Development and sustainment of professional relationships within longitudinal integrated clerkships in general practice (LICs): a narrative review.

BACKGROUND: Longitudinal integrated clerkships (LICs) are a relatively new model of clinical medical education, whereby students participate in patient care over time and develop relationships with those patients', their clinicians, and other health care staff involved in the care of those patients. It has been called 'relationship-based education' but, to date, no review has investigated the development and impact of these central relationships within this curricula model. AIMS: The aim of this study is to review the literature pertaining to relationships in LICs, specifically to understand how they come about and how they affect learning. METHODS: The search strategy systematically explored PubMed, ERIC (EBSCO) and Academic Search Complete, using key words and MESH terms. Original research published in peer-reviewed journals between January 2007 and August 2020 that were written in the English language were included in the review. RESULTS: After applying set inclusion and exclusion criteria, 43 studies were included in this review. A qualitative thematic analysis was undertaken, and results were synthesised narratively. Four distinct categories were identified: defining relationships in LICs, developing relationships in LICs, relationship maintenance and multi-stakeholder impact. CONCLUSIONS: The longitudinal integrated clerkship model of clinical education facilitates the development of meaningful triangular relationships between student, clinical teacher and patient, which are the central drivers of successful learning within the context of an LIC. These relationships are nested in a set of important supporting relationships involving other supervisors, the medical school and university, the practice clinical and administrative team and peers.

SARS-CoV-2 infection in general practice in Ireland: a seroprevalence study.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody testing in community settings may help us better understand the immune response to this virus and, therefore, help guide public health efforts. AIM: To conduct a seroprevalence study of immunoglobulin G (IgG) antibodies in Irish GP clinics. DESIGN & SETTING: Participants were 172 staff and 799 patients from 15 general practices in the Midwest region of Ireland. METHOD: This seroprevalence study utilised two manufacturers' point-of-care (POC) SARS-CoV-2 immunoglobulin M (IgM)-IgG combined antibody tests, which were offered to patients and staff in general practice from 15 June to 10 July 2020. RESULTS: IgG seroprevalence was 12.6% in patients attending general practice and 11.1% in staff working in general practice, with administrative staff having the lowest seroprevalence at 2.5% and nursing staff having the highest at 17.6%. Previous symptoms suggestive of COVID-19 and history of a polymerase chain reaction (PCR) test were associated with higher seroprevalence. IgG antibodies were detected in approximately 80% of participants who had a previous PCR-confirmed infection. Average length of time between participants' positive PCR test and positive IgG antibody test was 83 days. CONCLUSION: Patients and healthcare staff in general practice in Ireland had relatively high rates of IgG to SARS-CoV-2 compared with the national average between 15 June and 10 July 2020 (1.7%). Four-fifths of participants with a history of confirmed COVID-19 disease still had detectable antibodies an average of 12 weeks post-infection. While not proof of immunity, SARS-CoV-2 POC testing can be used to estimate IgG seroprevalence in general practice settings.

Medical students and clinical placements - a qualitative study of the continuum of professional identity formation.

Background: To explore graduates' perceptions of significant factors affecting professional identity formation (PIF) throughout their graduate medical school education journey and early practice years.Methods: A qualitative study with medical graduates using non-probability sampling. Data collected with graduates via face to face and telephone interviews. Interviews (n = 9) completed with medical graduates of the School of Medicine, University of Limerick.Results: Graduates described their experiences in general practice, during the early patient contact programme and the longitudinal integrated clerkship (LIC) as highly influential. The lasting impact of positive role models was highlighted. The importance of socialisation and entering a community of practice were identified as drivers of professional development. Role modelling and mentorship between students and GP tutors were pivotal as part of early clinical years and clinical LIC. This seemed to have a positive influence on graduate's consideration of general practice as a future career pathway.Conclusion: Professional identity formation occurs for medical students who participate in early patient contact programmes and longitudinal integrated clerkships in GP. Factors such as positive role modelling, good mentorship, communities of practice and a positive learning environment appear to be the main contributors to this process. Experiences as part of longitudinal integrated clerkships are meaningful for graduates, regardless of postgraduate specialisation choices. Educators should acknowledge this when designing medical curricula to ensure that students' professional identity formation is optimally facilitated. Training should be available to support the educators involved in longitudinal integrated clerkships, as they become role models and mentors to students.

Career destinations of graduates from a medical school with an 18-week longitudinal integrated clerkship in general practice: a survey of alumni 6 to 8 years after graduation.

BACKGROUND: There is a worldwide recruitment and retention crisis in general practice. Workforce planning has identified the need to train more general practitioners as an urgent priority. Exposure of medical students to general practice as part of the formal and hidden curriculum, the use of longitudinal integrated clerkships, and positive experiences and role models in general practice are all thought to be contributing factors to doctors choosing careers in general practice. AIM: The aim of this study was to identify career destinations of medical school graduates in a medical school with an 18-week longitudinal integrated clerkship in general practice. DESIGN AND SETTING: This study was conducted in a single graduate entry medical school at the University of Limerick, Ireland. PARTICIPANTS: Medical school alumni 6-8 years after graduation. METHOD: A survey of graduating cohorts of the medical school from 2011 to 2013 was conducted through email and telephone. RESULTS: There were a total of 175 alumni for the period 2011 to 2013. Data was collected on 92% (161/175) through an online survey, follow-up email and telephone interview, and was triangulated with searches of professional registration databases and information from key informants. Between 6 and 8 years after graduation, a total of 43% of alumni were engaged in general practice as a career. CONCLUSION: The reform of the delivery of general practice within medical school curricula should be considered by medical schools, curriculum designers and policy-makers as part of an overall strategy to address the recruitment and retention of general practitioners as part of the global healthcare workforce.

The University of Limerick Education and Research Network for General Practice (ULEARN-GP): practice characteristics and general practitioner perspectives.

BACKGROUND: A well-functioning general practice sector that has a strong research component is recognised as a key foundation of any modern health system. General practitioners (GPs) are more likely to collaborate in research if they are part of an established research network. The primary aims of this study are to describe Ireland's newest general practice-based research network and to analyse the perspectives of the network's members on research engagement. METHOD: A survey was sent to all GPs participating in the network in order to document practice characteristics so that this research network's profile could be compared to other national profiles of Irish general practice. In depth interviews were then conducted and analysed thematically to explore the experiences and views of a selection of these GPs on research engagement. RESULTS: All 134 GPs responded to the survey. Practices have similar characteristics to the national profile in terms of location, size, computerisation, type of premises and out of hours arrangements. Twenty-two GPs were interviewed and the resulting data was categorised into subthemes and four related overarching themes: GPs described catalysts for research in their practices, the need for coherence in how research is understood in this context, systems failures, whereby the current health system design is prohibitive of GP participation and aspirations for a better future. CONCLUSION: This study has demonstrated that the research network under examination is representative of current trends in Irish general practice. It has elucidated a better understanding of factors that need to be addressed in order to encourage more GPs to engage in the research process.

Mixing test specific cut-off is more sensitive at detecting lupus anticoagulants than index of circulating anticoagulant.

INTRODUCTION: Recent guidelines for lupus anticoagulant (LA) detection recommend mixing test interpretation with either a mixing test-specific cut-off (MTC) or index of circulating anticoagulant (ICA). Few studies directly compare efficacy of these approaches. We retrospectively applied MTC and ICA assessment to raw data of 350 LA-positive plasmas from non-anticoagulated patients to compare detection rates of inhibition. MATERIALS AND METHODS: Screen and confirm dRVVT and dilute APTT assays were performed on undiluted plasma and 1:1 mixtures with normal pooled plasma. Samples were considered LA-positive if one or both screening test ratios were elevated and corrected by ≥10% with the confirmatory test. Mixing tests were assessed against locally derived cut-offs for MTC (dRVVT >1.13, dAPTT >1.15) and ICA (dRVVT >11.9%, dAPTT >13.2%). RESULTS: 105 of 350 (30%) were positive in dRVVT and dAPTT, 109/350 (31.1%) were dRVVT positive only and 136/350 were dAPTT positive only (38.9%), from undiluted plasma results. Of the 214 dRVVT positive plasmas, 53 (24.8%) were negative for inhibition by MTC and 65 (30.4%) negative by ICA. Of the 241 dAPTT positive plasmas, 48 (19.2%) were negative by MTC and 97 (40.2%) negative by ICA. CONCLUSION: Whilst integrated testing often detects LA without mixing tests they are diagnostically useful in certain circumstances. Thus, it is valuable to maximise mixing test interpretation as the dilution can lead to false-negative results. These data on a large cohort of LA-positive plasmas reveal that, with the reagents and equipment employed, MTC is superior to ICA in detecting the in vitro inhibition of LA.

Taipan snake venom time coupled with ecarin time enhances lupus anticoagulant detection in nonanticoagulated patients.

A study is presented which assesses the diagnostic impact of incorporating Taipan snake venom time (TSVT) with ecarin time confirmatory test into an existing dilute Russell's viper venom time (dRVVT) and activated partial thromboplastin time (APTT) repertoire when testing nonanticoagulated patients for lupus anticoagulants. A total of 387 plasma samples from nonanticoagulated patients being investigated for antiphospholipid antibodies were tested for lupus anticoagulant by dRVVT and dilute APTT with confirmatory and mixing tests, and TSVT with ecarin time, with commercially available reagents. All were analyzed on a Sysmex CS2000i automated analyzer. Lupus anticoagulant was not detected by dRVVT, dilute APTT or TSVT screening in 265 of 387 (68.5%) samples. A lupus anticoagulant was detected in 60 (15.5%) samples in dRVVT and/or dilute APTT analysis, but gave normal TSVT ratios. Thirty-nine (10.1%) were positive by TSVT and ecarin time and one or both of dRVVT and dilute APTT testing, whereas a further 23 (5.9%) were only positive in TSVT/ecarin time testing. Most of the lupus anticoagulants manifested in dRVVT and/or APTT analysis, as might be anticipated for this reagent pairing. The samples positive by TSVT/ecarin time only, as has been previously demonstrated, emphasize that the many variables that impact lupus anticoagulant testing mean that even a well established dRVVT and APTT pairing cannot deliver diagnostic certainty. Interference by direct factor Xa inhibitors in dRVVT testing could pave the way for wider adoption of TSVT screening as we gain more evidence of its diagnostic performance.

Integrating postgraduate and undergraduate general practice education: qualitative study.

BACKGROUND: Educational activity in general practice has increased considerably in the past 20 years. Vertical integration, whereby practices support students and trainees at different stages, may enhance general practices' capacity to fulfil this role. AIMS: To explore the potential for vertical integration in undergraduate and postgraduate education in general practice, by describing the experience of (and attitudes towards) 'vertical integration in general practice education' among key stakeholder groups. METHODS: Qualitative study of GPs, practice staff, GPs-in-training and medical students involving focus groups which were thematically analysed. RESULTS: We identified four overarching themes: (1) Important practical features of vertical integration are interaction between learners at different stages, active involvement in clinical teams and interagency collaboration; (2) Vertical integration may benefit GPs/practices, students and patients through improved practice systems, exposure to team-working and multi-morbidity and opportunistic health promotion, respectively; (3) Capacity issues may challenge its implementation; (4) Strategies such as recognising and addressing diverse learner needs and inter-agency collaboration can promote vertical integration. CONCLUSIONS: Vertical integration, whereby practices support students and trainees at different stages, may enhance general practices' teaching capacity. Recognising the diverse educational needs of learners at different stages and collaboration between agencies responsible for the planning and delivery of specialist training and medical degree programmes would appear to be important.