Evaluation of extended training for general practice in Northern Ireland: qualitative study
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7421.971 (Published 23 October 2003) Cite this as: BMJ 2003;327:971
- Caryl H Sibbett, lecturer (c.sibbett{at}qub.ac.uk)1,
- William T Thompson, director2,
- Maureen Crawford, associate director3,
- Agnes McKnight, director3
- 1Graduate School of Education, Queen's University Belfast, Belfast BT7 1HL
- 2DPO Consultants, Belfast BT7 1LN
- 3Northern Ireland Council for Postgraduate Medical and Dental Education, Belfast BT7 3JH
- Correspondence to: C Sibbett
- Accepted 25 July 2003
Abstract
Objective To evaluate participants' perceptions of the impact on them of an additional six months' training beyond the standard 12 month general practice vocational training scheme.
Design Qualitative study using focus groups.
Setting General practice vocational training in Northern Ireland.
Participants 13 general practitioner registrars, six of whom participated in the additional six months' training, and four trainers involved in the additional six months' training.
Main outcome measures: Participants' views about their experiences in 18 month and 12 month courses.
Results Participants reported that the 12 month course was generally positive but was too pressurised and focused on examinations, and also that it had a negative impact on self care. The nature of the learning and assessment was reported to have left participants feeling averse to further continuing education and lacking in confidence. In contrast, the extended six month component was reported to have restimulated learning by focusing more on patient care and promoting self directed learning. It developed confidence, promoted teamwork, and gave experience of two practice contexts, and was reported as valuable by both ex-registrars and trainers. However, both the 12 and 18 month courses left participants feeling underprepared for practice management and self care.
Conclusions 12 months' training in general practice does not provide doctors with the necessary competencies and confidence to enter independent practice. The extended period was reported to promote greater professional development, critical evaluation skills, and orientation to lifelong learning but does not fill all the gaps.
Introduction
The general practitioner vocational training scheme in the United Kingdom requires three years' training, normally two years in hospitals and one in general practice.1 Twelve months is not considered long enough to adequately prepare doctors for general practice,1 2 and the original proposal was for two years in general practice.3 There is debate on whether to extend the 12 months to 18 months4 5 or to develop higher professional education after this training.2
In the United Kingdom, training in a medical specialty takes a minimum of seven years, compared with three years for general practice, only one of which is normally spent as a general practitioner registrar. The approach to training family doctors varies across northern Europe, but most programmes are longer than three years, with the general practice component ranging from 18 months to four years (European Academy of Teachers of General Practice, personal communication, 2002) (table 1).
Duration (years) of training for general practitioners
Some newly qualified general practitioners in the United Kingdom are reluctant to commit themselves and often drift away from general practice,6 and many take four to six years to become principals.2 7 Reluctance to enter partnerships immediately after the 12 month scheme is due to feeling inadequately prepared to manage the business aspects and the difficulties of balancing life with work, growing NHS responsibilities, workload, stress of patients' demands, and potential violence.2 8
An evaluation of a Scottish initiative giving registrars 18 months in general practice found that participants reported increased confidence in practising and greater capacity to address self identified gaps in knowledge and skills.9
In Northern Ireland a pilot study involving seven registrars, selected at random from 30 volunteers out of the 1999 intake, undertook an extra six months in training practices. Six completed the training; one left for personal reasons. In their first year these six attended courses and meetings to plan the extra six months and promote group formation. Objectives of the course included identifying and filling clinical gaps; improving information technology and research skills and capacity for teamwork; and completing a project.
Methods
The qualitative evaluation used focus groups to collect data. Data analysis was based on grounded theory10 and used participants' verbatim comments.11 The study used systematic, non-probabilistic sampling; the purpose was not to establish a random or representative sample drawn from a population but rather to identify specific people whose characteristics and circumstances were relevant to the focus of the research.11 Three categories of individuals were identified and invited to five focus groups (table 2).
Participants in study
Participants for two of the focus groups (B and D) were selected from the 35 doctors who began their standard 12 month training concurrently with the six who went on to complete the additional six month pilot. We identified individual doctors who matched participants from the 18 month training in age, sex, and examination results. Despite considerable efforts, only four were available for focus group B and three others, unmatched, were available for focus group D.
Two researchers, both independent of the Northern Ireland Council for Medical and Dental Education (NICPMDE), facilitated each focus group, using humanistic skills and clarifying that confidentiality and anonymity would be ensured. All participants freely gave permission to audiotape the focus groups.
Two researchers (WTT and CHS) analysed field notes and audiotape transcripts.11 They identified, coded, and modified emerging themes until saturation was reached.12
Results
Quotations concerning the 12 month programme are from both 12 month and 18 month ex-registrars, and those concerning the additional six months are from 18 month ex-registrars only.
Experience of 12 month programme
Most ex-registrars perceived their one year training programme as positive. However, there was consensus that general practice training was “stressful” and that the one year course was intense and dominated by examinations. A trainer echoed this: “Twelve months seemed educationally too short a time. They are learning skills to pass exams as opposed to practice skills.”
One ex-registrar stated that the examinations are “not relevant to the occupation.” Most participants expressed similar views, although some felt not all study was wasted: “Hot topics got you to look at journals and critical reading was valuable, but I couldn't do it.”
Study pressure seemed to have made the 12 month ex-registrars averse to further continuing education: “As a learner, at the end of the year I had completely had it.”
Ex-registrars reported feeling unable to give direct negative feedback about their training to their trainers and NICPMDE. However, they felt freer to report such aspects to the researchers:
“You feel you can't tell and you're frightened to tell because there's a power perception.”
“The trainer's report is a threat and will it be signed if you complain?”
“You cover for a practice saying something is being done when it isn't, for example the half day for tutorials. When [NICPMDE visitors are there do you speak up? No!”
Individuals reported training gaps, including palliative care, dealing with patients from deprived areas, and practice management. Overall the responses were equivocal; it was acknowledged that although “it prepares you to a certain extent” they did not feel prepared for independent practice. One 18 month ex-registrar reported that a new principal who had recently completed the one year course rang the ex-registrar regularly during the additional six month course. This new principal felt unable to ask partners questions, and this principal's only source of support was to trainers indirectly through the 18 month registrar, who was still doing the course.
Experience of additional six months
The additional training was reported as valuable, particularly as the focus of tutorials shifted from examinations to patients. There was broad agreement that “in first year tutorials were about passing exams; now they are about becoming a good GP.”
The additional training was generally reported as less pressured than the 12 month course, partly due to a shift towards intrinsically motivated learning: “The last six months has made you more interested in learning because you're learning for yourself or your patients. You're not learning for the royal college or to remember the author of a journal, so it's made it more relevant, more interesting, and you're more likely to do it.”
Participants reported that over the additional six months they developed confidence in making “clinical judgments,” in “psychiatric emergency admissions” and in handling “grey areas” such as knowing whether to refer to hospital or wait until results came back before referring. They reported increased confidence in being more assertive with patients. They said they were better prepared for life as a principal or locum than they were at the end of 12 months. However, even after the extra six months they still reported not being “100%” confident, and said that they were underprepared with regard to practice management and self care. Other studies have reported that recently qualified doctors are not aware of how best to look after their own health.13 14
Another benefit of the additional training was the experience of being a team member “rather than the trainee.” This included contributing to the second practice by sharing the “richer experience” from the first practice and through undertaking the projects which were a component of the additional training: “I started an asthma clinic in the second practice and felt more confident in negotiating and being a working part of the team.” Being “listened to” in practice meetings also increased confidence.
Ex-registrars said that experiencing “how completely differently things were done in two practices” was enriching and promoted evaluation of various approaches to clinical issues. Trainers said that their practices had benefited from ideas that registrars brought from other training practices.
Discussion
Although extending the general practice component of general practitioners' training by six months remedies some deficiencies, it is not the whole answer. This study supports previous publications that questioned the adequacy of existing general practice training.1 2 4–9 It also indicates that the reported benefits of the 18 month course are not due simply to experience gained over time but that they are associated with features of the course itself.
After 12 months' training for general practice, newly certified general practitioners are aware of gaps, and these have a negative effect on their confidence. Participants observed that the present training programme does not develop clinical judgment sufficiently for them to be able to practice with confidence and safety. They were concerned that they still needed support in making some clinical judgments and that structures were inadequate in provide such support. These concerns may exacerbate the problem of retaining general practitioners.
Pressures related to assessment generated an aversion to engaging in subsequent continuing professional development. However, the additional six months of training restimulated an interest in learning and continuing professional development, reportedly due to its being more self directed and context related.
Points to consider
This small scale study highlights two aspects of general practice training for consideration. Firstly, does the time-span for training need to be extended beyond three years? Our study indicates that at least 18 months of training is required, and this would be more consistent with the practice in other specialties and other European countries. Potentially this would shift the balance to most of the training being in general practice.
Secondly, does the qualitative nature of the training need to change? Our study suggests that the additional element focusing on patients develops confidence and capacity for independent practice. The opportunity to work in more than one practice was also reported as beneficial.
With the development of primary care organisations, a new general medical services contract, the establishment of the postgraduate medical education and training board, and considerable new funding for the NHS, a real opportunity exists to design vocational training capable of producing the “fit for the purpose” general practitioner required for the new NHS.
What is already known on this topic
Twelve months' training in general practice does not provide doctors with the necessary competencies and confidence to enter independent practice
Registrars completing the existing training lack confidence and feel underprepared
What this study adds
The nature of learning and assessment in the existing 12 month programme left participants averse to continuing lifelong learning
Extending training in general practice by six months led to an increase in confidence, particularly in relation to clinical judgment, but did not fill all the gaps, such as practice management and self care
Experience in a second training practice developed confidence and the capacity for critical evaluation
Footnotes
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Contributors CHS and WTT planned the design and schedules, ran the focus groups, gathered and analysed the data, summarised the results, conducted the literature review, and wrote the first and later drafts of the paper and are the guarantors. MC and AMcK both contributed in the planning stages, assisted in validating the data, reviewed drafts, and contributed to writing the paper. MC and Colin Kenny facilitated the day release course for the third six months of 18 month training. CHS and WTT are guarantors.
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Funding Evaluation funded by Department of Health, Social Services and Public Safety Northern Ireland (via NICPMDE training budget)
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Competing interests None declared
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Ethical approval Not needed