Undergraduate medical education: recommendations

Appendix B: From medical student to GP: primary care leading in medical education delivery workshop notes

Summary

In this workshop, experts and stakeholders were tasked with generating solutions to questions relating to primary care, generalism and undergraduate medical education. Briefly, these were: How can more undergraduate teaching be moved to primary care and how can more general practices be involved in undergraduate education? How can primary care assist in the teaching of generalism and how can healthcare professionals be trained in less siloed ways, with more organisational partnerships?

These notes summarise discussions relating to these questions. Though the discussions were separated by individual questions, the suggestions given were, in many cases, overlapping so have been grouped here by theme.

These themes are as follows, with a brief summary of points in each:

Changing teaching in primary care: A number of examples given of innovative teaching methods; some suggestions for new models of teaching; suggestions that trainee and/ or junior GPs should be more involved in teaching; some cautions about various elements of teaching in primary care; and a discussion about the dynamic between teaching quality and quantity.

Primary and Secondary Care Interface: Suggestions to alter the relationship between primary and secondary care included primary care clinicians practicing and teaching in secondary care (and vice versa); in order to facilitate more teaching, various ways of altering GP practice structure were suggested; there was also some discussion about the advantages of teaching for GP practices.

Alterations to curriculum or placement structure: A common comment was on the importance of GPs being involved in university teaching; there were concerns about possible contradictions in teaching and alignment with the GMC MLA; several calls for increased undergraduate placements in primary care; suggestion that all FY2 doctors should spend time in primary care and that GPST training should be increased to 4 years and involve teaching.

Changing perceptions of general practice: A number of examples of "selling points" of GP were generated, though there was also discussion of negative perceptions of GP; it was suggested that the media and student societies could play a part in improving perceptions.

Contractual changes: Calls for altered or increased ACT payments; arguments that changes to GP contract should make teaching part of the core business of GP.

Theme detail

Changing teaching in primary care

Several examples were given of innovative primary care teaching methods. These included:

• A model in Calgary where one GP was allocated solely to teaching, with 4 undergraduate students in each session and involved additional appointments.
• Another featuring simultaneous student teaching, this time 3 students in separate consultations, monitored by video link
• Teaching taking place in out of hours services. Albany Medical School runs an out of hours clinic which is staffed by medical students
• GP Live, a system where consultations are broadcast in to lectures, was mentioned several times as a system useful for the junior curriculum as it provides insight to a large number of students with minimal extension to consulting times.
• Aberdeen "cell" model, where 6 students have a tutorial once a week, which encourages peer learning
• A consulting lab 'mastery' system of joint learning
• Anchoring learning in a patient case, for example as in longitudinal integrated clerkship learning or "following a patient".

There were also suggestions for new models of teaching, including some teaching roles being taken on by other professionals in primary care, or whole practice based learning. There was a general suggestion to challenge the 1 to 1 learning model to increase capacity and that an educational model could be a lever for change in primary care (but that this would require additional ACT funding).

A recurrent line of comments were about trainee or junior GPs becoming more involved in teaching, both in clinical practice and in universities. Rationale for this were suggestions that this would aid teaching capacity, but also that trainees may be "better" role models and have more up to date knowledge. One GP tutor mentioned that opportunities to teach in universities were not offered to GPs until at partner level. Difficulties for universities to access non-teaching GPs to offer teaching opportunities were discussed, with the idea of a one point of advert suggested as a possible solution, and also that universities should attend GP options events to discuss teaching. Another suggestion was the development of some sort of GP training fellowship, where a GP with a special interest in teaching could have a role where part of their time was spent teaching in university and some of their time spent as a practice mentor.

There were warnings about the finding the right time in students' training to introduce different types of learning, concerns about the effectiveness of observation as a teaching method, concerns about needing to unify teaching approaches for consistency and differences in language used between professions as well the necessity for "backfill" of GP time to cover additional appointments and administrative tasks and other resource issues including practice space and funding for travel.

A medical student suggested that quality should be prioritised over quantity, or depth, with a move to fewer sessions in GP placements, for example by having Mondays and Fridays off. At another table there was discussion, foregrounded by acknowledgement that placements in primary care are already highly evaluated by students, about increasing teaching in GP potentially lowering average quality of teaching and whether lowering in quality would be acceptable.

GP practice capacity and the relationship between Primary and Secondary Care

Several changes to the relationship between community and hospital settings with regards to teaching and patient care were suggested. These included hospital generalists coming out in to primary care, perhaps though joint clinics; the possibility of primary and secondary care sharing outpatient appointments; the need for acute clinicians to understand general practice better in order for there to be a shift of undergraduate teaching to primary care; that GPs should teach on wards (possibly trainee GPs may have more flexibility to do this); altering the balance between primary care and secondary care in terms of budget for education; that there could be links made to other community facing specialities and that GPs can complement secondary care teaching around topics like hypertension, perspectives about which in secondary care may be limited.

There were a number of suggestions as to ways in which GP practice structure could be altered to facilitate more teaching in primary care. One of these were that practice cluster delivery systems could be developed and another was about how to develop an engagement strategy for non-teaching practices, possibly using a buddy scheme and how a personal connection when making university- practice links is helpful in ensuring practices know what teaching involves. There was opinion that practices should be encouraged to make space available for students to consult on their own but concerns about space required for this. A suggestion to address the space issue was to use empty rooms if GP staff not there at that time and others were about utilising community hospital facilities, for example using rooms when staff were out and using meeting rooms to take patient histories (with an acknowledgement that there may be a cost involved in using these spaces).

Advantages to practices of teaching were also discussed: There was an argument that teaching is seen as a discrete activity and somewhat of a badge of honour and also a presentation of anecdotal evidence that GPs are more likely to want to work in teaching practices as there is an indication that this is better for their career development and progression.

Alterations to curriculum or placement structure

There were general comments about the importance of GPs delivering lectures and being involved in central teaching and teaching of clinical skills, in part to act as role models but also to highlight the GP as a scholar, with broad knowledge. One GP tutor argued that "primary care issues" or "fluffy stuff" should be removed from the GP curriculum, which should instead be about managing complexity/ the day job of GPs. There was also an argument that the medical curriculum should move away from a reductionist model to teach Realistic Medicine. There were some warnings or provisos related to the curriculum. These included a concern students need to get appropriate exposure to general practice (but there was no expansion as to what this would entail), a warning that there were explicit contradictions in teaching that need to be removed and that exams must be set by a diverse group, including GPs. One person was concerned that the GMC's MLA was becoming increasingly reductionist and that a generalist curricular may be at odds with it and another spoke about GPs being reticent to teach as it may not be aligned to the exams faced by students but that this is a shame as GPs have important, realistic perceptions managing asthma, CVD and diabetes. There was a suggestion that attempts should be made to influence the curriculum at year three as this is when undergraduate students are making choices.

Another general line of comment was that there should be an increase in undergraduate placements in primary care and/ or that placements should be longer and immersive so as to develop a sense of ownership ("my practice"). With regards to generalism, there was an argument that case based learning encouraged generalism, ahead of specialisation, and that exposure to patients' stories of multimorbidity at undergraduate level is key to developing generalist skills. One person commented that understanding multimorbidity and not viewing disease in silos is at the core of generalism, while others warned that there is not a universal, shared understanding of generalism and that medical schools should lead on defining it.

Some argued that all FY2s should spend time in primary care and accident and emergency so they can learn about unscheduled care and related decision making. Another that developing medical training within speciality training should include mentorship skills and there was also a suggestion that GP training should be extended to 4 years and that the extra year could be spent teaching.

Changing perceptions of general practice

There were several comments about how GP is perceived, what needs to be done, some suggestions of how to do that and some comments on the selling points of GP which should communicated to improve perceptions.

There was some discussion on GP being seen as a back-up or ineffective and that clinicians in the acute sector were disparaging about primary care. There was a suggestion that the media should be used to combat negativity about GP and that medical school societies can be used to increase interest. Some called for general practice to develop a sense of uniqueness and that GP needs a strong set of principles and identity to raise its status. It was reported that Denis Pereira Gray has written about the unique aspects of general practice, including skills, theory and principles.

Of the comments that appeared to be various "selling points" of GP, these seem to be largely about the advantages to students. They included:

• That in GP, students see a wide range of things including paediatrics, cardiology and dermatology
• That GP encourages self-directed learning
• That students have a safe space to make mistakes
• That there is power in a 1:1 relationship
• Students can see a "bigger picture" by working with families
• That community centric education is patients centric and therefore promotes generalism
• That in general practice there is an opportunity for independence, too see the patient by themselves and that students' knowledge can be applied to real world settings
• That general practice teaches about complexity, uncertainty and risk

There was some discussion about GP academia and academic careers with some pushing for the option of portfolio careers to be promoted and others concerned about the separation of teaching and research in medical schools, particularly in light of REF funding.

Contractual changes

The idea that teaching should be part of the core business of general practice was expressed by several people, with some offering that this should be an integral part of new GP contracts and primary care improvement plans. There were calls for clarity over funding for teaching (with some simply saying more funding was required, particularly to pay for "backfill") and several comments about the need for changes to ACT funding. In discussion about multidisciplinary learning, some were concerned about contractual issues and funding silos acting a barrier. One person suggested that perhaps 10 minute appointment times in GP were simply not long enough. In terms of solutions to issues of capacity, it was suggested that sometimes institutes have underspends even when there is no operational money; that there may be untapped capacity at individual level as well as at practice level, that some GPs working LTFT may want to teach, rather than have more sessions in GP and that possibly NES could play a part in out of programme experiences.