Integrating postgraduate and undergraduate general practice education

Education for Primary Care (2013) xx: xx–xx

© 2013 Radcliffe Publishing Limited

Integrating postgraduate and undergraduate general practice education: qualitative study Andrew O’Regan PBL Tutor & Researcher

Aidan Culhane Adjunct Senior Lecturer, Early Patient Contact Programme Coordinator

Colum Dunne Director of Research

Michael Griffin Adjunct Senior lecturer

Deirdre McGrath Director of Education

David Meagher Professor of Psychiatry

Pat O’Dwyer Adjunct Senior lecturer and General Practice Coordinator

Walter Cullen Professor of General Practice Graduate Entry Medical School University of Limerick, Limerick, Ireland

What is already known in this area ⦁⦁ Educational activity in general practice, due to expanded specialist training and an increased role in medical degree programmes, has increased considerably in the past 20 years. ⦁⦁ Vertical integration, whereby practices support students and trainees at different stages, may enhance their capacity to fulfil this role. What this work adds ⦁⦁ Important features of vertical integration in practice may include: interaction between learners at different stages, negotiating learning, active involvement in clinical teams, inter-agency collaboration and involvement of other healthcare professionals as ‘teachers’. ⦁⦁ Vertical integration is likely to benefit GPs/practices, students and patients through benefits such as improved practice systems, exposure to team-working and opportunistic health promotion, respectively. ⦁⦁ While capacity issues may pose a challenge to vertical integration, strategies such as addressing diverse learner needs and collaboration between medical schools and GP training can aid promotion. suggestions for future research ⦁⦁ Further examination of vertical integration in settings where there has been an expansion in general practice teaching, adopting quantitative methodologies and exploring the issue in practices that are relatively less engaged in clinical teaching, is justified.

Keywords: general practice/primary care, medical education, postgraduate, qualitative research, undergraduate, vertical integration

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2 A O’Regan, A Culhane, C Dunne et al

Summary Background Educational activity in general practice has increased considerably in the past 20 years. Vertical integration, whereby practices support students and trainees at different stages, may enhance general practices’ capacity to fulfil this role.

Aims To explore the potential for vertical integration in undergraduate and postgraduate education in general practice, by describing the experience of (and attitudes towards) ‘vertical integration in general practice education’ among key stakeholder groups.

Methods Qualitative study of GPs, practice staff, GPs intraining and medical students involving focus groups which were thematically analysed.

Results We identified four overarching themes: (1) Important practical features of vertical integration are interaction between learners at different stages, active involvement in clinical teams and interagency collaboration; (2) Vertical integration may benefit GPs/practices, students and patients through improved practice systems, exposure to teamworking and multi-morbidity and opportunistic health promotion, respectively; (3) Capacity issues may challenge its implementation; (4) Strategies such as recognising and addressing diverse learner needs and inter-agency collaboration can promote vertical integration.

Conclusions Vertical integration, whereby practices support students and trainees at different stages, may enhance general practices’ teaching capacity. Recognising the diverse educational needs of learners at different stages and collaboration between agencies responsible for the planning and delivery of specialist training and medical degree programmes would appear to be important.

Introduction Medical education activity in general practice at undergraduate and postgraduate level has


increased.1–3 In Ireland, medical education reforms,4,5 expansion in specialist training,6 the introduction of a new medical degree programme with a strong primary care orientation7 and the increase in the general practice element of existing degree programmes8 have increased clinical education in general practice. ‘Vertical integration’, whereby teaching and learning roles are shared across all learner stages, has been identified as an important element of increasing the capacity of general practice to meet this need.9 Defined previously as the ‘coordinated, purposeful, planned system … in the delivery of education and training throughout the continuum of the learner’s stages of medical education’10 or the ‘educational pathway from medical school to postgraduate hospital post to vocational training and ultimately part of continuing professional development for the qualified GP’,11 for the purpose of this study, we considered vertical integration as the framework that surrounds general practices supporting students and trainees at different stages. Advantages of vertical integration may include: more effective and efficient use of resources (especially time and expertise of GPs involved in education), provision of teaching opportunities to GPs in training and improved learning experience for medical students.12 Indeed, closer integration between undergraduate and postgraduate educational activity in primary care has been advocated and may lead to efficient use of resources, involving doctors-intraining as teachers.9 With clinical education in general practice increasing,13,14 this research aims to explore the concept of vertical integration, or the framework that surrounds general practices supporting students and trainees at different stages from the perspective of key stakeholders, in a region where considerable expansion in GP education activity has occurred.

Methods Overview A focus group study of key stakeholders, including GPs, practice staff, GPs in training and medical students.

Setting Focus groups were held in Ireland’s Southwest and Midwest regions, where considerable expansion in undergraduate and postgraduate teaching has taken place in recent years.7 This expansion includes Ireland’s most recently established medical school, the Graduate-Entry Medical School at University of Limerick (UL-GEMS). Established in 2007, the four-year curriculum has a strong GP component including early patient contact (years 1, 2) and 18week clinical attachments in general practice in

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Vertical integration 3

year 3. In November 2011, 92 practices/GPs were affiliated with the UL teaching programme, of which we estimated 49% were also involved in specialist training.7 Considerable expansion in specialist GP education has also taken place regionally in recent years, with more trainees on two of Ireland’s longest established specialist training programmes (Cork and HSE Midwest) and a recently established training programme, the Southwest. Thus, many practices in the region are actively involved in both undergraduate and postgraduate teaching. Focus groups were held at four locations: Limerick, West Clare, North Cork and Kerry.

at minimum describes and organises the possible observations and at maximum interprets aspects of the phenomenon’.15 Transcripts were read repeatedly and constant collaboration used to ensure codes created were accurately reflective of the data and not driven by researcher influence or bias. Two researchers (AOR, WC) coded the interviews individually and corroborated themes to reach inter-rater reliability. Both researchers had access to coding materials and followed an agreed coding protocol where any new codes, and changes to existing codes were highlighted.15 Data saturation, whereby no new emergent themes or concepts were generated from the data,17 was reached after analysis of the third of four focus groups.

Subjects All GPs affiliated with UL-GEMS (n=92), students on clinical placement at the time of the study (n=45), as well as GP trainees on two postgraduate training programmes (n=14) were considered eligible for the study. Potential participants were invited by email, which included an information pack, topic outline for the focus group, consent form and a list of potential venues and dates. Potential participants were invited to express their interest in participating by returning the consent form and indicating their preferred location and time for the focus group. We recruited 33 participants: 16 GPs, six GPs in training, nine students and two non-clinical staff.

Data collection Four focus groups were facilitated by the principal investigator (WC) and the lead researcher (AOR). Participants were sent a topic guide in advance, which was informed by a review of the literature on the subject and an outline of how focus groups would proceed. The topic guide elicited information on: participant characteristics, experiences of vertical integration, perceived benefits and challenges and finally their attitudes towards it. Discussions were allowed to develop in the direction that the group choose; each focus group was recorded using a digital voice recorder and subsequently transcribed verbatim. Where focus group discussions did not relate to the study objectives or part of the topic guide, facilitators endeavoured to re-focus discussions and considered this during data analysis.

Data analysis For the purpose of this research, inductive thematic analysis was considered the most appropriate method of analysis. This approach has many benefits for studies such as this which are interpretive in nature. An approach to analysis, based on that described by Braun and Clarke15 and Boyatzis16 was followed, with data driven coding, where themes were defined as ‘a pattern in the information that


Ethics The UL Education and Health Sciences Research Ethics Committee approved this study. Key ethical issues were: (1) confidentiality (data was anonymous, comments made by participants were recorded but no names/identifying details included during wider dissemination); (2) informed consent (each potential participant was provided with written information, an opportunity to contact researchers to answer any questions about the research and asked to sign a consent form before participating); (3) voluntary nature of participation (potential participants were advised that non-participation would not affect their relationship with UL-GEMS and that participation carried no remuneration).

Results We identified four overarching themes: (1) important practical features of vertical integration, (2) vertical integration may benefit GPs/practices, students and patients, (3) capacity and organisational issues may challenge its implementation and (4) strategies such as recognising diverse learner needs and interagency collaboration can promote vertical integration (see Table 1).

Theme 1: Features of vertical integration in practice Facilitating medical students and doctors at different career stages to achieve learning outcomes at different levels is the key feature of vertical integration in practice. Teachers must address different levels of learning need, especially recognising differences between the needs of medical students, interns and GP trainees: ‘so we are lucky to have myself and the Registrar integrating with the intern and other students. I think students learn more from people closer to their age. They are going to be more open to the experience. I think that is why the intern has been useful in the education side of things’.

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Table 1 Summary of overarching themes and sub-themes Overarching theme

Sub-theme

1. Important practical features of vertical integration

a. Interaction between learners at different stages b. Active learning through small groups c. Negotiated learning d. Active involvement in clinical team e. Organisational collaboration f. Involving other healthcare professionals as ‘teachers’

2. How vertical integration may benefit stakeholders

a. GP/practice: enables improved practice systems, professional development by GP b. Student: promotes learning from role models (especially behaviours and attitudes), hypothesis generation/clinical decision making, team-working, and multi-morbidity c. Patient: greater opportunity to discuss problems and opportunistic health promotion, improved practice protocols and systems

3. Capacity and organisational issues may challenge its implementation

a. Capacity issues for students (learner fatigue), practices (space, workload, etc), trainees (teaching role), patients b. Organisational issues, e.g. variation between practices and curricula

4. Strategies such as recognising diverse learner needs and interagency collaboration can promote vertical integration

a. GP as coordinator of practice-based learning b. Recognition of diverse learning needs c. Collaboration between organisations involved in curriculum planning and delivery

Active learning, especially small group interaction in which participants can share experience and knowledge is also a key feature: ‘… each then has their own contribution to make. The student might be more knowledgeable in the actual disease processes, the Registrar might be more knowledgeable in the actual care and management and planning, and the GP will be able to give you the broader context’. Vertical integration depends on inter-personal and inter-professional relationships, and this is especially the case for the GP trainee–student relationship. Negotiation between parties, sharing teacher and learner roles, involving the student in the clinical team and allowing him/her to contribute to the practice promotes ‘multi-directional’ learning. Collaboration between organisations, especially agencies and professional bodies involved in organising and delivering undergraduate and postgraduate training was also identified as a key feature, especially in terms of pooling resources and curriculum planning. Organisationally, rotating the facilitator role, involving other staff such as nurses and practice-based researchers and recognising the differing needs of students and trainees on different programmes were other key features.

Theme 2: Benefits of vertical integration Benefits to all stakeholders were identified. For the GP/practice, vertical integration allows education to become a core activity, making it a natural interaction for patients and staff: ‘I think it is very good for the morale of the entire practice. And it is good for that thing of just working together, collegiality’. Improved practice systems due to clinical audit


performed by students and trainees and an intrinsic learning culture were also identified: ‘I think it is a good catalyst for growth in practice because you have fresh blood coming through all the time and it is invigorating’. For the GP, vertical integration facilitates learning and can be a form of continuing medical education or professional development, fulfilling teaching duties helping to keep the busy doctor ‘up to date’: ‘There is no doubt that it is good for the GP to keep up to date, you have to attend the courses, you have to go to the workshops’. For students’ personal development, ‘role modelling’, especially learning behaviours and attitudes from GPs and trainees who may be closer in age were identified as key benefits. Other benefits included developing critical thinking skills, clinical acumen and team working skills, with longer clinical placements allowing a graded exposure to learning in a general practice environment and patients with complex multi-morbidity. For GPs-in-training, exposure to practice-based teaching and increased job satisfaction were potential benefits. Increased patient centeredness, positive relationships with students (e.g. more time to voice concerns, more opportunistic health and re-evaluation of ongoing medical problems) and improved practice protocols and systems that often accompany involvement in education were identified as possible benefits for patients.

Theme 3: Challenges associated with vertical integration Capacity was the most frequently cited barrier to successful implementation of vertical integration. With increased practice-based educational activity,

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students were felt to be at risk of ‘learner fatigue’ and experiencing difficulty adapting to multi-level learning. Clinical space, time and remuneration were highlighted as factors that may limit a practice’s capacity to engage in increased educational activity. Also an initial reticence from GPs to take on a teaching role was identified: ‘A lot of GPs who weren’t used to it would be worried about it and nervous about how it would affect their working day’. For GPs-in-training, their ability, time and willingness to teach were highlighted as important considerations, especially recognising they too may have an initial reticence to take on a teaching role and should have an opportunity to ‘opt out’. At an organisational level, clinical attachments of shorter duration (that occur in most medical schools in Ireland), variability between practices and between medical school curricula and dealing with learners at different levels were especially highlighted as important challenges: ‘the worry that are we giving too much information to, and pitching it at a level that is too much for the medical student, and then is there a tendency to under pitch it for the GP registrar, or is it the case that you can never give enough about anything’. Where patients are concerned, suitability, consent, fatigue and discussion of sensitive issues were also highlighted: ‘If she gets a half an hour every time that she comes she gets “browned off” fairly quickly’.

Theme 4: Strategies that facilitate implementation The GP plays a pivotal role in organising people around him – patients, learners and other staff. ‘The GP is like the conductor of an orchestra, and I think that concept of vertical learning, if you can get it going, if you can get the chemistry going, if you can get the interaction between the patient and the student and the Registrar, and the GP and the student and the Registrar, you know, it has to be productive.’ For effective learning, students should be exposed to different styles and because vertical integration involves various learner levels there will be diverse learning needs. Strategies that enable this involve sharing the dual role of teacher and learner and involving as many staff as possible in the process: ‘If you happen to have two or three doctors in a practice I think it is important that students get exposed to them all’. Providing practical support for those providing education was highlighted as an important function of postgraduate training bodies and medical schools. Such supports include: instruction for GPs and GPsin-training on how to teach, clear guidelines on essential topics to be covered during attachments and in examinations and providing feedback on practice-based teaching programme.


Discussion Key findings and how they relate to other literature This study describes the key features of vertical integration in practice, its benefits and challenges/ enablers to its implementation in a region of Ireland where considerable expansion in general practice educational activity has taken place in recent years. The key features of vertical integration identified are consistent with previous work on this topic, especially multi-directional, active learning involving learners at different levels and inter-agency collaboration.18 Consistent with Harding et al,19 our findings also suggest collaboration between medical schools and specialist GP training programmes is especially important. Potential benefits for GPs (and their practices) were increased collegiality, stimulation and practice growth which correspond to previous work. In a qualitative study involving semi-structured interviews with 60 Brisbane-based GPs to enhance understanding of the GP clinical teacher experience, a number of key inter-related perceived rewards, costs and challenges of teaching were described, including intellectual stimulation, enhanced practice morale and teamwork.20 Glasgow and Trumble, through working groups on the subject, described enhanced collegiality and morale among GPs and increased credibility as a teacher and expertise/ efficiency as an educator.21 In reporting the findings of focus groups on the topic which suggest vertical integration can enhance a practice’s capacity to teach medical students, Dick et al also suggest how it can improve time efficiency, decrease stress levels and foster a culture for continuous improvement, benefits which can extend to all in the practice.12 Our findings did not suggest cost and resource saving as likely outcomes, though Johnson et al previously suggested ‘one recognised driver of vertical integration is the search for efficiency of effort coupled with economy of resource utilisation’.22 Benefits for students, especially learning from positive role models and a wider range of teachers (especially those closer in age), have also been identified. Birks et al describe the advantages of learning from a range of teachers,23 while Dick et al discuss the rewards of learning from those closer in age to students, especially registrars and interns.12 Studies from the Netherlands and Sweden also point to longer term positive outcomes for students such as greater tendency to lifelong learning and better preparation for postgraduate training.24,25 Our findings suggest capacity, organisational issues and patient fatigue as factors that may limit practice-based educational activity. While financial considerations are important considerations,2,3,26 vertical integration can help overcome time and resource constraints.22 Organisational issues are also widely recognised in the literature, lack of a clear educational pathway for students,27 lack of

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consistency between medical schools 28 and differing learner needs29 are the main challenges previously described. Our findings also suggest recognising the key role of the GP in coordinating practice-based education, diversity of learning needs and inter-agency collaboration are key to effective implementation. Thus, GPs should play and share a facilitator role, with the support of the undergraduate and postgraduate bodies, in terms of guidelines, standardisation and feedback. Bentley concurs with this view, recommending GPs foster a learning environment in their practices, supported by relevant training bodies.11

Methodological considerations Our qualitative approach facilitated the indepth investigation of views and opinions of the stakeholders. Each focus group consisted of GPs, trainees and students and this process enabled stimulating discussion between groups, indeed some of the most valuable information was collected from such exchanges. The study was set in a region of Ireland where general practice education has expanded considerably in recent years. In addition, internships in general practice and increased numbers of trainees on existing postgraduate GP training programme have also added to the educational activity in general practice and this is consistent with Ireland’s national medical education policy.4,5,30 While we acknowledge some potential weaknesses of the study, including the relatively small number of participants and the fact that it was conducted a single region, the results are likely to be reflective of national trends.4,5 While this in-depth examination of smaller numbers is a feature of qualitative research, a quantitative study to complement this study would be helpful.31 In addition, our sampling methods are likely to have biased participants towards those practices where education is core activity. The applicability of our findings to practitioners and practices who are less engaged in educational activity should be the focus of future research.

Implications for research, education, practice The study raises some interesting questions and possibilities for further research. A more geographically representative study on the subject, adopting a quantitative approach is warranted to further define the potential for vertical integration in general practice education. Further investigation of learning activities and outcomes may help clarify roles for those who deliver undergraduate and postgraduate education in general practice. In addition, the wider societal impact of increased educational activity, especially key stakeholders


such as patients and practices should be explored further. Our findings suggest considerable wider benefits associated with increased educational activity in general practice, including those previously documented which include: comparable educational outcomes32 and multiple efficiencies in time and costs33 to clinical training in secondary care. Widening the pool of practices for whom medical education is core activity therefore, warrants consideration by policy makers and should certainly be explored in future research. Our findings highlight the importance of collaboration between agencies responsible for the planning and delivery of undergraduate and postgraduate general practice education, especially in respect of resources and curriculum planning. Further and closer alignment of medical schools, specialist training programmes, professional bodies and health organisations may help realise the potential of general practice to support educational activity at all levels. This study suggests benefits for all stakeholders: students, trainees, GPs, practices and ultimately patients.

Authors’ contributions, source of funding and acknowledgements AOR led the project, recruitment of participants, facilitated the focus groups, performed data analysis and drafted the initial and subsequent drafts of the manuscript. WC drafted the original protocol, established the steering group, supervised the recruitment of participants, supervised/facilitated focus groups, supervised/performed data analysis and drafted the initial and subsequent drafts of the manuscript. CD, DMG, AC, POD, MG commented on the original protocol, acted as the project steering committee, commented on the initial findings and contributed to the initial and subsequent drafts of the manuscript. All authors have seen and approved the final draft. We thank the HSE Medical Education & Training Unit for funding this study, our colleagues and students in ULGEMS who participated in this study and Ms Michelle Murnane for her support and help with this study.

Ethical approval The study was reviewed and approved by the University of Limerick Faculty of Education & Health Sciences Research Ethics Committee.

Conflict of interest The authors declare that there are none.

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Correspondence to: Prof Walter Cullen, Graduate Entry Medical School, University of Limerick, Limerick, Ireland. Email: [email protected]

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