Introducing undergraduate medical teaching into general practice: an action research study

Abstract

Following the publication of Tomorrow's Doctors and as a result of increasing numbers of students recruited to medical school it is necessary to involve more general practitioners (family physicians) in undergraduate medical education. Students have responded positively regarding experiences in general practices with a broad spectrum of clinical conditions to be seen and greater involvement in clinical decision-making. This action research study followed a small group general practice in South Wales through the required preparation for undergraduate medical education and its first year of teaching. Preparatory work for the practice focused mainly on summarizing patient notes, setting up a practice library and arranging accommodation for the students. Members of the Primary Health Care Team (PHCT) found that having students in the practice gave them a sense of achievement and enhanced self-worth. Individuals within the practice felt more confident in their professional role and the team ethic within the practice was strengthened. Doctors’ anxieties regarding the adequacy of their clinical skills proved unfounded. Patients were reported to feel more included in their care and to have enjoyed hearing their condition being discussed with the students. Students valued the one-to-one teaching, seeing common illnesses and a variety of consulting styles. It is hoped that this paper will be of value to those responsible for recruiting GP practices into undergraduate teaching. It demonstrates benefits for the primary health care team in terms of improved morale and sense of professional self-worth. Patients felt more involved in their care. Generalization from these findings is limited by only one practice having been involved. Undergraduate teaching offers advantages, particularly in terms of professional self-esteem and team morale.

Table

Practice points
•Having medical students in the practice gave members of the primary health care team an enhanced sense of self-worth and made them feel more confident in their professional role.
•The team ethic within the practice was strengthened by the presence of the students.
•Doctors were anxious about the adequacy of their clinical skills before the students started but this proved unfounded.
•Reports suggested that patients felt more included in their care and enjoyed hearing their condition being discussed with the students.

Introduction

Background

The last decade has seen a greater proportion of undergraduate medical education take place in general practice (Society for Academic Primary Care, 2002; Mathers et al., 2004; Morrison & Spencer, 2004). This has largely been driven by the General Medical Council's report Tomorrow's Doctors (General Medical Council, 1993). In 1986 the number of sessions delivered in general practice in the whole curriculum at British medical schools was between 20 and 40. By 2001 it had increased to an average of 120. In 2002 academic general practice was contributing an average of 9% of the entire undergraduate curriculum (Society for Academic Primary Care, 2002).

Whilst teaching in general practice provides students with enhanced learning opportunities, it requires teaching practices to accommodate more students and more practices to be recruited by medical schools (Mathers et al., 2004).

Community-based education offers a strategy for introducing new health professionals into primary care. In the declaration of Alma Ata (WHO, 1978) it was proposed that teaching health care professionals in the community, away from tertiary care centres, would result in more students, after qualifying, electing to work in primary care with some choosing to go back to the areas where they had trained. This idea was echoed by some UK general practitioners who, when interviewed, said that students who had enjoyed a good GP placement were more likely to return to the area to practise themselves (Mathers et al., 2004). A number of initiatives have been successful in increasing recruitment of doctors to rural and under-serviced areas by increasing the proportion of undergraduate teaching in those areas (Worly et al., 2000).

Students report that their teachers in general practice are more enthusiastic than in secondary care, that they have fewer changes of teacher and that their time is used more productively (Parry & Greenfield, 2001). Early exposure to general practice gives students increased confidence in talking to patients, and a better understanding of the doctor's role and the doctor–patient relationship (Hampshire, 1998). Some schools have offered students the opportunity to undertake a larger part of their studies on a ‘parallel track’ in primary care while their peers follow the traditional secondary/tertiary care-based course. Such students like the broad spectrum of general medical conditions and the ability to learn decision-making in the context of the whole patient, his/her family and local facilities (Lewin et al., 1999; Worley et al., 2000).

As students progress through medical school the proportion expressing an interest in general practice as a career rises but the proportion entering general practice at the end of training is still too small to meet the numbers required (Mathie, 1997; Howe & Ives, 2001). This proportion may be improved by providing increased opportunities for favourable learning experiences in general practice.

Furthermore, teaching medical students has a positive effect on GPs’ morale (Hartley et al., 1999) and can offer a ‘cycle of satisfaction’ to which personal motivation, shared team responsibility for teaching and enhanced professional self-image all contribute (Howe & Ives, 2001). Teaching has tended to be concentrated in larger practices but single-handed practices have been found to be very welcoming to students and to offer them a learning experience comparable to that found in larger practices (Wylie et al., 1999).

Setting

The Heads of the Valleys (HOV) project, supported by a grant from the Welsh Assembly Government, offered GPs incentives in the form of paid non-clinical sessions (for personal and practice development or academic work) to fill vacancies in practices in the South Wales Valleys where recruitment had been difficult. The practice where the current study took place had been without a permanent principal for two years and had not been involved in undergraduate teaching or in training GP registrars (Family Medicine Residents) in recent memory. At the time of the study there was no practice training GP registrars within the borough.

The practice comprises 3300 patients with three doctors working a total number of sessions equivalent to two full-time GPs. One of the doctors (AG) is a senior lecturer in general practice who splits his time equally between the practice and the Department of General Practice where he has considerable responsibility for teaching.

Premises comprise two surgeries (offices), the smaller of which has very limited space for teaching. To make teaching possible a spare consulting room must be available enabling students to see the patients on their own before sitting in on the consultation with the GP. This is possible at the larger but not the smaller surgery.

This action research project followed the practice as it prepared to accept students on the final-year attachment at Cardiff University. Our question was to determine what effort was required by the practice before teaching could start and during teaching. We also wanted to determine the effects of having a medical student in the practice on all members of the primary health care team. We explored the extent to which the practice team's initial expectations about teaching had been realized.

Method

We chose an action research approach, which is described as a ‘Small scale intervention in the real world’ (Cohen et al., 2000).

Unlike a controlled trial or an observational study action research involves observation of an intervention and reflection on its effect, in this case preparation for teaching and teaching itself. The outcome of the reflection may be to amend the intervention with evaluation by further cycles of action research. It was at the two meetings to discuss the introduction of teaching that most reflection took place. It was at these meetings that amendments would have to be decided if problems related to teaching had been identified. At subsequent meeting it would have been discussed whether such amendments had made the necessary changes. If not, further changes and reflections on their effects would have been necessary.

Two formal meetings were held with all members of the primary care team (general practitioners, practice nurses, district nurses, a health visitor and the practice manager). The first was held in May 2003, five months before teaching commenced, and was held in two parts. The meeting began with the head of the Department of General Practice presenting the university's requirements for new teaching practices. After her departure the team discussed how these requirements could be met. The second meeting occurred at the end of the first year of teaching, by which time three students had been placed at the practice.

Both authors attended each meeting, AG as a team member and MR as researcher/observer. The second meeting reviewed the preparatory process and the first year of teaching. It was facilitated by AG and followed a broad topic guide that sought to identify experiences of teaching, and the extent to which the initial expectations were met. Opportunities for all members of the team to comment on their experiences were explicitly provided. The third medical student, who was still attached to the practice, was present.

Additional data were generated by means of a semi-structured interview conducted by MR with the GP taking responsibility for teaching within the practice. The interview took place in March 2004. To inform the development of the interview schedule and the topic guide for the follow-up practice team meeting, and to provide additional perspectives on the teaching initiation process, semi-structured interviews were conducted with two GPs from practices that had started teaching the previous year. Each author carried out one interview. A total of three one-to-one interviews were therefore carried out.

Meetings and interviews were digitally audio-recorded and transcribed and, in addition, MR kept notes. Transcripts were initially analysed by both authors independently to identify emergent themes. At this point the authors met several times and discussed the thematic framework that was emerging from the data. Through discussion they then developed a single framework by consensus (see Box 1). The thematic framework was then refined across a series of meetings between the authors. Analysis was managed using the qualitative software package QSR N6 (Richards, 2002). The results will be presented according to the emergent themes and supported by illustrative quotes.

Box 1. Data analysis—thematic framework

• Preparation for teaching

• Student accommodation and travel

• Team experience of teaching

• Patients’ perception

• Effects of being a directly managed practice

• Student's experience

• Feedback on the process

• Connection with other teaching practices

Results

Venue and duration of meetings

Both practice meetings were held at lunchtime in the practice seminar room; the first meeting lasted one and three-quarter hours and the second lasted approximately one hour. The first meeting took place in May 2003 and the second in April 2004; 10 participants attended both. Participants appeared comfortable being recorded and all contributed to the discussion. The individual interviews both lasted 45 minutes.

Preparation for teaching

The university required the practice to have all or most of its records summarized and to maintain a small, up-to-date practice library before it was allowed to take on students. Summarizing records has been a requirement for practices training postgraduate vocational trainees for many years. It offers students and trainees one page containing all the patients’ major medical conditions and other important information. Summaries save the learner from having to read through the sometimes hefty notes of each patient to access this information. Summaries also enable the practice to develop disease registers, which form the basis for chronic disease management.

Students would need a desk in a quiet area where they could study when there was no scheduled teaching activity. The Department of General Practice would give the practice £1000 towards the setting up costs for the library. The two interviewed GPs in new teaching practices reported that their notes were already summarized and they had practice libraries in place already. They had previously had to comply with similar requirements before becoming involved in training GP registrars. However, one practice had needed to buy a few books particularly relevant to undergraduate students.

There was some initial concern, in the study practice, that the process of summarizing notes was slow. However, the practice was told that it would be acceptable if some notes had been summarized and it could be demonstrated that a programme was in place that would, in time, complete the task. By the time of the final meeting only a small proportion of notes had actually been summarized. There was a discussion about whether having notes summarized had made any difference to teaching. Although the practice recognized and valued the clinical benefits of summarized notes their absence was not felt to have been detrimental to teaching.

Student accommodation and travel

As the practice is situated about 30 miles from the university it was necessary to offer students the option of staying overnight rather than commuting on a daily basis. At the outset two viable options were identified: a guest house near the surgery and a room at the local district general hospital. The second option was considered to be less acceptable to students without a car as they would still have to travel from the hospital to the surgery each day (approximately four miles with infrequent buses). Concerns were expressed both about a student being in an unfamiliar place where she/he knew no one if she/he did decide to stay and, conversely, about students having a long drive home if they chose to commute. Much of the discussion in the first meeting had revolved around this issue and arranging accommodation was described as ‘the biggest headache’ by the practice manager.

In the end all three students in the first year chose to commute so providing accommodation proved unnecessary. None of the students said that they found travelling daily onerous.

No money was available from the university to cover the costs of travel but students may have been eligible for some remuneration from their local authority.

Team experience of teaching

Before teaching commenced some doctors had voiced anxieties that their methods of clinical examination would be different from the way students were taught at medical school. These fears were not realized; in fact doctors commented that in teaching the students they had felt a sense of increased professional skill and satisfaction. Having students in the practice also provided stimulation and the professionals felt refreshed by the experience:

I suppose you must do, you must grow as a GP, but when you’re explaining a case to a student, it's amazing how much you pick out of that case. (GP 5)

Certainly having a student with you it keeps the practice quite fresh. I think we do benefit from it … . I think people quite enjoy having students around. (GP6)

One GP said they would give this advice to another practice contemplating taking on a student:

It's quite enjoyable, it's refreshing, quite exciting at times. Can be hard work but you get a lot back from the students because they’re so enthusiastic and that's something that does re-kindle you a bit … . You think ‘What's it all about?’, but students come in with this starry eyed freshness that does rejuvenate your spirit sometimes and that's something I’ve found very useful. I think I’d probably highlight that … that it's all good fun. (GP1)

The students’ presence was valued by the team as an opportunity to learn and to have the perception of a fresh pair of eyes in the practice:

Sometimes it's good to see things from their point of view as well, because [where] I’ve known patients for quite a while you can become complacent, and it's interesting to see fresh ideas [and] fresh views. (Practice nurse)

Teaching the students was shared out amongst the doctors and other members of the primary health care team. The consensus was that this had led to a strengthening of the team spirit:

We all wanted to be involved in, um, to the point where if I did a rota and it didn’t involve somebody for a few days [they were] saying ‘Well why haven’t I got the student?’ What I’ve done is try to sort of expose them to each of the doctors as equally as we can. (GP2)

Every member of the team said that they had enjoyed having students in the practice. Moreover, team members commented that teaching the students had given them a sense of achievement and raised their sense of self-worth.

The receptionists all got quite excited about it and made a fuss of the student and really quite enjoyed the process. (Second group)

What went well was, um, everybody enjoyed it and that includes the reception staff upwards and I think it also was a little injection in the arm if you like for the practice of feeling … it does make you feel that you’re achieving something by bringing people who are observing your practice it does make you [feel] we’re not that bad are we, you know, this is going OK, um, and the practice, I think everybody felt a bit more valued. (GP2)

AG: “Do you think it's been valuable to you as health visitors to share your experiences?”

Health visitor: “Oh definitely, yes, yes.”

A GP newly out of vocational training appreciated the opportunity to contribute to teaching of future doctors and was motivated to keep up to date:

Yes I think it's been great because I’ve just qualified—finished my VTS training—so for me personally I’ve just been the registrar or the trainee if you like so to have a chance now to teach and put something back has been great. Also as an individual doctor I think it makes you go up and read more because you try and teach the student something or speak about a condition—certainly there are times when I’ve thought I’d better go and refresh my memory. (GP4)

I think it does make you practise ever so slightly differently because you become blasé, and you sort of think about what you do, its just like riding a bike, you don’t think about … . (GP4)

Having team members involved in teaching had enhanced the team ethic:

Yes I think that, I think that there was a bit of team spirit there anyway and I think it's gelled a little bit more with the students. (Practice nurse)

Students and members of the primary health care team appreciated the opportunity to explain the role of nurses and health visitors to future doctors. Team members felt that an attachment to the practice had a great deal to offer students:

This practice covers a gypsy site. I mean I think it's a wonderful experience for students to see some ethnic minorities and how they live. (Health visitor)

Patients’ perception

Patients had commented that they had enjoyed listening to the doctors discussing their condition with the student and had felt more involved in their care as a result of this.

Just to pick up on the point about the patients and the feedback the patients give me, they absolutely love it. (Practice nurse)

Patients perceived the presence of future doctors being educated in their GP practice as evidence of it having kudos within the profession. There was no negative feedback about the presence of students from any patient.

Effects of being a directly managed practice

The Local Health Board (LHB) directly manages the practice, because of its status as part of the Heads of the Valleys project. This presented problems related to handling money, which would not occur in an independent contractor practice (the usual relationship between GPs and the NHS). It was necessary to set up a special account for teaching income to ensure that it remained identifiable and was not lost in the general LHB funds.

Students’ experience

The students were perceived to be appreciative of the individual attention they received, the one-to-one teaching and the exposure to a variety of consulting styles. The student present at the second meeting also commented on how approachable they had found the teachers within the practice:

What they’ve all said is we were very attentive to them. They’re not used to that sort of attention. They don’t [normally] get someone worrying if they are enjoying it. (GP2)

It's been good having one-to-one teaching and experiencing patients. (Student 3)

I felt as if I can ask questions and you know interrupt and kind of try and get things clear in my mind …. Everyone's been very happy to answer my questions and talk me through things and give me tutorials. (Student 3)

Another interesting thing I found is experiencing different individuals’ ways of consulting and interacting with the patients. (Student 3)

Students commented on how much their confidence in their clinical work grew during the attachment. This was a perception shared by the doctors:

I was quite nervous to begin with, ’cos I didn’t know anybody and I hadn’t really done much GP experience but as I’ve been here more and seen more patients and got more involved, I have felt my confidence increase. I think that's quite important especially so close to finals ’cos your confidence is half the battle. (Student 3)

It had been apparent during the year that the students had differed in personality and in the way they related to the practice team as well as in their individual knowledge and skills:

[With] the first one the overwhelming impression was that we had a warm friendly individual who just integrated into our team and just felt literally part of the team, like one of the doctors, um, to the point where the staff spontaneously bought her a bouquet of flowers on her leaving, ’cos they thought that much of her you know, she was great, she’d get involved with the practice, with hindsight she was 10/10. The second one was much, much quieter and didn’t really integrate into the team at all. I think that was just two different personalities and no more than that, ’cos we didn’t approach them in any different way, um, and that was a bit of a—a bit more challenging for us as a group because the previous one had been very self-motivated, just got on and knew what she wanted and found out everything and that was easy, that was an easy student. (GP2)

The practices had needed to adapt to the ability levels and personalities of the individual students. After the initial shock of finding that the second student was not exceptional like the first the practice adapted quickly to the students’ individual needs.

Feedback on the process

The lead GP did comment that he would have welcomed a phone call from someone in the department during the first placement to check that all was going well.

Connection with other teaching practices

One of the GPs we visited had joined a group of doctors from other local teaching practices who organized group learning events and took turns at giving seminars to six or seven students at a time:

We’ve developed in [this area] a local support group as well linked in with the consultants who do the teaching on the speciality blocks, the psychiatrists and the paeds, and the palliative care specialists. We had a meeting before the last block. The GPs locally had already arranged to share some of the sort of, the um, the tutoring and we thought of just having a common day where we all met to exchange ideas and maybe one GP take on the teaching that day and the rest could go off and do their work or have their half-day. (GP6)

Discussion

In this action research project a newly formed practice team was able to reflect on its experiences of teaching medical students. All members of the primary care team enjoyed having students in the practice and experienced an enhanced sense of professional identity as a result. Despite initial anxieties about their clinical skills the doctors felt more, not less, confident clinically as a result of teaching. Team members welcomed the opportunity to explain their role to future doctors. The practice had a good team spirit before the students arrived and this helped in giving the students a good learning experience but teaching also strengthened the team ethic. Teaching medical students was, overwhelmingly, a positive experience for this practice.

We did not directly evaluate patients’ reactions to medical students being taught in their GP practice but from reports of their comments by team members they felt more involved in their care and they also perceived the practice as having greater kudos. This is in keeping with other studies (Mathers et al., 2004) but it must be borne in mind that patients have reported that they are less likely to discuss personal matters with their GP when a student is present (O’Flynn et al., 1999).

We were fortunate to have detailed feedback from one student whose clinical confidence grew during the placement. The student reported feeling free to ask questions and was appreciative of the one-to-one nature of the GP teaching. The same individual also commented on having had greater access to patients with common conditions, which has been reported elsewhere as a benefit of placements in primary care (Lewin et al., 1999; Worley et al., 2000).

Getting notes summarized was not a barrier to this practice beginning teaching. Due to flexibility in application of the rules there were a significant number of patients whose notes had not been summarized when teaching started. The doctors were not aware of an occasion when the lack of a summary of a patient's notes had been detrimental to teaching. There are many good reasons why patients’ notes should be summarized and the new GP contract provides new incentives for this. We do not wish to detract from the clinical value of summarized records.

Generalization from these results

The experience of teaching in this practice was positive. Would the message from this practice's experience then be ‘If you’re not involved in teaching you should be!’ to every practice? What caveats should be applied? How typical a practice is this? At the time of the first meeting this practice team had only formed five months previously and all members of the team had chosen to work in this practice and so a ‘missionary zeal’ might have existed, which might not be the case elsewhere. Our data did not contain any comments about the added workload of teaching, which is in contrast to the views of GPs interviewed in other studies (Mathers et al., 2004). This work is limited by data having been drawn from only one practice, which was probably not typical of practices teaching undergraduate students.

Having an academic (AG) forming a major contact with the department of general practice and having significant experience of teaching would not be the case in most practices. Because this member of the practice was also one of the researchers we believe that the independent analysis of the data by the two researchers was particularly important. It is notable that even with this level of contact between the department and the practice the GP taking responsibility for teaching would have welcomed a telephone call from the department enquiring if all was well during the first student's placement. A practice with its first student may be reluctant to raise any concerns about a student but may welcome an opportunity to discuss uncertainties if a member of the department contacts them. In the experience of the study practice it might have been helpful to talk over whether the second student was having problems or whether (as was decided to be the case) that student was just markedly different from their predecessor.

What might be generalized from this experience is advice for a practice that has not taught before as to how much enjoyment and professional enhancement can be derived by teaching undergraduate students. Teaching enhanced this practice's team ethic but what happens in other practices would vary according to individual context. Our findings should help those recruiting practices for undergraduate teaching.

Methodology

We commenced this action research study ready to respond to our findings. However, at our second meeting after teaching had been introduced there were no changes requiring modification of the way in which teaching was managed within the practice. We did not, therefore, as we might have expected in an action research study, go through a number of cycles of observation and reflection after changing the intervention in response to prior findings.

Suggestions for further research

The extent to which the benefits observed here are sustained or amended over the course of time is unclear. Furthermore, the experiences of only a small and select number of clinicians have been explored. Identifying strategies for success and negotiating common barriers that are more broadly applicable are, therefore, still required. These factors indicate further exploratory work with a larger, more purposive sample and ultimately a more quantitative assessment, probably by survey. A longitudinal study, assessing the impact of student experience of teaching in general practice on subsequent career choice, would address whether this current and future teaching effort is reflected in the desired benefit for primary care.

Acknowledgement

Thi project was supported by a grant from the Institute of Learning and Teaching in Higher Education (now the Higher Education Academy).

Additional information

Notes on contributors

Andy Grant

ANDY GRANT is a senior lecturer in general practice. He joined Blaen y Cwm Surgery, part of the Heads of the Valleys project, in January 2003. He has completed a PhD on reflective learning in undergraduate medical education.

Michael Robling

MIKE ROBLING is a health science researcher and lecturer in general practice. His methodological research interests include educational interventions in primary care, health outcome assessment, quality of life assessment, the application of mixed research methods and research ethics. Clinical research areas included musculoskeletal problems, common respiratory infections and diabetes.