Undergraduate medical education: recommendations

Chapter Five: Medical School Plans to Increase Undergraduate Educational Capacity in Primary Care

Introduction

The previous chapter on innovations developed by the GP HoTs indicates the potential to substantially increase undergraduate education in primary care. While that chapter covers a great many different approaches, this chapter contains the current commitments to change from all Scottish medical schools.

The following summarises potential early gains:

• Developing GP Teaching Centres in which GPs support multiple learners in clinical practice concurrently
• Using live streamed consultations in group teaching sessions
• Making more clinical teaching sessions in the Medical Schools jointly designed and delivered by primary and secondary care faculty
• Establishing GP led small group sessions to discuss cases encountered in all clinical settings
• Establishing 'near peer' teaching to include working with the Scottish Deanery to facilitate involvement of FY doctors and GP Specialty Trainees
• Considering how to extend GP led teaching into community hospitals and other community healthcare settings including the Third Sector

It is recognised that increasing undergraduate education in primary care is challenging and will take time. 'Quick wins' are limited and many of the initiatives required to develop increased capacity across the whole primary care system (including increasing the number of GPs) cannot be achieved by medical schools alone.

A summary of the current plans from each medical school is set out below.

Aberdeen

The University of Aberdeen is taking a multi-pronged approach to developing a GP enhanced programme for its students which offers them multiple additional opportunities to develop their understanding of general practice, in addition to excellent experience relating to other medical specialties. They are doing this by further strengthening the role of general practice in the curriculum, with GPs teaching alongside secondary care colleagues across clinical blocks and implementing a number of new experiences referenced earlier. These include embedding students in the Third Sector and Out of Hours care. Alongside these changes they are developing the role of existing GP tutors in the community, expanding opportunities for GP mentorship and expanding the clinical teaching time in Primary care, including community hospitals and using case based learning. An additional 30 student places is facilitating the development of multiple opportunities across the curriculum for students to select further GP experience during their studies. Further details below:

GP Enhanced MBChB Programme Curriculum Model

The University of Aberdeen GP Enhanced MBChB Programme will follow a core and options curriculum model. To reduce the risk of potential reinforcement of negative views and divisions between hospital-based disciplines and general practice, we have made a positive decision to adopt a core and options model for our GP Enhanced MBChB Programme. In this all students will experience a GP Enhanced programme where ultimately a minimum 28% of clinical teaching is experienced in a GP context. The figure for community-based placements would be significantly higher than this and is steadily increasing as care moves to the community. These additional placements in the community context feature widely in the curriculum and would include some which are hospital based clinician led and others where there is a combined GP / hospital based clinician activity e.g. diabetic care in North East, mental health (72 sessions in Year 4), child health and care of the elderly.

Dundee

The overall curricular time for students in GP focused or placement based teaching varies between 8% to 12.5% across Years 1 to 5 (with an option in Year 5 to increase to 25% via an immersive clinical placement in rural practice).

Dundee would ideally increase the clinical placement time across all five years, however, teaching capacity in general practice means this is unlikely to be feasible in the near future. They therefore propose to look at sustainable alternatives that give students opportunities to experience the breadth, complexity and intellectual challenge of general practice, to work with positive role models. This could include, for instance, in Years 1 to 3, introducing a series of either one GP day per fortnight or a half day every week, plus two GP weeks per year for a mixture of classroom based learning activities and half day placement in local practices. This might involve:

• Case based student led clinical reasoning focused sessions - mixture of prepared cases progressing to real cases from clinical experiences over years 1-3. Small group format: 8-10 students max (currently in development) with continuity of tutor
• GP Live (GP facilitated discussion of live streamed real consultations - currently in pilot phase)
• 'Experiences' in a mixture of clinical, campus and Third Sector organisations, includes Interprofessional Education (IPE). These currently exist but need refining and expanding.
• GP led small group sessions with continuity of tutor (already exist but to be expanded significantly)
• Formal involvement of GP-STs in teaching
• Whole consultation simulation
• Continue patient journey sessions

In Year 4 and 5, planned or aspirational activities include a continuation of four week immersive GP placements and LIC option for 10 students in Year Four; development of GP Teaching Centres to address capacity issues; whole consultation simulation in Year 4; and student-led clinics for real patients in Year 5.

Edinburgh

Edinburgh are currently reviewing arrangements for delivery of the MBChB programme from 2020 onwards. This will involve changes mostly in years 1 and 2 and year 4. A number of these proposed changes are described below:

Year 1

• The innovative Health, Ethics and Society module will continue with patient case studies delivered through GP practices focusing on the patient's experience of illness, and role and importance of family in promoting and maintaining health.
• Introduction of "live-streamed" GP consultations. This will occur in semester 1 to introduce the students to the nature of GP consultations and communication.
• Patient stories: Interview older patients about their life. The cases will be selected by GP practice. This will include care home residents. The focus will be on talking to patients and becoming comfortable in writing narrative accounts. Students will produce a biography of the patient (not only health focused)
• Introduction to Clinical Practice to start in Year 1 delivered through local GPs. This component will focus on history taking and communication.

Year 2

• Introduction to Clinical Practice will continue through Year 2 with further teaching on history taking and clinical examination of all the major systems. This will be taught through local GPs as in Year 1.

Year 4

• GP placements will expand from four weeks currently to 10 weeks, with a focus on an embedded experience where the GP tutor will be able to provide detailed feedback on students' clinical ability. It is likely that practices will be required to take additional 2-3 students. This will also include out of hours shifts in GP. This component will also focus on the interface between GP and hospital by for example following patients to outpatient appointments or acute admission to hospital. This will also include a strand through the year called "Team" where students will need to work or meet with all the members of the team both in GP (e.g. Practice Manager, District Nurse, Pharmacist etc.) and provide a written report on their role. The same process will also run through Year 4 in hospital based placements. There will also be tutorials developed by GPs to groups of students in local practice placements. These will be case based and co-created with hospital specialists. This is the most practically challenging aspect of the plan. It is already clear from multiple discussions with GP partners that this plan cannot be delivered without an increase in funding.

Year 6

• Aim for students to have a 4-6 week GP placement, which will be similar to current provision. The emphasis will be acting a senior student and seeing patients as first point of contact.
• Edinburgh is aiming to bring clinical exams forward to December, at the end of semester 1. This will allow us to develop semester into a Preparation in Practice module. This will have an assistantship and a local elective in either GP or hospital medicine. They will look to find partners in remote and rural locations for these.

Edinburgh's aspirations are for teaching in primary care settings to represent around 10% of the year one and year two curriculum by 2021; in year four 30% of clinical placement would be in primary care (a 150% increase on current levels) from 2021 onwards; while for year six the aspiration is 25% from 2023 onwards.

Glasgow

Glasgow intends to employ a multifaceted approach to increasing the profile of general practice in the curriculum. Alongside the introduction of the new COMET programme (see point 3 below), they are reviewing the curriculum experienced by all students. Future plans are underpinned by the current evidence base for effective interventions supporting medical students considering a career in general practice.

Proposed or potential initiatives include:

• Enhancing Quantity and Profile of GP during Specialty Placements - in Phase 4 of the curriculum Glasgow are looking at a number of potential options, including amending timetables to provide a GP-delivered section of scheduled specialty teaching within their Integral teaching week and, with additional funding, a placement of students in GP for one half-day during each of the Specialty Blocks in ENT / Ophthalmology, Obstetrics, Gynaecology, Neurology / Cardiology, Musculoskeletal medicine, Paediatrics, and Psychiatry.
• Establishment of the COMET Programme to showcase and develop GP Leadership - in 2019 Glasgow will select its first cohort of students who have expressed an interest in taking on a career in General Practice. Over the remainder of the 4 years in the undergraduate curriculum they will roll out an enhanced exposure to the clinical and leadership challenges presented in primary care settings.
• Promotion of near-peer teaching - following a pilot of Near Peer Teaching by GP Specialty Trainees in third year, Glasgow will be exploring development of practice-based near peer teaching.
• Integration of GP throughout the broader curriculum - general practice lends itself to spanning across the medical school curriculum. In recognition of this, Glasgow have already started to explore promotion of the role of the GP as the 'Expert Medical Generalist'. This includes the proposed creation of a new 'Expert Medical Generalist slot' in year 3 specialty weeks from 2019 and a review of representation of general practice in teaching material used across the curriculum.
• Utilisation of Technology Enhanced Learning and Teaching (TELT) - development of online resources such as GP Live and Online Case Resources will enable greater numbers of students to experience the diversity of experiences available across the West and Scotland as a whole.
• Creation of attractive teaching opportunities for GP teachers in all capacities - investment in GP teaching has the potential to facilitate creation of innovative posts which have been employed successfully in other areas e.g. GP teaching fellow posts for GPSTs, hybrid service and teaching posts, academic and portfolio career opportunities. As a first step, we are in process of employing GPs as Heads of Senior Years (4 and 5) to provide role models for General Practice.

St Andrews

Currently approximately 20% of the BSc Hons clinical curriculum is within primary care. Their short term goal is therefore to increase this to 25% (in line with the SFC target). However, recognising the shortage in primary care physicians and problems within GP retention and recruitment, over the longer term they aspire to a greater shift towards primary care teaching.

Spanning short to long-term plans, St Andrews aims to cross fertilise ideas and innovations with the ScotGEM programme; for example, adoption of a more case-based approach to learning, alongside prominent positive GP role models.

Short-term (0 to 12 months)

• Increase the proportion of simulated scenarios and case-based discussions set in primary care
• Ensure resources that support learning events are relevant to primary care; for example, referencing primary care journals and guidelines
• Introduce joint teaching on placement, delivered by both primary and secondary care physicians
• Introduce joint lectures, delivered by both primary and secondary care physicians
• Directly address and discuss concept of "badmouthing" within lecture theatre event
• Recruit GP registrars for future GP careers events and near peer learning experiences
• Strengthen existing GP society, building on membership and provision of educational events

Mid-term (1 to 2 years)

• Provide Out of Hours (OOH) learning opportunities for students, with placements supported by GP tutors
• Introduce further community-based placement in year 1 of course
• Introduce community-based placements in year 3 of the curriculum (currently secondary care based)
• Provision of third sector placements in early years
• Share Quality Assurance visits of GP practices across institutions to reduce administrative load
• Build on existing GP Showcase day model, sending multiples of students to single sites, promoting "USPs" of General Practice

Over the longer term (two years plus) St Andrews will seek to build a bank of shared primary care learning resource between institutions, including placement sites for "swaps". They also have an aspiration to build on community hospital teaching model, towards a teaching hub/centre but note that this would require significant additional resource.

Facilitating Innovation

The submissions by the GP Heads of Teaching and discussions at the Working Group emphasise that there are significant barriers to delivering increased capacity. In particular, GP HoTs have been clear that the implementation of many of the innovations noted in this chapter will require a significant uplift in the Category A tariff. They feel that a static tariff will not only prevent innovation but risks a decline in the number of practices taking students due to on-going workload issues. In addition campus-based teaching is also dependent on appropriate funding streams, GP tutor and team capacity, physical infrastructure, competing demands on curricular time and professional support staff.

GP HoTs further highlight that clinical placements are very changeable and dynamic, dependent on staffing on the ground, and wider pressures on clinical service provision. Flexibility is therefore essential within medical school plans, with a need to take a longer term view. While it is clear that an increase in the category A tariff is essential to increasing the GP tutor workforce, that in itself will not deliver an increase in education in primary care. That will require the implementation of all the recommendations in chapter 6.