Inter-school variations in the standard of examiners' graduation-level OSCE judgements.

INTRODUCTION: Ensuring equivalence in high-stakes performance exams is important for patient safety and candidate fairness. We compared inter-school examiner differences within a shared OSCE and resulting impact on students' pass/fail categorisation. METHODS: The same 6 station formative OSCE ran asynchronously in 4 medical schools, with 2 parallel circuits/school. We compared examiners' judgements using Video-based Examiner Score Comparison and Adjustment (VESCA): examiners scored station-specific comparator videos in addition to 'live' student performances, enabling 1/controlled score comparisons by a/examiner-cohorts and b/schools and 2/data linkage to adjust for the influence of examiner-cohorts. We calculated score impact and change in pass/fail categorisation by school. RESULTS: On controlled video-based comparisons, inter-school variations in examiners' scoring (16.3%) were nearly double within-school variations (8.8%). Students' scores received a median adjustment of 5.26% (IQR 2.87-7.17%). The impact of adjusting for examiner differences on students' pass/fail categorisation varied by school, with adjustment reducing failure rate from 39.13% to 8.70% (school 2) whilst increasing failure from 0.00% to 21.74% (school 4). DISCUSSION: Whilst the formative context may partly account for differences, these findings query whether variations may exist between medical schools in examiners' judgements. This may benefit from systematic appraisal to safeguard equivalence. VESCA provided a viable method for comparisons.

A realist evaluation of how, why and when objective structured clinical exams (OSCEs) are experienced as an authentic assessment of clinical preparedness.

INTRODUCTION: Whilst rarely researched, the authenticity with which Objective Structured Clinical Exams (OSCEs) simulate practice is arguably critical to making valid judgements about candidates' preparedness to progress in their training. We studied how and why an OSCE gave rise to different experiences of authenticity for different participants under different circumstances. METHODS: We used Realist evaluation, collecting data through interviews/focus groups from participants across four UK medical schools who participated in an OSCE which aimed to enhance authenticity. RESULTS: Several features of OSCE stations (realistic, complex, complete cases, sufficient time, autonomy, props, guidelines, limited examiner interaction etc) combined to enable students to project into their future roles, judge and integrate information, consider their actions and act naturally. When this occurred, their performances felt like an authentic representation of their clinical practice. This didn't work all the time: focusing on unavoidable differences with practice, incongruous features, anxiety and preoccupation with examiners' expectations sometimes disrupted immersion, producing inauthenticity. CONCLUSIONS: The perception of authenticity in OSCEs appears to originate from an interaction of station design with individual preferences and contextual expectations. Whilst tentatively suggesting ways to promote authenticity, more understanding is needed of candidates' interaction with simulation and scenario immersion in summative assessment.

Every doctor an educator?

INTRODUCTION: The education of the future health care workforce is fundamental to ensuring safe, effective, and inclusive patient care. Despite this there has been chronic underinvestment in health care education and, even though there is an increased need for educators, the true number of medical educators has been in relative decline for over a decade. PURPOSE: In this paper, we focus on the role of doctors as medical educators. We reflect on the culture in which medical education and training are delivered, the challenges faced, and their origins and sustaining factors. We propose a re-framing of this culture by applying Maslow's principles of the hierarchy of needs to medical educators, not only as individuals but as a specialist group and to the system in which this group works, to instigate actionable change and promote self-actualization for medical educators. DISCUSSION: Promoting and supporting the work of doctors who are educators is critically important. Despite financial investment in some practice areas, overall funding for and the number of medical educators continues to decline. Continuing Professional Development (CPD) schemes such as those offered by specialised medical education associations are welcomed, but without time, funding and a supportive culture from key stakeholders, medical educators cannot thrive and reach their potential. CONCLUSION: We need to revolutionise the culture in which medical education is practised, where medical educators are valued and commensurately rewarded as a diverse group of specialists who have an essential role in training the health care workforce to support the delivery of excellent, inclusive health care for patients. By reimagining the challenges faced as a hierarchy we show that until the fundamental needs of value, funding and time are realised, it will remain challenging to instigate the essential change that is needed.

Using video-based examiner score comparison and adjustment (VESCA) to compare the influence of examiners at different sites in a distributed objective structured clinical exam (OSCE).

PURPOSE: Ensuring equivalence of examiners' judgements within distributed objective structured clinical exams (OSCEs) is key to both fairness and validity but is hampered by lack of cross-over in the performances which different groups of examiners observe. This study develops a novel method called Video-based Examiner Score Comparison and Adjustment (VESCA) using it to compare examiners scoring from different OSCE sites for the first time. MATERIALS/ METHODS: Within a summative 16 station OSCE, volunteer students were videoed on each station and all examiners invited to score station-specific comparator videos in addition to usual student scoring. Linkage provided through the video-scores enabled use of Many Facet Rasch Modelling (MFRM) to compare 1/ examiner-cohort and 2/ site effects on students' scores. RESULTS: Examiner-cohorts varied by 6.9% in the overall score allocated to students of the same ability. Whilst only a tiny difference was apparent between sites, examiner-cohort variability was greater in one site than the other. Adjusting student scores produced a median change in rank position of 6 places (0.48 deciles), however 26.9% of students changed their rank position by at least 1 decile. By contrast, only 1 student's pass/fail classification was altered by score adjustment. CONCLUSIONS: Whilst comparatively limited examiner participation rates may limit interpretation of score adjustment in this instance, this study demonstrates the feasibility of using VESCA for quality assurance purposes in large scale distributed OSCEs.

Determining influence, interaction and causality of contrast and sequence effects in objective structured clinical exams.

INTRODUCTION: Differential rater function over time (DRIFT) and contrast effects (examiners' scores biased away from the standard of preceding performances) both challenge the fairness of scoring in objective structured clinical exams (OSCEs). This is important as, under some circumstances, these effects could alter whether some candidates pass or fail assessments. Benefitting from experimental control, this study investigated the causality, operation and interaction of both effects simultaneously for the first time in an OSCE setting. METHODS: We used secondary analysis of data from an OSCE in which examiners scored embedded videos of student performances interspersed between live students. Embedded video position varied between examiners (early vs. late) whilst the standard of preceding performances naturally varied (previous high or low). We examined linear relationships suggestive of DRIFT and contrast effects in all within-OSCE data before comparing the influence and interaction of 'early' versus 'late' and 'previous high' versus 'previous low' conditions on embedded video scores. RESULTS: Linear relationships data did not support the presence of DRIFT or contrast effects. Embedded videos were scored higher early (19.9 [19.4-20.5]) versus late (18.6 [18.1-19.1], p < 0.001), but scores did not differ between previous high and previous low conditions. The interaction term was non-significant. CONCLUSIONS: In this instance, the small DRIFT effect we observed on embedded videos can be causally attributed to examiner behaviour. Contrast effects appear less ubiquitous than some prior research suggests. Possible mediators of these finding include the following: OSCE context, detail of task specification, examiners' cognitive load and the distribution of learners' ability. As the operation of these effects appears to vary across contexts, further research is needed to determine the prevalence and mechanisms of contrast and DRIFT effects, so that assessments may be designed in ways that are likely to avoid their occurrence. Quality assurance should monitor for these contextually variable effects in order to ensure OSCE equivalence.

Determining the influence of different linking patterns on the stability of students' score adjustments produced using Video-based Examiner Score Comparison and Adjustment (VESCA).

BACKGROUND: Ensuring equivalence of examiners' judgements across different groups of examiners is a priority for large scale performance assessments in clinical education, both to enhance fairness and reassure the public. This study extends insight into an innovation called Video-based Examiner Score Comparison and Adjustment (VESCA) which uses video scoring to link otherwise unlinked groups of examiners. This linkage enables comparison of the influence of different examiner-groups within a common frame of reference and provision of adjusted "fair" scores to students. Whilst this innovation promises substantial benefit to quality assurance of distributed Objective Structured Clinical Exams (OSCEs), questions remain about how the resulting score adjustments might be influenced by the specific parameters used to operationalise VESCA. Research questions, How similar are estimates of students' score adjustments when the model is run with either: fewer comparison videos per participating examiner?; reduced numbers of participating examiners? METHODS: Using secondary analysis of recent research which used VESCA to compare scoring tendencies of different examiner groups, we made numerous copies of the original data then selectively deleted video scores to reduce the number of 1/ linking videos per examiner (4 versus several permutations of 3,2,or 1 videos) or 2/examiner participation rates (all participating examiners (76%) versus several permutations of 70%, 60% or 50% participation). After analysing all resulting datasets with Many Facet Rasch Modelling (MFRM) we calculated students' score adjustments for each dataset and compared these with score adjustments in the original data using Spearman's correlations. RESULTS: Students' score adjustments derived form 3 videos per examiner correlated highly with score adjustments derived from 4 linking videos (median Rho = 0.93,IQR0.90-0.95,p < 0.001), with 2 (median Rho 0.85,IQR0.81-0.87,p < 0.001) and 1 linking videos (median Rho = 0.52(IQR0.46-0.64,p < 0.001) producing progressively smaller correlations. Score adjustments were similar for 76% participating examiners and 70% (median Rho = 0.97,IQR0.95-0.98,p < 0.001), and 60% (median Rho = 0.95,IQR0.94-0.98,p < 0.001) participation, but were lower and more variable for 50% examiner participation (median Rho = 0.78,IQR0.65-0.83, some ns). CONCLUSIONS: Whilst VESCA showed some sensitivity to the examined parameters, modest reductions in examiner participation rates or video numbers produced highly similar results. Employing VESCA in distributed or national exams could enhance quality assurance or exam fairness.

Understanding patient involvement in judging students' communication skills in OSCEs.

INTRODUCTION: Communication skills are assessed by medically-enculturated examiners using consensus frameworks which were developed with limited patient involvement. Assessments consequently risk rewarding performance which incompletely serves patients' authentic communication needs. Whilst regulators require patient involvement in assessment, little is known about how this can be achieved. We aimed to explore patients' perceptions of students' communication skills, examiner feedback and potential roles for patients in assessment. METHODS: Using constructivist grounded theory we performed cognitive stimulated, semi-structured interviews with patients who watched videos of student performances in communication-focused OSCE stations and read corresponding examiner feedback. Data were analysed using grounded theory methods. RESULTS: A disconnect occurred between participants' and examiners' views of students' communication skills. Whilst patients frequently commented on students' use of medical terminology, examiners omitted to mention this in feedback. Patients' judgements of students' performances varied widely, reflecting different preferences and beliefs. Participants viewed variability as an opportunity for students to learn from diverse lived experiences. Participants perceived a variety of roles to enhance assessment authenticity. DISCUSSION: Integrating patients into communications skills assessments could help to highlight deficiencies in students' communication which medically-enculturated examiners may miss. Overcoming the challenges inherent to this is likely to enhance graduates' preparedness for practice.

'What do we do, doctor?' Transitions of identity and responsibility: a narrative analysis.

Transitioning from student to doctor is notoriously challenging. Newly qualified doctors feel required to make decisions before owning their new identity. It is essential to understand how responsibility relates to identity formation to improve transitions for doctors and patients. This multiphase ethnographic study explores realities of transition through anticipatory, lived and reflective stages. We utilised Labov's narrative framework (Labov in J Narrat Life Hist 7(1-4):395-415, 1997) to conduct in-depth analysis of complex relationships between changes in responsibility and development of professional identity. Our objective was to understand how these concepts interact. Newly qualified doctors acclimatise to their role requirements through participatory experience, perceived as a series of challenges, told as stories of adventure or quest. Rules of interaction within clinical teams were complex, context dependent and rarely explicit. Students, newly qualified and supervising doctors felt tensions around whether responsibility should be grasped or conferred. Perceived clinical necessity was a common determinant of responsibility rather than planned learning. Identity formation was chronologically mismatched to accepting responsibility. We provide a rich illumination of the complex relationship between responsibility and identity pre, during, and post-transition to qualified doctor: the two are inherently intertwined, each generating the other through successful actions in practice. This suggests successful transition requires a supported period of identity reconciliation during which responsibility may feel burdensome. During this, there is a fine line between too much and too little responsibility: seemingly innocuous assumptions can have a significant impact. More effort is needed to facilitate behaviours that delegate authority to the transitioning learner whilst maintaining true oversight.

Clinical assessors' working conceptualisations of undergraduate consultation skills: a framework analysis of how assessors make expert judgements in practice.

Undergraduate clinical assessors make expert, multifaceted judgements of consultation skills in concert with medical school OSCE grading rubrics. Assessors are not cognitive machines: their judgements are made in the light of prior experience and social interactions with students. It is important to understand assessors' working conceptualisations of consultation skills and whether they could be used to develop assessment tools for undergraduate assessment. To identify any working conceptualisations that assessors use while assessing undergraduate medical students' consultation skills and develop assessment tools based on assessors' working conceptualisations and natural language for undergraduate consultation skills. In semi-structured interviews, 12 experienced assessors from a UK medical school populated a blank assessment scale with personally meaningful descriptors while describing how they made judgements of students' consultation skills (at exit standard). A two-step iterative thematic framework analysis was performed drawing on constructionism and interactionism. Five domains were found within working conceptualisations of consultation skills: Application of knowledge; Manner with patients; Getting it done; Safety; and Overall impression. Three mechanisms of judgement about student behaviour were identified: observations, inferences and feelings. Assessment tools drawing on participants' conceptualisations and natural language were generated, including 'grade descriptors' for common conceptualisations in each domain by mechanism of judgement and matched to grading rubrics of Fail, Borderline, Pass, Very good. Utilising working conceptualisations to develop assessment tools is feasible and potentially useful. Work is needed to test impact on assessment quality.

Understanding and developing procedures for video-based assessment in medical education.

INTRODUCTION: Novel uses of video aim to enhance assessment in health-professionals education. Whilst these uses presume equivalence between video and live scoring, some research suggests that poorly understood variations could challenge validity. We aimed to understand examiners' and students' interaction with video whilst developing procedures to promote its optimal use. METHODS: Using design-based research we developed theory and procedures for video use in assessment, iteratively adapting conditions across simulated OSCE stations. We explored examiners' and students' perceptions using think-aloud, interviews and focus group. Data were analysed using constructivist grounded-theory methods. RESULTS: Video-based assessment produced detachment and reduced volitional control for examiners. Examiners ability to make valid video-based judgements was mediated by the interaction of station content and specifically selected filming parameters. Examiners displayed several judgemental tendencies which helped them manage videos' limitations but could also bias judgements in some circumstances. Students rarely found carefully-placed cameras intrusive and considered filming acceptable if adequately justified. DISCUSSION: Successful use of video-based assessment relies on balancing the need to ensure station-specific information adequacy; avoiding disruptive intrusion; and the degree of justification provided by video's educational purpose. Video has the potential to enhance assessment validity and students' learning when an appropriate balance is achieved.

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.

Twelve tips for expanding undergraduate clinical teaching capacity.

Undergraduate medical education has expanded substantially in recent years, through both establishing new programs and increasing student numbers in existing programs. This expansion has placed pressure on the capacity for training students in clinical placements, raising concerns about the risk of dilution of experience, and reducing work readiness. The concerns have been greatest in more traditional environments, where clinical placements in large academic medical centers are often the "gold standard". However, there are ways of exposing medical students to patient interactions and clinical supervisors in many other contexts. In this paper, we share our experiences and observations of expanding clinical placements for both existing and new medical programs in several international locations. While this is not necessarily an easy task, a wide range of opportunities can be accessed by asking the right questions of the right people, often with only relatively modest changes in resource allocation.

Non-disclosure of symptoms in primary care: an observational study.

Background: Symptoms form a major component of patient agendas, with the need for an explanation of symptoms being a prominent reason for consultation. Objectives: To estimate the prevalence of different symptoms pre-consultation, to investigate whether intention to mention a symptom in the consultation varied between patients and across symptoms, and to determine how patients' intended agendas for mentioning symptoms compared with what was discussed. Method: We videorecorded consultations of an unselected sample of people aged 45 and over consulting their GP in seven different practices in UK primary care. A pre-consultation questionnaire recorded the patient's agenda for the consultation, current symptoms and symptoms the patient intended to discuss with their GP. The videorecorded consultation was viewed and all patient agendas and 'symptoms with intention to discuss' were compared with the actual topics of discussion. Results: Totally, 190 patients participated. Eighty-one (42.6%) were female and the mean age was 68 (range 46-93). Joint pain was the most commonly reported symptom. One hundred thirty-nine (81.8% of those reporting symptoms) patients reported intention to discuss a symptom. In 43 (22.6%) consultations, 67 symptoms (27.2%), where an intention to discuss had been expressed, remained undisclosed. Tiredness and sleeping difficulty were more likely to be withheld than other symptoms after an intention to discuss had been expressed. Of the more physically located symptoms, joint pain was the most likely to remain undisclosed. Conclusion: This study suggests that the extent of symptom non-disclosure varies between patients, physicians and symptoms. Further work needs to explore the consequences of non-disclosure.

Chronic venous leg ulcer care: Putting the patient at the heart of leg ulcer care. Part 1: exploring the consultation.

This article, the first of two, summarises a study that explored the lived experiences of patients with leg ulcers and the impact of this condition on their quality of life. The study had four study phases; phases 1 and 2 employed qualitative methods and are reported here. Initially, unstructured interviews were held; these revealed significant issues for the patients including the dominance of pain, issues relating to exudate and odour, social isolation and psychological effects. A checklist based on these issues was completed by the researcher during observations of routine care for these same patients; this revealed the extent and depth to which these matters were addressed. On many occasions, significant issues were not disclosed or explored during consultations. These findings confirmed that participants with chronic venous leg ulcers have concerns far beyond wound care.

'Knowledge leech' to 'part of the team': students' learning in rural communities of practice.

BACKGROUND: Keele Medical School has a small accommodation hub for students placed within ten associated general practices in a predominantly rural area of England. Groups of up to eleven final year students spend fifteen weeks learning generic and transferable clinical skills in these practices. AIM: To explore the evolving perceptions on students on their experiences throughout their placements. METHOD: All ten students placed at the hub between August and December 2013 were invited to participate in focus groups in weeks zero, seven, and fifteen. Analysis was qualitative and thematic. RESULTS: Ten, five and eight students chose to participate in successive focus groups. Five themes were identified from the data; acceptance, learning opportunities, relationships, development, and injustice with a subtheme of isolation. CONCLUSION: The placements had a powerful impact on students' learning and development. Their perceptions changed from seeing themselves as 'knowledge leeches' to legitimate contributors to health care over the course of fifteen weeks. They did not recognise that managing perceived adversity led to personal development. This illustrates the need to both identify perceived adversity and explicitly signpost and scaffold life learning. The students described experiences which challenged them intellectually and offered them opportunities to recognise the breadth and complexity of general practice.

Chronic venous leg ulcer care: Putting the patient at the heart of leg ulcer care Part 2: Development and evaluation of the consultation template.

Part 2 in this article series summarises the final two phases of a study which explored the experiences of patients with leg ulcers and the impact of this condition on their quality of life. Early phases of the study revealed a mismatch between issues that affected a patient's quality of life and what they discussed during subsequent health care consultations. In light of this, a nominal group technique was employed to facilitate the development of a new leg ulcer consultation template with patient partners. The aim of this was to include many of the issues raised in phases 1. The new template was evaluated in terms of its utility, significance and clinical potential. The application of this template during routine consultations appears to encourage the patient to disclose issues that are important to them and may have otherwise been overlooked.

An innovative long final year assistantship in general practice: description and evaluation.

We describe and evaluate an innovative immersive 15 week final year assistantship in general practice. Evaluation data was taken from five years of routinely collected School data and available national comparative data. The assistantship aims to enable students to consolidate knowledge and hone their skills through central participation in the care of large numbers of patients with acute and long term conditions. We estimate that most students consulted with over 450 patients during the assistantship. Students report that they became useful to their practice teams, had multiple episodes of feedback on their performance which they found useful and, in the school exit survey, reported that they were highly prepared for practice. 9.4 per cent of students reported that the assistantship was 'too long' and, especially those who completed the assistantship in the second semester, they were out of hospital for too long before F1. Some described a learning 'plateau' after the 10th week which was addressed by modifications to the assistantship. Nevertheless, in national surveys, our graduates' self-reported preparedness for practice is high, a perception shared by their F1 supervisors. General practice can make a valuable contribution to the education of senior medical students and contribute to their preparedness for practice.

Qualitative research using realist evaluation to explain preparedness for doctors' memorable 'firsts'.

CONTEXT: Doctors must be competent from their first day of practice if patients are to be safe. Medical students and new doctors are acutely aware of this, but describe being variably prepared. OBJECTIVES: This study aimed to identify causal chains of the contextual factors and mechanisms that lead to a trainee being capable (or not) of completing tasks for the first time. METHODS: We studied three stages of transition: anticipation; lived experience, and post hoc reflection. In the anticipation stage, medical students kept logbooks and audio diaries and were interviewed. Consenting participants were followed into their first jobs as doctors, during which they made audio diaries to capture the lived experiences of transition. Reflection was captured using interviews and focus groups with other postgraduate trainee doctors. All materials were transcribed and references to first experiences ('firsts') were analysed through the lens of realist evaluation. RESULTS: A total of 32 medical students participated. Eleven participants were followed through the transition to the role of doctor. In addition, 70 postgraduate trainee doctors from three local hospitals who were graduates of 17 UK medical schools participated in 10 focus groups. We identified three categories of firsts (outcomes): firsts that were anticipated and deliberately prepared for in medical school; firsts for which total prior preparedness is not possible as a result of the step change in responsibility between the student and doctor identities, and firsts that represented experiences of failure. Helpful interventions in preparation (context) were opportunities for rehearsal and being given responsibility as a student in the clinical team. Building self-efficacy for tasks was an important mechanism. During transition, the key contextual factor was the provision of appropriate support from colleagues. CONCLUSIONS: Transition is a step change in responsibility for which total preparedness is not achievable. This transition is experienced as a rite of passage when the newly qualified doctor first makes decisions alone. This study extends the existing literature by explaining the mechanisms involved in preparedness for firsts.

Improving the quality of written feedback using written feedback.

BACKGROUND: Educational feedback is amongst the most powerful of all learning interventions. RESEARCH QUESTIONS: (1) Can we measure the quality of written educational feedback with acceptable metrics? (2) Based on such a measure, does a quality improvement (QI) intervention improve the quality of feedback? STUDY DESIGN: We developed a QI instrument to measure the quality of written feedback and applied it to written feedback provided to medical students following workplace assessments. We evaluated the measurement characteristics of the QI score using generalisability theory. In an uncontrolled intervention, QI profiles were fed back to GP tutors and pre and post intervention scores compared. STUDY RESULTS: A single assessor scoring 6 feedback summaries can discriminate between practices with a reliability of 0.82.The quality of feedback rose for two years after the introduction of the QI instrument and stabilised in the third year. The estimated annual cost to provide this feedback is £12 per practice. Interpretation and recommendations: It is relatively straightforward and inexpensive to measure the quality of written feedback with good reliability. The QI process appears to improve the quality of written feedback. We recommend routine use of a QI process to improve the quality of educational feedback.

The epidemiology of teaching and training General Practices in England.

There is no national picture of teaching and training practices or the communities they serve. We aimed to describe the association between general practices' engagement with education and their characteristics, locality and patients' health-status and satisfaction. This data linkage study of all English practices calculated odds ratios for teaching and training status and practice, locality and patient variables. Teaching and training practices are larger than practices which do neither (mean list size (SD) 7074 (3736), 10112 (4934), and 5327 (3368) respectively, p < 0.001 and have fewer patients per GP (1932 (951), 1838 (544), and 2117 (1585) respectively, p < 0.001). Their localities have a higher proportion of White British residents (77.99% (24.17), 81.66% (20.81), 73.07% (26.91), p < 0.001). Practices with more GPs (OR 1.21 (95%CI 1.18-1.20)), fewer male GPs (0.45 (0.36-0.55)) and a higher proportion of White British people in their locality (1.30 (1.06-1.60)) were more likely to teach. Practices in rural areas (1.68 (1.43-1.98)), with more GPs (1.22 (1.27-1.39)), more full time equivalent GPs (2.68 (1.64-4.40)), fewer male GPs (0.17 (0.13-0.22)) and a higher proportion of White British people in their locality (1.34 (1.02-1.75)) were more likely to train. Teaching and training practices had higher patient satisfaction (0.293 (0.190, 0.397) and (0.563 (0.442, 0.685)) respectively and quality and outcomes framework scores (0.507 (0.211, 0.804)) and (0.996 (0.650, 1.342)) respectively than those which did not. Educationally engaged practices are unrepresentative in serving less ethnically diverse and (for training practices) less urban environments. Investment is needed to increase the proportion of educational practices in diverse urban localities.