A qualitative study of the perspectives of key stakeholders on the delivery of clinical academic training in the East Midlands.

OBJECTIVE: Major changes in the design and delivery of clinical academic training in the United Kingdom have occurred yet there has been little exploration of the perceptions of integrated clinic academic trainees or educators. We obtained the views of a range of key stakeholders involved in clinical academic training in the East Midlands. DESIGN: A qualitative study with inductive iterative thematic content analysis of findings from trainee surveys and facilitated focus groups. SETTING: The East Midlands School of Clinical Academic Training. PARTICIPANTS: Integrated Clinical Academic Trainees, clinical and academic educators involved in clinical academic training. MAIN OUTCOME MEASURES: The experience, opinions and beliefs of key stakeholders about barriers and enablers in the delivery of clinical academic training. RESULTS: We identified key themes many shared by both trainees and educators. These highlighted issues in the systems and process of the integrated academic pathways, career pathways, supervision and support, the assessment process and the balance between clinical and academic training. CONCLUSIONS: Our findings help inform the future development of integrated academic training programmes.

A preliminary investigation to explore the cognitive resources of physicians experiencing difficulty in training.

BACKGROUND: Treating patients is complex, and research shows that there are differences in cognitive resources between physicians who experience difficulties, and those who do not. It is possible that differences in some cognitive resources could explain the difficulties faced by some physicians. In this study, we explore differences in cognitive resources between different groups of physicians (that is, between native (UK) physicians and International Medical Graduates (IMG); those who continue with training versus those who were subsequently removed from the training programme); and also between physicians experiencing difficulties compared with the general population. METHODS: A secondary evaluation was conducted on an anonymised dataset provided by the East Midlands Professional Support Unit (PSU). One hundred and twenty one postgraduate trainee physicians took part in an Educational Psychology assessment through PSU. Referrals to the PSU were mainly on the basis of problems with exam progression and difficulties in communication skills, organisation and confidence. Cognitive resources were assessed using the Wechsler Adult Intelligence Scale (WAIS-IV). Physicians were categorised into three PSU outcomes: 'Continued in training', 'Removed from training' and 'Active' (currently accessing the PSU). RESULTS: Using a one-sample Z test, we compared the referred physician sample to a UK general population sample on the WAIS-IV and found the referred sample significantly higher in Verbal Comprehension (VCI; z = 8.78) and significantly lower in Working Memory (WMI; z = -4.59). In addition, the native sample were significantly higher in Verbal Comprehension than the UK general population sample (VCI; native physicians: z = 9.95, p < .001, d = 1.25), whilst there was a lesser effect for the difference between the IMG sample and the UK general population (z = 2.13, p = .03, d = 0.29). Findings also showed a significant difference in VCI scores between those physicians who were 'Removed from training' and those who 'Continued in training'. CONCLUSIONS: Our results suggest it is important to understand the cognitive resources of physicians to provide a more focussed explanation of those who experience difficulties in training. This will help to implement more targeted interventions to help physicians develop compensatory strategies.

Can colleagues', patients' and supervisors' assessments predict successful completion of postgraduate medical training?

BACKGROUND: Workplace-based assessments (WPBAs) are widely used in postgraduate training programmes internationally. WPBAs can function as both an assessment and an educational tool. Although some WPBAs are a mandatory requirement of approved curricula (as in the UK), little previous research has explored the extent to which such assessments are associated with adverse outcomes in postgraduate training. The present study examines whether the assessment element of Multisource Feedback, Patient Satisfaction Questionnaire and Educational Supervisors Review ratings can indicate if a trainee is likely to experience difficulty in successfully completing their planned training programme (i.e. fail one of their licensing assessments or need additional training time). METHODS: Data were collected for trainees undergoing a General Practice specialty training placement in Health Education East Midlands (UK). Multivariate analyses were used to examine the predictive validity of the WPBAs and the outcome measures (n = 327 to 329) and t-tests to calculate whether there were significant differences in performance between trainees who received low versus high WPBA ratings (t = 4.03 to 10.27, p < 0.01). RESULTS: Multisource Feedback, Patient Satisfaction Questionnaire and Educational Supervisor's Review ratings were significantly correlated with subsequent performance in licensing exams (r = 0.14 to 0.47, p < 0.01), and in addition explained significant variance in the likelihood of requiring additional training time (15.6% to 25.6%, p < 0.01). CONCLUSIONS: Based on the findings, we assert that Multisource Feedback, Patient Satisfaction Questionnaire and Educational Supervisor's Review ratings have validity for predicting performance during training and are thus a useful tool for identifying trainees who are more likely to experience difficulty and could benefit from early additional support.

GP trainers and trainees - trait and gender differences in personality: implications for GP training.

This study looked at differences between established GP trainers and current GP trainees in relation to personality traits. Personality differences are particularly important for training in the UK context where the attributes of successful GPs may be evolving as the context changes, and where there is a unique one-to-one relationship between trainer and trainee. GP trainers and trainees attending educational events were invited to participate in this study by completing the NEO-PI-R, a personality measure. Correlation and multiple regression analysis demonstrated differences between these groups; some in line with expected differences relating to age and gender. Others, such as lower reported levels of emotional resilience, may be particular to this trainee population. Overall the gender differences are significant given the trend towards the feminisation of the medical profession. Generational differences may also explain some behaviour and attitudinal differences which can aid trainers' understanding of training issues. The findings have important implications for training, particularly in relation to the development of emotional resilience for GP trainees, and for recruitment. Further research correlating educational outcomes and perceived satisfaction with a GP career and GP training would indicate if trainer/trainee personality differences have a direct bearing on educational outcomes and future practice.

How best to assist struggling trainees? Developing an evidence-based framework to guide support interventions.

OBJECTIVE: To gather rich, qualitative data on typical types and causes of problems faced by specialty trainees who have completed their foundation training, from people with experience of assisting them, as well as the different methods used to support individuals facing those problems. METHOD: We conducted interviews with 20 individuals with experience of assisting struggling GP trainees in the East Midlands Local Education and Training Board (12 GP trainers and eight employees of the Training Support Unit). Interviews were audio recorded and field notes were made. Content analysis was conducted on the field notes, and a framework was developed to summarise the data. This framework was checked for accuracy and comprehensiveness by 32 GP trainers who did not take part in the interviews. RESULTS: Our analysis identified four general categories of difficulties faced by trainees: (a) clinical skills and knowledge; (b) performance in exams or assessments; (c) effectiveness of consultations; and (d) engagement in training. Each of these categories contained between one and four types of specific difficulties faced by trainees. Up to three current sources of support were identified for each category including support from trainers, support from coaching, and other interventions. CONCLUSIONS: Key mechanisms identified for assisting struggling trainees all involve increasing trainees' awareness of gaps in their knowledge and ways of communicating. These included timely and accurate feedback delivered sensitively, potentially from multiple sources. Once GP specialty trainees are aware of their learning needs they can then engage with further support from the local education and training board (LETB) and external specialists. Therefore, LETBs should consider the support they are able to give trainers to facilitate their work with trainees in difficulty.

A new competency model for general practice: implications for selection, training, and careers.

BACKGROUND: Recent structural and policy changes in the UK health service have significantly changed the job responsibilities for the GP role. AIM: To replicate a previous job analysis study to examine the relevance of current competency domains and selection criteria for doctors entering training. DESIGN AND METHOD: A multisource, multimethod approach comprising three phases: (1) stakeholder consultation (n = 205) using interviews, focus groups and behavioural observation of practising GPs; (2) a validation questionnaire based on results from phase 1 (n = 1082); followed by (3) an expert panel (n = 6) to review and confirm the final competency domains. RESULTS: Eleven competency domains were identified, which extends previous research findings. A new domain was identified called Leading for Continuing Improvement. Results show that, Empathy and Perspective Taking, Communication Skills, Clinical Knowledge and Expertise, and Professional Integrity are currently rated the most important domains. Results indicate a significant increase in ratings of importance for each domain in the future (P<0.001), except for Communication Skills and Empathy and Perspective Taking, which consistently remain high. CONCLUSION: The breadth of competencies required for GPs has increased significantly. GPs are now required to resolve competing tensions to be effective in their role, such as maintaining a patient focus while overseeing commissioning, with a potential ethical conflict between these aspects. Selection criteria remain largely unchanged but with increased priority in some domains (for example, Effective Teamworking). However, there is an urgent need to review the training provision arrangements to reflect the greater breadth of competencies now required.

How GPs learn.

As the requirements for the revalidation of general practitioners (GPs) unfold, there is an increasing emphasis on demonstrating effective continued medical education (CME) based on identified learning needs. This qualitative study aimed to promote understanding of how GPs currently approach their learning. The behaviour of one group of GPs was studied to explore how they assessed and met individual learning needs. The GPs studied showed a pragmatic approach, valuing learning that gave them practical advice and instant access to information for patient-specific problems. The main driver for the GPs' learning was discomfort during their daily work if a possible lack of knowledge or skills was perceived. However, some learning benchmarked current good practice or ensured continued expertise. Learning purely for interest was also described. The GPs in this study all demonstrated a commitment to personal learning, although they were not yet thinking about demonstrating the effectiveness of this for revalidation. The GPs prioritised their learning needs and were beginning to use some objective assessment methods to do this and the GP appraisal process was found to have a mainly positive effect on learning.

The challenge of providing mentorship in primary care.

In the changing National Health Service, there is an increasing awareness of stress related problems in the medical workforce. Mentorship has been shown to help with both stress reduction and adaptation to change. There are recognised difficulties with providing mentorship for doctors but there are ways in which these can be overcome. The medical profession is now considering revalidation, re-certification, and the standards required for these. Perhaps it is also time to consider ways in which mentorship can be provided to support the medical workforce, promote ongoing development and thus improve our ability to care for patients.