eliminate ambiguity and reduce non-response and skewed responses; questionnaire survey of out of hours care. SETTING: Greater Manchester and Leicester. SUBJECTS: 11 general practice patients participated in the focus groups and 28 in the semistructured interviews; 41 in the preliminary interviews; 41 and 378 in the postal pilots; and 1466 in the survey of out of hours care. RESULTS: A 32 item questionnaire was developed. Component analysis indicated seven scales (satisfaction with communication and management, doctor's attitude, continuity of care, delay until visit, access to out of hours care, initial contact person, telephone advice) related to overall satisfaction and containing issues identified as important to patients. Levels of reliability were satisfactory, Cronbach's alpha correlation coefficient exceeding 0.60 for all scales. CONCLUSION: A reliable, valid measure of patient satisfaction has been developed, suitable for large scale evaluation of out of hours care.

Comparison of out of hours care provided by patients' own general practitioners and commercial deputising services: a randomised controlled trial. I: The process of care.

OBJECTIVE: To compare the process of out of hours care provided by general practitioners from patients' own practices and by commercial deputising services. DESIGN: Randomised controlled trial. SETTING: Four urban areas in Manchester, Salford, Stockport, and Leicester. SUBJECTS: 2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals) who responded to those requests. MAIN OUTCOME MEASURES: Response to call, time to visit, prescribing, and hospital admissions. RESULTS: 1046 calls were dealt with by practice doctors and 1106 by deputising doctors. Practice doctors were more likely to give telephone advice (20.2% v 0.72% of calls) and to visit more quickly than deputising doctors (median delay 35 minutes v 52 minutes). Practice doctors were less likely than deputising doctors to issue a prescription (56.1% v 63.2% of patients) or to prescribe an antibiotic (43.7% v 61.3% of prescriptions issued) and more likely to prescribe genetic drugs (58.4% v 32.1% of drugs prescribed), cheaper drugs (mean cost per prescription pounds 3.28 v pounds 5.04), and drugs in a predefined out of hours formulary (49.8% v 41.1% of drugs prescribed). There was no significant difference in the number of hospital admissions. CONCLUSIONS: By contrast with practice doctors, deputising doctors providing out of hours care less readily give telephone advice, take longer to visit at home, and have patterns of prescribing that may be less discriminating.

Comparison of out of hours care provided by patients' own general practitioners and commercial deputising services: a randomised controlled trial. II: The outcome of care.

OBJECTIVE: To compare the outcome of out of hours care given by general practitioners from patients' own practices and by commercial deputising services. DESIGN: Randomised controlled trial. SETTING: Four urban areas in Manchester, Salford, Stockport, and Leicester. SUBJECTS: 2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals in general practice) who responded to the requests. MAIN OUTCOME MEASURES: Health status outcome, patient satisfaction, and subsequent health service use. RESULTS: Patients seen by deputising doctors were less satisfied with the care they received. The mean overall satisfaction score for practice doctors was 70.7 (95% confidence interval 68.1 to 73.2) and for deputising doctors 61.8 (59.9 to 63.7). The greatest difference in satisfaction was with the delay in visiting. There were no differences in the change in health or overall health status measured 24 to 120 hours after the out of hours call or subsequent use of the health service in the two groups. CONCLUSIONS: Patients are more satisfied with the out of hours care provided by practice doctors than that provided by deputising doctors. Organisation of doctors into large groups may produce lower levels of patient satisfaction, especially when associated with increased delays in the time taken to visit. There seem to be no appreciable differences in health outcome between the two types of service.

The use of and attitude to peak flow measurement in general practice.

The use of and attitudes to peak flow meters and monitoring were surveyed in a random sample of general practitioners in Northern Ireland. There was an 87% response. Almost all general practitioners had a peak flow meter or spirometer in their practice but only 48% usually took a meter on home visits. The meters were more likely to be used for the diagnosis and management of asthma than chronic obstructive airways disease. General practitioners felt that meters were more useful when used in the consulting room than for domiciliary monitoring and that domiciliary monitoring was more useful in the management than the diagnosis of asthma. Although 79% of general practitioners felt that domiciliary peak flow measurement was useful for the management of asthma, only 3% of all asthmatic patients were using it. General practitioners' attitudes to peak flow monitoring are positive but they are not actually using them as much as they could.

Change in the use of and attitude to peak flow measurement among general practitioners in Northern Ireland between 1989 and 1994.

In 1994 we repeated a study first performed in 1989 to assess the change in general practitioners' use of and attitudes to peak flow measurement. Of 232 general practitioners surveyed, 199 (86%) and 192 (83%) responded in 1989 and 1994 respectively. The percentage who reported having patients using domiciliary peak flow monitoring rose form 58.3 (95% confidence limits 51.4 to 65.2)% to 97.9 (95.9 to 99.9)%. The percentage who reported 'usually' using peak flow measurements for the diagnosis and management of asthma rose from 81.9 (76.5 to 87.3)% to 93.2 (89.6 to 96.8)% and from 83.3 (78.1 to 88.5)% to 95.8 (92.9 to 98.7)% respectively. An unchanged proportion took peak flow meters on house calls. General practitioners have become more aware of the potential of peak flow measurements but are still unlikely to have a meter available to assess patients seen at home. They are therefore likely to be ill-equipped to manage acute exacerbations of asthma in this setting.