Leadership and Education Fellowship Project Report Dr Evaluation of Education and Training of Foundation Year 2 Doctors in General Practice posts Background Since August 2005, UK medical graduates have entered the two-year Foundation programme. Trainee s progress and competencies are assessed during the scheme; if progress is satisfactory full GMC registration is achieved after one year. The second year of the programme focuses on providing junior doctors with the chance to experience different medical fields and help them decide on their future career specialty. There have been many changes to medical education over the past decade including the development of Modernising Medical Careers (MMC) and the Medical Training Application System (MTAS). Professor Sir John Tooke led the enquiry into MMC and MTAS following the flaws that were revealed in their implementation. In his report, Tooke comments that ninety-five percent of patient contacts are in primary care and he highlights the importance for all doctors to receive training in (although not necessarily with a view to a career in) General Practice. At present, fifty-five percent of Foundation Year Two (FY2) doctors spend part of the year in General Practice. Tooke suggests that this should be increased so all Foundation doctors get experience within primary care in line with the Tooke report corrective action number eight for addressing the issues created by MMC: the structure of postgraduate training should be modified to provide a broad based platform for subsequent higher specialist training, increased flexibility, the valuing of experience and the promotion of excellence. 1 At present, FY2 Doctors indicate preferences for specialty placements and therefore Doctors currently completing these posts have an interest in general practice for their future career. However, if, as planned, placement numbers in primary care increase, more doctors will be working in the specialty although they are not considering it as their future specialty. The learning needs of these doctors may be different to doctors with a pre-existing interest in specialising in General Practice and it is important that the educational needs of both groups are met. The Operational Framework for Foundation Training 2009 describes the nature of the learning environment for FY2 Doctors as: Centred on trainees; assessed against specific competencies; based on providing a service; of a high quality; flexible; supervised; structured. 2 Whilst these descriptors of a learning environment are clear, how they are implemented in practice can be open to differing interpretations and thus the educational experiences of trainees can vary markedly. 1
FY2 doctors undertake their primary care placements mostly within practices accredited for training General Practice Specialty Trainees supervised by a General Practice Trainer. However, the educational needs and clinical experience of the FY2 doctors are different to GP Registrar s within a practice and there has been no formal assessment of how these differing needs would be best met. Trainers receive no additional training for clinical supervision of FY2 doctors and taking on additional trainees requiring higher levels of supervision can have significant impacts on service provision for practices. Aims To establish the career aims of FY2 doctors completing General Practice posts and the effect of completing a placement within the specialty on their career planning. To establish current educational experiences and arrangements of FY2 Doctors in General Practice within the Windsor scheme area of the Oxford Deanery. To examine the relevance of primary care placements in terms of transferable skills and competencies for doctors in view of their future career plans. Methods of research Both GP trainers and Foundation Year 2 doctors who had completed a post within the past eighteen months were contacted via email or face to face approach. An initial pilot free-form interview with one GP trainer was completed and from this a semi-structured interview was devised. The interview covered areas including their experience of supervising FY2 doctors, which training areas were focussed on, how training needs were identified and what techniques had been used for training. Foundation year 2 doctors from the 2008-2009 cohort and from the 2009-2010 cohort who had completed their GP posts were given or emailed a questionnaire regarding their training experiences in General Practice. A questionnaire was developed which covered areas including the perceived usefulness of a GP FY2 post, what training areas were felt to be important for an FY2, what formal training was given and what impact undertaking the post had on their future career direction. This questionnaire was piloted on two trainees from the 2009-2010 cohort. All questions were answered in free text. No significant changes were made to content after this pilot some format changes were made. The same questionnaire questions were used for the two cohorts but further format changes were made for the 2008-2009 cohort who were contacted via email. Analysis Interview responses were written down verbatim by the interviewer. The responses from all interviews were then collated and analysed for emerging themes. 2
Questionnaire responses were given as free form text. These responses were all collated and then reviewed for emerging themes. Results GP trainer Interviews Eight GP trainers from the Windsor scheme area were interviewed. Evaluation of the experience of supervising FY2 doctors in general practice Two trainers (twenty-five percent) described the experience of supervising an FY2 doctor as a positive experience with no caveats placed. The remaining six trainers (seventy-five percent) interviewed reported that the experience was generally positive but with some variability. No trainers reported an overall negative experience. The two trainers who described the experience as purely positive had each only trained one FY2 trainee. The reasons for positive experience included the opportunity to work with enthusiastic, bright and knowledgeable trainees. The main reason identified for problems with FY2 doctors were clinical incompetence (three trainers), confidence problems (two trainers) and attitude problems (two trainers). Areas of training focussed on Areas of training covered a wide range of clinical and non-clinical topics. The single largest area reported was the nebulous concept of teaching what General Practice involves on a daily basis. All trainers reported in some format that clinical knowledge was an important area to be covered. Some trainers identified separate clinical areas which they focussed on whilst others reported that the content of clinical learning was more trainee-dependent and therefore they did not identify clinical areas of teaching which could be applied to all of their trainees. These different subgroup responses are shown within Table 1 below. The results of the areas viewed as important by trainers for focussed training are shown in table 1. Area of training Number of GPs reporting (%) Experience of general practice 7 (87.5) Consultation skills 6 (75) Clinical learning 5 (62.5) Chronic disease management 3 (37.5) Emergencies in general practice 3 (37.5) GP and primary care teams 2 (25) Safety netting 2 (25) Developing management plans 1 (12.5) Common minor problems 1 (12.5) Managing uncertainty 1 (12.5) Clinical systems and referrals 1 (12.5) Table 1: Areas of training focussed on by trainers 3
An assessment was also undertaken as to why trainers focussed on these areas; five (62.5%) reported that this followed a formal assessment with the trainee of what their learning needs were. Tools for carrying out this assessment included the Kiddy Ring interview 3. Four trainers (50%) reported that they used information learnt from having previous trainees of what training was needed and/or requested. Training methods used Most trainers reported that when training FY2 doctors they used techniques also used with their GP specialty trainees but slightly modified. The areas which were identified as being used most frequently and reported by trainers to be successful are shown in Table 2. Please note that this reflects tools which were thought to work particularly well, not whether they were simply taking place. Teaching tools used which worked well Number of GPs reporting (%) Audit 8 (100) Individual tutorial 6 (75) Joint tutorial with other trainees 6 (75) Joint surgery 4 (50) Video or role play work 4 (50) Random and problem case analysis 3 (37.5) Observation of GP surgery 3 (37.5) Significant event analysis 2 (25) Shadowing duty Doctor 2 (25) Weekly log of learning 2 (25) Completing FY2 assessments 2 (25) Practice treasure hunt 2 (25) Tutorials with Practice Manager 2 (25) Attending practice management and clinical meetings 1 (12.5) Long case follow up of patient with chronic condition 1 (12.5) Patient unmet needs/drs educational need assessment 1 (12.5) Table 2: teaching tools which have worked well with FY2 trainees General principles rather than specific techniques were often referred to in trainers responses. Many reported that part of learning general practice is seeing patients in surgery. Also, many highlighted the importance of matching specific skills with need for example by tutorials on specific topics being led by a GP or nurse with a special interest in that area. The trainers were also asked if there had been any training tools which worked less well; there were no themes which ran throughout the trainers responses. Three trainers reported tailoring learning to a trainee s future career path (if not general practice) worked well, whilst two reported this approach did not work well. Trainers were also asked if any adaptations had been required for specific trainees: many trainers identified a single trainee with unique problems such as their GMC registration status, but no enduring themes could be extrapolated from their responses. 4
Day to day surgery running The commitments required by surgeries for their FY2 trainees were diverse. The current recommendations in The Rough Guide to the Foundation Programme 4 are that FY2 doctors should spend an average of six half days ( sessions ) per week engaged in clinical work the remaining four half days should be spent on project work or teaching. Four trainers (50%) were working to this model; four had clinical requirements which were higher than those recommended, the highest being nine clinical sessions with one tutorial session although they did report this was changeable for specific requirements or commitments. Areas of uncertainty or further guidance needed All trainers interviewed reported that prior to taking on their first FY2 doctor there had been uncertainty about what was required, but after training one FY2 doctor they felt more comfortable and confident with this. They also reported this tended to be a result of difficulty finding guidance, but once found the current guidance was useful. Two areas were highlighted by trainers as being useful to have additional guidance on: four trainers (50%) reported that information on the nature (what is required and how to do them) of FY2 assessments would be beneficial; four trainers (50%) also reported that they had more uncertainty about the administrative aspects of having an FY2 doctor in their practice (specifically relating to contracts, pay and leave requirements). Foundation Year 2 questionnaires A total of eight out of twenty-two approached doctors completed questionnaires - four out of twelve of the 2008-2009 cohort and four out of ten or the eligible 2009-2010 cohort. Is general practice a useful FY2 placement? Seven out of eight (87.5%) reported that General Practice was a useful FY2 placement. One (12.5%) reported that it had been useful in some respects. Trainees were asked why they had found it a useful placement or not - see Table 3 for data. Reason for usefulness Number of FY2s reporting (%) Evaluation of GP as a career choice 4 (50) Understanding of what general practice and 3 (37.5) community medicine involves Experience different areas of medicine and 2 (25) medical conditions not seen in hospital Chronic condition management 1 (12.5) Communication skills 1 (12.5) Building patient relationships 1 (12.5) Table 3: Why was general practice a useful FY2 post 5
What were the most important clinical and non-clinical things you learnt whilst in General Practice and what areas of training should be focussed on for FY2 Doctors in General Practice? Trainees were asked what areas they felt were important to be taught whilst they were in general practice. Several doctors (three 37.5%) reported that while in general practice they learnt how to practice independently. Full results are shown in Table 4. Areas of training to focus on Number of FY2 Doctors reporting (%) Referrals who and how 4 (50) Communication skills 3 (37.5) Medical specialties e.g. paediatrics, 3 (37.5) dermatology How to work independently 3 (37.5) Management in primary care 3 (37.5) Minor medical conditions 2 (25) Safety netting 2 (25) Community services 2 (25) Chronic conditions 2 (25) General medical knowledge 1 (12.5) Table 4: FY2 recommended areas of training to focus on Trainees were also asked what different training modalities they had been exposed to in their FY2 General Practice posts. Types of training identified by the trainees as having been undertaken are shown in Table 5. Training tool used Number of FY2 Doctors reporting (%) Tutorial 7 (87.5) Structured F2 teaching - hospital based 3 (37.5) Practice meetings 3 (37.5) Audit 3 (37.5) FY2 assessments 1 (12.5) Joint surgeries 1 (12.5) GP teaching session not specific to trainee 1 (12.5) Table 5: Types of training experiences by FY2 Doctors Seven (87.5%) of FY2 doctors reported that they had been involved in the selection of topics which were covered in their training sessions. FY2s were also asked what training they would have liked to receive. Two (25%) reported wanting more individual tutorial time as they received on average one session per month. One (12.5%) reported no time for audit and felt this would have been useful. One (12.5%) reported more time with GPs with special interests. One (12.5%) reported that joint surgeries would be useful. One (12.5%) reported that teaching on common presenting problems would be useful. Responses were also given as to what they would change about the overall experience rather than just the training. One trainee (12.5%) reported that they felt there was a lack of senior support and that they did not feel safe at times. One (12.5%) reported that they 6
felt their hours were too long. No other changes were suggested aside from those to training already given. Day to day surgery running The FY2 doctors also reported marked variation in how many sessions, supervision of these and appointment timings they did. The number of clinical sessions varied from five to ten per week with five doctors (62.5%) doing eight or more clinical sessions per week. Most trainees started at around thirty minute appointments and this was reduced over the length of the placement. Career plans after placement FY2 doctors were asked if their career plans changed following a GP placement and if they would consider a career in general practice. Three (37.5%) reported their career plans changed after completing the post, one (12.5%) reported possibly. The trainee reporting possibly had already been accepted onto specialty training in another field but reported that he was considering changing to general practice in the future. Of the three trainees reporting that their career plans had changed one had changed to general practice, one changed away from a career in general practice and one trainee it is not clear what the outcome of the change was. Six (75%) reported they would consider a career in general practice, one (12.5%) reported yes, maybe in the future, not now, one (12.5%) reported absolutely not. Discussion The results from GP trainers and questionnaire responses from FY2 doctors show quite different information. The trainer interviews were undertaken until no new themes emerged from responses and so it is possible to feel quite confident in the data gathered from this group. Only 36% of FY2 doctors who were approached with questionnaires completed and returned them and there is therefore potential for bias in those results. It is possible that only those with a favourable approach to general practice chose to complete and return their questionnaire. However, it is also possible that those with a more negative experience would take the opportunity to voice their concerns about training they received. At present only 55% of FY2 doctors complete general practice posts and therefore it may be that the current cohorts have chosen to do placements in this specialty as it is where their career interests lie. Were all FY2s to undertake these placements, the results might show a reduction in those who find it useful. Overall, both trainers and FY2s find a general practice post to be useful and positive. There is an increasing shift for more healthcare to be delivered by primary care specifically chronic disease management - and with this is mind it is probable that the proportion of doctors in primary care will increase and those which are based in secondary care will be required to deliver community based management plans as well as the traditional hospital based strategies. When looking at the nature of training given, audit was universally agreed to be a good tool to use. However, some trainers reported that not many of their trainees have completed an audit during their time and the reason for this seemed to be if the trainee was not keen to do this. Many trainers did report that 7
they often suggested topics for the trainee to audit and if the recommended weekly structure suggested in The Rough Guide to the Foundation Programme 4 is adhered to, it would seem quite feasible for all trainees to complete an audit during the four month post. This is often the first opportunity a trainee will have to undertake their own audit and, whatever their chosen field, this will be an ongoing requirement in their future practice. It seems that an FY2 GP posts offers an excellent opportunity to start developing the skills they will need throughout their career. As shown in the results section the weekly timetable followed by trainees can be quite variable and many are not following the suggested structure. This is something for practices to examine. One of the areas identified as being important by both trainers and trainees was the concept of learning what it is like to be a GP. There were no specific techniques described that trainers were using to teach this aside from giving on the job experience of general practice. However, this does seem to be working as 37.5% of trainees identified it as being an important element of what they learnt. It is important to remember that FY2 is a stage at which final career paths have not always been decided and giving the experience of what this career would involve is an important lesson and an outcome showing a trainee that this is not the career for them is as important as a trainee deciding to pursue a path in general practice. Other transferable skills which FY2 doctors reported learning in general practice include learning how to be an independent doctor how to make their own decisions and install their own safety nets - important skills regardless of specialty. An important area is patient-centred consulting and community care. Seventy-five percent of trainers and 37.5% or trainees identified communication skills as being an important area to focus on within their general practice placement. Traditionally, communication skills have not been well taught in hospital specialties and general practice is an excellent environment to teach these skills. South Central Strategic Health Authority in Towards a Healthier Future 5 has identified two key ambitions which require good community service provision and also the ability for doctors to be able to communicate well with their patients and share information and decisions with them. These two ambitions are: Ambition 3: Encourage patients to be partners in their care, taking responsibility for their own health and treatment with the guidance and help of professionals. 5 Ambition 6: Offer real choice to patients within the framework of services we commission. We will support patients in exercising choice by providing better access to clinical and other information to help them make decisions that will achieve the best care and outcome for them. 5 Both trainers and trainees identified common and chronic conditions to be areas where training was of benefit. The number of trainers identifying this as important is difficult to extrapolate as some named chronic and common diseases as an area to focus training on whilst others referred more generally to clinical knowledge which may incorporate 8
these specific clinical areas. Currently, 27% of people in the UK are living with a chronic condition. The elderly population is increasing and this will be associated with an increase in people with long term conditions. As a result there will be increasing focus on patient-centred management and keeping management community-based. Again the South Central SHA identifies the need to manage chronic conditions in the community along with increasing focus on disease prevention 5. However, this seems to be one of the key areas that Tooke identifies in his report when he describes the increase in community-based medicine. Offering trainees the opportunity to work in general practice before commencing specialty training has only been possible since the development of the foundation year programme. Prior to this it was one of very few specialties that would be entered as an almost unknown as to what the career involved with no prior experience working in the field. As can be seen from the results, giving trainees an opportunity to experience a career path can greatly affect the choice they make. Thirty seven and a half to fifty percent of trainees reported that they had changed their career path after completing the FY2 post in general practice and 75-87.5% reported that they would consider a career in general practice. With increasing community-based care in the future it would seem that trainees find the opportunity to discover what general practice involves an invaluable option when considering this as a future career path. It is also a useful experience for those who had not previously considered this specialty. Conclusions and future directions Only GPs and trainees in the Windsor VTS region of the Oxford Deanery were included in this assessment and it would be important to assess if these results are extendable more widely. Windsor currently uses GP training practices as the base for their FY2 doctors entering general practice. There is an increasing trend for FY2 doctors to be placed in non-training practices and it would be beneficial to assess if the result of this being a useful FY2 placement for trainees is mirrored in non-training practices. Overall, assessing interview and questionnaire responses with information about the Foundation programme within the Tooke report and documents from the Foundation school, the overall message from trainers (with some caveats) is that they find training FY2 doctors a positive experience and trainees find this a very useful placement. Areas to focus training on within the four-month placement include audit, patient-centred consulting and community management, and chronic and common disease management. These are important to establish skills and knowledge for the trainee which they can use in the future regardless of specialty. Aside from these specific aims, GPs want to teach and trainees want to know what being a GP involves and this seems to be taught via first hand experience of the job. It is this direct experience in general practice which gives doctors experience in community based medicine which will be increasingly needed in most specialties. It is also this hands-on experience which is helping trainees to make an informed choice on general practice or not as a career. 9
References 1) Aspiring to Excellence. Findings and Final Recommendations into the Independent Inquiry into Modernising Medical Careers Led by Professor Sir John Tooke January 2008 2) Operational framework for Foundation Training 2009 Amendment 3)http://www.dundee.ac.uk/gptraining/SPTC%20Files/CD%20Rom/Unit%201/The%20K iddie%20ring.rtf 4) Foundation Programme A Rough Guide 2007 5) South Central strategic Health Authority Towards a Healthier Future 2008 Acknowledgements With thanks to all the trainers and trainees in the Windsor VTS region who gave up their time to be interviewed and complete questionnaires. 10
Assistant Programme Director Windsor VTS As part of my six month ST4 post as an Educational Fellow based with the Windsor VTS I spent one day a week as Assistant Programme Director. This gave me the unique opportunity to see the roles played by team members and the amount of work that is required on a day to day basis to run a VTS scheme! I organised and ran teaching sessions for ST1/2 and ST3 and was involved in exam preparation for current ST3s. As well as this element I also attended meetings with the Windsor scheme and also meetings joint with the Reading scheme PDs. I have seen first hand the problems that can come up from trying to fit trainees into limited available posts and how these decisions and negotiations are made. The Windsor scheme has recently had two new(ish) programme directors who have been charged with not only keeping a scheme going but also working out the potential future direction of the scheme. Being involved in discussions about priorities and learning directions of the scheme was a fantastic experience. Also I grew to appreciate how creating a mission statement can help to cement those elements which are the most important to all team members. My role with the Windsor VTS allowed me to get great experience with education, which is a role which will be in my future, although the exact nature of that future role is still unclear. It also gave me the opportunity to use the leadership skills learnt in the monthly education sets for the ST4s. When I started the assistant programme director role I was not clear what the role entailed but having now done it for six months and been fantastically supported by Joanne Byfleet, Amandeep Dosanjh, Manjinder Uppal (programme directors) and David Taylor and Jackie Stallwood (administrative) I can say the role involved education, organisation and leadership and was a role which I was very sad to leave at the end of the six months. I now feel more confident in the skills which I learnt and used over the fellowship period. I hope to be involved in education either as a trainer or possibly a programme director in the future and this six months has given me exposure and experience in education which will be invaluable in the future. 11