BERA 2000 Symposium Presentation for session 5.17 Dr Ed Peile FRCP FRCGP MRCPCH

Better learning for better doctors? Towards improved training in General Practice.

Grounded theoretical categories and dimensions from a pilot study.

Ed Peile

Paper presented at the British Educational Research Association Annual Conference, Cardiff University, September 7-10 2000

Introduction

Doctors wishing to pursue a career in General Practice in the UK must undergo at least 3 years of vocational training following full registration. Two of these years are spent rotating through hospital posts in relevant specialities, and one year consists of an attachment to a training practice.

General Practice trainers are accredited by their local Postgraduate Medical Education Department, and are responsible for the one-on-one training of a GP Registrar during the year spent in the training practice. GP Registrars work as a form of supervised apprentice, and should receive frequent debriefing on their caseload, as well as formal and informal teaching by the trainer and other members of the practice. They have at least 2 hours of protected tutorial time each week, and attend a local Day-release scheme with neighbouring GP Registrars.

There have been a number of surveys of Trainees views on their training year, (Whitfield, 1966; Freer and Reid, 1978; Martys, 1979; Thornham, 1980; Hilton, 1981; Ronalds, Douglas et al., 1981; Anyon, 1987; Short, 1987; Crawley and Levin, 1990; Duncan, 1994) but none has addressed what has added value to lifelong learning in General Practice. Mature, considered feedback on training from former ‘consumers’ could shed light on which are the most worthwhile elements of the (expensive) training process, and how can it be improved?

Several authorities have been looking at the continuum of undergraduate training (GMC, 1993), Vocational Training, (Freeman and Byrne, 1976; Kelly and Murray, 1991; Duncan, 1994; Bain, 1996) and Continuing Medical Education (Marinker, 1992; Smith, Singleton et al., 1998) reflecting critically on the contribution towards development of the skilled doctor, (RCGP, 1985; Calman, 1994; Southgate, 1994), but a lot remains elusive about the process of learning and what facilitates it.

We know that knowledge increases during vocational training to a peak, which is maintained for the first 10 years of postgraduate practice, and which then declines thereafter (Van Leeuwen, et al. 1995). If knowledge erodes, then lifelong learning becomes all the more important, although some qualitative work shows that education plays only a relatively small part in influencing doctors’ behaviour (Smith, Singleton et al. 1998). There is evidence that vocationally trained GPs are ‘better’ GPs in terms of ‘performing the tasks of a GP to a level of providing quality care’ (Hindmarsh, et al. 1998). Hindmarsh’s evidence was multifaceted, but it could not shed light on the processes which contribute to the betterment.

In the absence of any reliable evidence on how trainers are "adding value" to their trainees' learning process (Crawley and Levin, 1990), the accreditation of training practices concentrates more on structure than process, and in order to redress the balance, the quest for evidence, as to which training behaviours have lasting value, must continue.

This study is the first phase of a larger study, the aim of which is to investigate training of Registrars in General Practice. What do they learn that has lasting value to their subsequent work as General Practitioners? The ultimate objective is to relate the educational process to the adult learner's subsequent performance. In order to do this, it is necessary first to determine which aspects of the educational process to investigate, and therein lies the rationale for a pilot study to ascertain the perceptions of doctors who have been trained.

Methods

The idea of obtaining the perceptions of ex-Registrars (now working independently as practitioners), was floated at a meeting of the Aylesbury Trainers’ Group, to which I belong. Aylesbury Vocational Training Scheme is one of 8 schemes in the Oxford Postgraduate Deanery. Trainers were keen that I interviewed their former Registrars to obtain a consumers’ perception of the training. The sample was a convenience sample: trainers provided contact addresses for all Registrars trained in the past 10 years, and those that were contactable were interviewed until data saturation was reached. My own former trainees were excluded from the main sample but used for pilot-testing a semi-structured interview, designed to address what had contributed to lasting value from GP training.

Participating doctors were invited to be interviewed over the telephone for 20 minutes at the time of their choosing. These interviews were recorded, transcribed and analysed using both audiotapes and transcripts.

Using a grounded theory methodology (Strauss and Corbin, 1998) interview transcripts were submitted to open coding (“the analytic process through which concepts are identified and their properties and dimensions are discovered in the data”). Categories (“ building blocks of theory that stand for the central ideas in the data”) began to emerge, and their properties became definable. The interviews also demonstrated the dimensions (“the range along which general properties of a category vary, giving specification to a category and variation to a theory”).

When it appeared that theoretical saturation had occurred (defined by Strauss and Corbin as “the point in category development at which no new properties, dimensions, or relationships emerge during the analysis”), I conducted 6 more interviews with selective coding to affirm the eight selected 'categories' and their dimensions.

A sample of 10 transcripts was examined independently and in depth by an experienced GP educator (who was blind to the categories previously evinced) using the same process of open-coding.

Findings

All categories were meaningful to an audience of GP trainers, educators, and current registrars, providing evidence of face validity. Discussion between the two coders revealed that there was close agreement on the important categories and the only differences were semantic.

Table 1 Categories and Dimensions

PREFERRED BEHAVIOUR / LESS-HELPFUL BEHAVIOUR
1 / Training or Education / Problem-Based Approach
Teaching based on approaches to problems which are not limited to present-day contexts / Emphasis on Managing Disease
Teaching focused on current policies for disease management
2 / Style Spectrum / Wide variety of styles
Learner exposed to different consulting styles and role-models in tutorials / Narrow range of styles
Teaching dominated by personal style and behaviour of trainer
3 / Space for Reflection / Encouraging reflective practitioner
Safe environment to learn from mistakes / Protocol driven behaviour
Black and white approach adopted where learner is expected to adhere to guidelines and elements of blame culture likely.
4 / Modelling Personal Development and Team Skills / Personal development and team management skills taught
Guided learning of skills like time management, assertiveness, boundary-setting / No emphasis on team behaviours
Little attempt is made to help learner understand the importance of team-working and the areas of personal development that are involved
5 / Learning Cycles / Learning cycles completed
A culture exists in the practice where reflection, audit, assessment all promote change and re-evaluation / Haphazard change
Culture is reactive to external pressures, and little evidence of information about the practice inspiring meaningful change
6 / Family practice in context / Contextualised Learning
Trainer introduces the broader dimensions of family and health expectations / Emphasis on presenting problem
Focus remains on sorting and shifting
7 / Control and Direction / Learner centred approach
Trainer listens to trainee and positively seeks out their educational needs adapting the training accordingly / Trainer centred approach
Trainer adopts rigid structure with fixed views on the educational diet to feed trainees or abdicates responsibility inappropriately
8 / Feedback / Sensitive feedback
Both positive and negative feedback delivered where appropriate, stimulating confidence in the learner, and encouraging change. / Inappropriate criticism
Feedback either inadequate or misplaced or poorly delivered, often not timely or specific enough to be useful to learner.

Each of these categories will be explained and then the dimension illustrated with quotations from interviews. For ease of understanding, the preferred behaviour will be illustrated first (subheading on left side), followed by the behaviour which was seen as less helpful under a subheading on right side. The quotes are attributed to individual registrars by superscript numbers (e.g. R20) and interviewer promptings are in italics.


Category 1: Training or Education

In the early days of their work, Registrars wanted some factual teaching to help them find their feet in general practice.

I think to begin with it was useful looking at disease management, sort of mild things you don’t come across in hospital.R9.

But after a very short while the majority of trainees found that disease management teaching covered areas that they preferred to pick up from reading or by practice.

Many registrars were able to acknowledge the trainer’s attention to needs not wants.

Problem-Based Approach
Teaching based on approaches to problems which are not limited to present-day contexts

Several registrars drew a distinction between the factual learning that you could “get from a book” and the more helpful, probing teaching. Thinking laterally; managing uncertainty; and keeping up to date were examples of osmotic learning (Claxton, 1997) which happened as trainers illustrated their approaches to problems.

Registrars were pressed for examples of tutorials where the approach turned out to be of lasting value.

There was, actually, it was one about rheumatoid arthritis and what was interesting was not necessarily the topic but for some reason it broke down the anxieties I had about having to help patients live with their chronic disorders’ R17.

Another example:

I had a real thing about contraception in terms of feeling I knew absolutely nothing at all and I hadn’t the first idea about how to go about counselling someone about contraception. My trainer took me very methodically through a kind of how-to consult on contraception. And I remember feeling ‘thank God I’ve got something in terms of a framework to work on’ R38.

Emphasis on Managing Disease
Teaching focused on current policies for disease management

Can you recall any unhelpful tutorials?

I think a few of them went by in a fog - things like ENT… rather nebulous, huge topics with no particular relevance to a patient didn’t particularly help.

I think the unhelpful tutorials were with other partners that were, in a sense, fact based, and I still find those a bit boring R17

We did hypertension and asthma and all those things but it was the general problem solving that I found more helpful. R2

Category 2 Style Spectrum

The former registrars were unanimous in valuing exposure to a wide variety of styles not just from the partners but from the whole practice team.

It was very much an educational atmosphere there, it must have come not just from the doctors but from everyone in the building.R17

One of the mechanisms for exposure to different styles that seemed to be valued was joint consulting throughout the year with different partners, enabling the learner to experience different approaches and different skills, especially in the early days when the trainer’s personal style sometimes seemed very foreign to the registrar. A large number of registrars also commented on the value of time out in a different practice, often with a different patient mix but certainly with a different ethos.

Wide variety of styles
Learner exposed to different consulting styles and role-models in tutorials

One Registrar who sat in with all the partners, illustrated the value of a broad style spectrum:

The fact that you can approach a problem in different ways with your own style and still come out with the same answer. You go into it thinking there’s a set way of doing things and that’s what you have to learn, but by the end of the year you come away thinking “I can still be me and approach it in my way” but actually still give the patient what they need.R10

Seeing different styles encouraged reflective practice

I think general practice is such a melting pot, there’s so many different approaches - they’re all valid and right but it just helps to think more broadly if you’ve been taught more broadly. R20

Narrow range of styles
Teaching dominated by personal style and behaviour of trainer

Sometimes Registrars could appreciate that there were different styles within the practice, but felt frustrated by the lack of exposure to them:

Objectively, one of the things I agree I’m sorry about is that most of my training was from my trainer apart from a handful of sessions… that was a shame because they did have very different styles at the practice.R29

In other practices there may not be quite such a diversity of approach on offer.

I think all the partners were too similar, or at least there was a very dominant outlook. Having worked with other GPs, I realise there’s a lot more variety out there in terms of outlook and ethos and I only had one sort of role model. R12

Category 3: Space for Reflection

Reflective learning is broadly recognised as having lasting value in medical learning (Slotnick, 1999) and the interviews not only endorsed this but went some way to revealing the role which trainers can play in developing reflective learning. Skilful training in a reflective culture involves many tools, like the use of silence.

In tutorials there really was quite a lot of silence. He’d reflect a point of view which would be in a good, open way, and then he’d leave it at that. His style, I think, was not so much to teach facts but more to reflect on the process, to let me draw my own conclusions.R1

Reflection implies an element of space.

I felt more equipped to step back from the 10 minute appointments and look at education. I think it was the introspection, the chance to think about what we were doing…She (the trainer) generally pulled on the reins but she didn’t tug, she wasn’t generally didactic - that was important.R5

Thus the trainer needs to not only provide time and space for reflection but to show how to use it, the modelling is important.

We’d sit down and look at various aspects of clinical problems and just the way he’d look at them would be slightly different to the ways perhaps I’d approached it. And that would encourage me to try and think of things from a different angle.R5