Educational CPD: An exploration of the attitudes of UK GP trainers using focus groups and an activity theory framework

Abstract

Background: There is a move to “professionalize” medical educators, but little has been published on the views of UK GP trainers to this change.

Aims: To explore the attitudes of GP trainers to their own professional development as teachers.

Methods: A focus group study was undertaken in a large UK Deanery. The emergent theory was developed using Activity Theory, which sees learning as a dynamic interaction between individuals and their cultural, social and historical setting.

Results: There were a range of factors influencing GP trainer development. GP trainers were more motivated to develop themselves as teachers when their GP registrar was perceived to be of high quality. There was ambivalence amongst trainers regarding university qualifications in medical education. The biggest obstacles to professional development were the attitudes of the GP trainer's partners, and the challenge of finding protected time. Trainers looked to the Deanery for leadership and direction for their educational CPD, but expressed disappointment that this was not more regularly in evidence.

Conclusions: Incongruity exists between the professionalization of GP training and the feeling that trainers themselves have about the way they are regarded. GP trainer development can be understood more fully when viewed as a product of discourses between the trainer and their environment.

Introduction

There is limited published literature giving the perspective of UK GP trainers on their own development as teachers (Spencer-Jones 1997; McKinstry et al. 2001; Main et al. 2006). The term “Educational CPD” will be used here to describe trainers’ professional development specifically in their educational role.

GP Trainers merit separate consideration from their hospital teaching colleagues (Langlois & Thach 2003; Starr et al. 2003), whose faculty development needs have been described (Wall & McAleer 2000). The general practice environment, usually with ownership of premises, direct employment of all surgery staff, and the “opt-in” to training contrasts with hospitals, where clinical supervision of trainees is routine for most consultant staff.

There are several factors which make GP Trainer Educational CPD relevant now: the NHS appraisal process (which requires GPs to demonstrate their development as teachers); the movement to professionalize medical teachers (Eitel et al. 2000; Herrmann et al. 2003; Rashid & Siriwardena 2005) and the recognition and accreditation of GPs with Special Interest (GPwSI) (Thornett et al. 2003).

Faculty development has been seen as a neglected area (Meurer & Morzinski 1997; Wilkerson & Irby 1998; Quirk et al. 2002, 2005; Langlois & Thach 2003; Bligh 2005). A recent extensive review of the published literature (Steinert et al. 2006) acknowledged the positive value of faculty development interventions, but highlighted the need to better understand what medical teachers did, and the obstacles to good practice that exist. The present study involves GP trainers in one UK Deanery, and is an attempt to understand what motivates this group of medical teachers to develop themselves in their teaching role.

Table

Practice points

GP trainers are ambivalent about university teaching qualifications. Trainers are motivated by high-performing GP Registrars, and can be de-motivated by poorly performing learners. GP trainers are not seeking “professional” status for their teaching role. GP trainers request communication, guidance and support from their Deanery. Activity Theory offers insight into the professional development of GP trainers.

Methods

Subjects and settings

The West Midlands Deanery is a large Deanery with a population of 5.6 million people, about 10% of the UK as a whole. This Deanery includes a very wide variety of geographical settings, from very rural areas, through small University cities, to industrial conurbations which contain inner city areas with notable deprivation, and can reasonably be said to represent the wide variety of geographical contexts in which GP training occurs in the UK as a whole. There were approximately 440 GP trainers in the West Midlands Deanery at the time of this study.

Focus group methodology

A questionnaire study has been conducted previously (Waters & Wall 2007). We now describe the follow-up study, using focus groups. In a focus group, discussion and interaction within the group are part of the methodology (Kitzinger 1996) and may help to clarify ideas and views that might be less accessible in a one-to-one interview. In order to explore in more depth the issues arising from the previous questionnaire study, an interview guide was designed to include the following areas for discussion:

• Establishing an understanding of what educational CPD is

• Exploring the difficulties

• The role of the Deanery

• University Qualifications

Each focus group was moderated by one of the authors (M. Waters). Focus groups were undertaken during routine study days organized by the Postgraduate Deanery, as one of several parallel activities to which participants were allocated. Recruitment in this way eliminated selection bias. In the questionnaire study, a difference in access to Educational CPD opportunities was identified between practices in rural and urban settings, and between male and female GP trainers. For this reason, focus groups were composed of a purposive sample of trainers, with two focus groups in Hereford and Worcestershire (a mixed rural/urban area) and two in Birmingham and Black Country (which includes significant inner city deprivation). Each group contained between five and seven trainers. The sessions were recorded and the recordings were transcribed by a secretary.

Data analysis

The data were coded to highlight important and recurrent themes. The timing of the focus groups was such as to allow transcription and initial analysis of the first groups before subsequent groups were undertaken, in order to facilitate the process of constant comparison and best allow emergent theory to be tested. After four focus group discussions no further new themes were identified, indicating saturation.

Activity theory

Activity Theory provides an alternative to the usual way of viewing faculty development. Rather than focusing on individuals, it recognizes the way that knowledge is held within an interacting system, and arises through discourse. This different approach can facilitate the identification of new insights (Daniels 2004). This framework was felt to be a very appropriate one to use because of the multiple forces at play in the context of GP Trainer Educational CPD.

Results

Focus groups were undertaken in late 2004 and early 2005, involving a total of 23 GP trainers. Ten principal codes were identified (Table 1).

Table 1.  Codes from focus groups

Codes from focus groups
1. Trainers as teachers
2. Effect of training on the practice
3. “Teaching” vs. “Training”
4. The importance of “Adult Learning”
5. Community
6. Time
7. Scaffolding
8. Educational CPD
9. Quality
10. Communication

The codes were used to interrogate, explore and interact with the data (Seidel & Kelle 1995; Coffey & Atkinson 1996), and are presented here, with illustrative quotes.

1. Trainers as teachers

Trainers identified themselves as teachers—but regarded this role as having a lower professional status than their clinical or managerial work. Some trainers drew an analogy with working one session a week in a hospital clinic. It was recognized that the status of the teaching role was reflected in the remuneration it received.

‘Education is part of our job but frankly we are not paid enough for it to be a major part.’

This recognition of “teacher identity” fits with the profiling carried out previously in the USA and England (Spencer-Jones 1997; Starr et al. 2003). However, many trainers felt that training was viewed by their partners (and by other non-training GPs) as not particularly valuable.

‘I don’t think training, as a tag-on, is perhaps valued as highly as it should be either within the profession or higher’

However, the training role was seen as enriching the clinical role, and the concept of “doctor as teacher” (General Medical Council 1999) was highlighted.

‘I think we are better with patients as a result of being an educator’

‘The whole role as a doctor in many ways is an educating teaching role’

2. Effect of training on the practice

Trainers felt that their practice benefited from training most of the time. However, when a GP Registrar (GPR) was seen as disruptive or difficult, this felt like a burden, and trainers felt isolated in carrying this burden in the practice.

‘When you have a bad registrar there is no way you can justify that the practice is benefiting—the practice now has a burden which you have as a trainer to see through’

3. “Teaching” vs. “Training”

The distinction between teaching and training linked with the idea of there being “higher level” and “basic” kinds of teaching provided by trainers, with “teaching” corresponding to the “higher” level content, and “training” to the “lower”. Where GPRs were perceived to be a higher standard, this promoted the feeling that they required (or deserved) a higher standard of teaching. “Higher” teaching was seen as more learner-centred, and in line with the principles of adult learning.

‘I could do with some training in adult education … because some of these guys are far more intelligent than me’

‘There is the high level stuff, which is the principle of adult education and learning styles and there is also a certain amount of basic stuff that we have to cover within the course of the year’

‘some of them are at such an appalling level of medicine before they start that they are pretty much back to primary school education’

Trainers referred to “Nuts and Bolts” training as basic, and saw this as important, but less satisfying. Trainers used this term to refer to assessment procedures, the membership examination for the Royal College of General Practitioners, and specific clinical issues like the rules for sickness certification. It was also used by trainers to refer to learning about these issues for themselves, as part of their own educational CPD.

‘Nuts and Bolts we can find out for ourselves—it doesn’t take a genius to look up the MRCGP criteria’

Trainers were aware of a drive to professionalize their role, and saw a link between being a “professional teacher” and higher qualifications in education, particularly in relation to other educational roles, such as course organizing.

‘I think you have to be realistic and I think there is definitely a push to professionalize us as teachers’

‘I was wanting to be a course organizer … I realised if I was going to do that I would have to commit myself to doing some sort of professional qualification. I feel quite sort of nervous about the amount of commitment and time its going to take’

4. The importance and place of “Adult Learning”

This was a term commonly used by trainers, but rarely defined. Sometimes it was used in contradistinction to other things (like Nuts and Bolts training). The only specific example of “adult learning” given by a participant in one of the focus groups was a reference to learning styles. Trainers did seem to value the idea of Adult Learning, and saw this as an area of learning need.

5. Community

A sense of community between GP trainers emerged from the data quite clearly. This was best exemplified by the local trainers’ workshop, but seemed to apply across the whole Deanery.

‘there is the local-ness, I like doing it with a local group of people and peers that we know’

Functions of the community included support, new ideas, “political clout” and a learning community. GP trainers identified a need for each other. The “isolation” of teaching in practice reinforced the need for the “community” of other trainers.

‘I think we are the people who know’

‘very important to discover that other people are facing the same problems and dilemmas’

‘one is teaching in isolation’

Trainers mentioned “isolation” a number of times—referring especially to the nature of the one-to-one relationship between trainer and GPR. This term also referred to the responsibility for assessment borne by the trainer, which cannot be entirely shared with others. Trainers voiced feelings of separation from the Deanery a lot. Trainers felt isolated from their partners too, and this was part of the “burden of being a trainer”.

6. Time

Trainers discussed in the focus groups how much time they spent on Educational CPD, and generally a consensus of around 4 days each year was reached. This triangulated with our earlier study (Waters & Wall 2007). Trainers spoke of the need to carry out their educational development in their own time for lack of protected time. Part-time trainers in particular had difficulties in getting time out of practice, and resented taking their own time for attending Deanery events and trainers workshops. Once again, attitudes of partners figured high in the issues raised.

‘and where does the time come, is that your free time or does it come out of the practice? And then your partners will question that and ask about that and you will pay for it.’

There was a feeling that time spent training to train was not as valuable to the practice as the core work of seeing patients. Partners’ attitudes were again a powerful force.

‘it's the whole concept of if you go off and have a jolly being a trainer all day, sitting around discussing the niceties of CPD, I am seeing 12 patients for you and I'm going to come out on my knees’

Trainers were conscious of the need to strike a balance between time spent on developing themselves in their teaching role, and time spent on their other professional development.

7. Scaffolding

This code has been used to capture a range of issues spoken of by trainers in relation to their teaching role. Bruner (1966) described how carefully planned social interactions, learning supports and purposefully structured learning settings can help a learner to develop. He emphasized the importance of the social environment for learning. The term “scaffolding” has a connotation with construction, where it refers to a framework within which building can occur. The term can be used epistemologically, referring to a constructivist framework for learning (Vygotsky 1978; Bandura 1986; Guba & Lincoln 1989; Biggs 2003). Pedagogically, this would incorporate the apprenticeship model, the development of professionalism and the facilitation of the personal development in the GPR necessary for independent clinical work in UK general practice. Sociologically, it can refer to the environment in which GP trainers work, and develop as teachers. This environment includes the contractual and statutory frameworks for GP training, assessment procedures, the mandatory demonstration of development, attendance on courses and the informal networks of support that exist for trainers. As this environment changes, new requirements are added (e.g. the requirement in some parts of England for GP trainers to undertake a Certificate in Medical Education).

When trainers are in their first year of training they find it difficult accessing support from their partners (Waters & Wall 2007). Their “scaffolding” for development then needs to come from outside the practice: linking with the GP trainer “community”.

‘Protected CPD time is a good idea, but must be supported and funded. A mentor is needed to advise on the options and implications of what's available.’

8. Educational CPD

Trainers valued their professional development, and recognized the resource they represent to their practices.

‘They (partners) see that you developing yourself is something the whole practice will also gain from’

Trainers were aware of a tension around their Educational CPD in terms of the locus of control. In some ways they wanted autonomy, but at the same time they called for more support and supervision.

Trainers identified a range of external controls on their Educational CPD:

• Money (funding for training, funding for courses and CPD)

• Curriculum: for GPR training and for trainer CPD

• Central appointment of GPRs

• Accreditation of practice and of the trainer

‘there are so many different things tearing us that it is quite difficult just to keep up with what we have to do and with respect to the government—at least they are paying for it’

‘… with PDPs the government have given us a financial incentive to continue with professional development, but if it comes to actually getting educated as an educator there is no financial incentive, you are doing it purely out of professionalism and personal pride. I think this is great, but it must take an awful lot of time’

There were a range of obstacles to Educational CPD described by trainers. These fell into three sub-categories, and cross-referenced some of the previous codes:

• Obstacles to assessing needs

  • The nature of the relationship with a GPR (which makes it difficult to get honest feedback)

  • Isolation in teaching role (which results in a difficulty with benchmarking)

• Obstacles to addressing needs

  • Clinical work pressure (lack of protected time)

  • Lack of support from partners

  • Lack of knowledge of what is available

  • At times, lack of provision

  • Locum issues (difficulty in finding locums, uncertainty about quality of locum cover)

• Obstacles to implementing new learning

  • Lack of support for maintaining and developing in role (no regular time or contact with mentor/coach/guide)

‘it would be nice to have some sort of person who you could make one appointment, go and see and they would know, they would have all this information, they would be up to date and they would be able to say this is the best way for you to do it.’

Trainers expressed a need for more direction in their Educational CPD, and expected this to come from the Deanery. Trainers were also looking for practical help with making time available for them to undertake Educational CPD activities. Payment for locums to cover the trainer's time was requested—but often finding a suitable locum is very difficult, and here help from the Deanery was sought also.

‘Is there a way there can be a pool of manpower that … doctors that have recently trained, whatever … that takes away some of the hassle of trying to find good locum support?’

The issue of university qualifications was significant in relation to Educational CPD. Trainers expressed a range of views, and there was no consensus established.

‘… it would seem sensible that all GP training courses are accredited in some way so that they can go towards a post graduate qualification’

‘You have to value why you are doing the masters for your own personal reasons, it's not worth doing because eventually in 10 years time somebody will say you will have to have this qualification to carry on teaching.’

‘I don’t think everyone should do educational qualifications. I think it's a spectrum and its right for some but not for others’

For those considering a university course, there was frustration that the qualification is not rewarded.

‘if one person has this degree in education and the other person has been a trainer for 1 year, the grant is the same’

Others who had a qualification felt that the Deanery should do more to support this kind of development.

‘I don’t think there is the support available that there should be in two different ways. The first is that I don’t think there is financial support in that having done it really it has been a huge financial cost to me, I have had to pay for time out of the practice, I have had to pay for hotel accommodation where I have been studying, I’ve had to pay for books, I’ve had a subsidy towards my course fees and that is all. The second thing is that there is not any joined-up thinking about this at all. It's very piecemeal, the way that education is being delivered.’

Once again, the attitudes of partners were important—and trainers were sensitive to this.

‘I am not inclined to think I want to impose that on my colleagues. It does cost, it costs an awful lot in terms of commitment and planning.’

There was awareness amongst trainers that there was an “educational marketplace” and that their privileged place as a provider in it may not always be protected. In this case, an accredited qualification might have more meaning.

‘a well experienced GP trainer who has done all the requisite courses may come up against, for instance for some educational post, comes up against some other guy who has actually got a university degree or post graduate degree in education or whatever who is going to be chosen for it, all other things being equal and so if people are putting the work in they should get the accreditation.’

Trainers were conscious that their own value (and that of the training role) within the practice could be increased by having a university qualification in education.

‘I think there may be some value in accreditation within our practices though because there is a feeling with partners who don’t have a teaching role that it is a very straightforward thing to do: “why do you need to go on a trainer's course to learn to teach because we can all teach? You just sit them down and you just tell them and that's the end.” So I think to actually have something that is accredited at least gives you some value to it’

Some trainers felt that a formal qualification would expand their own thinking.

‘I had no idea about education before I started learning about it, I didn’t understand loads of different issues about it but I have been training for ages and I think it helps within the region to have people who perhaps have gone and thought a little more deeply about it, can bring different ideas in and maybe change things, it stops you being in a rut.’

Whilst others were dubious about practical benefits for their GPRs.

‘I don’t know, my registrars may say I’m a useless trainer and I would have been far better had I done some sort of post graduate award like that … I am very sceptical about saying trainers should have a piece of paper’

‘they are pushing academic medicine as a career which means that youngsters are going into it straight away and getting qualifications and getting masters and things like that but they don’t actually have the experience that people have got over the years.

No evidence that “higher” educational qualifications e.g. PGA, Cert Med Ed make any difference to registrar's experience or outcome. Is this really progress?’

Trainers did not want to feel pressurized into undertaking a university qualification, and some would consider retirement from training if this happened.

‘Please don’t make us all do a CME—education is good, but our patients need us too!’

‘Cert Med Ed may be reasonable and sensible qualification for GP trainers but it is a big commitment for full time GPs without adequate protected time and finance. It may put off people from becoming trainers.’

‘I do feel personally that I would give up training if it was compulsory to have a Dip Ed. I have not got the energy to pursue this path.’

Perhaps in response to the appraisal process some trainers did see a need to be able to validate themselves in a demonstrable way.

‘In this day and age you have to accept that in the end we are going to have to justify and validate what we are doing as educators as well as we now have to do as clinicians.’

A final issue with regard to Educational CPD related to the question of who should be “teaching” GP trainers. As a group of educationalists, it might be expected that GP trainers could quite easily be self-resourced. However, there were tensions here. First, there was a sense that there are “real professionals” available outside the GP training community, who can do the job more effectively.

‘some real professionals that have been brilliant and inspiring’

‘you are giving up time to be there, wherever that time comes from, whether from the practice or your own time and I think there is a sense of wanting to go away with something at the end of that … and very often these very professional outsiders achieve that more successfully than low grade internal preparation.

Many GP trainers, whilst happy with their one-to-one teaching role, were not prepared to take on an educational role for the trainers’ workshop (typically 12–20 trainers at a session).

‘You couldn’t make people do it either. I’m never going to stand up and run a course because I’m not like that I would just hate it.’

GP trainers recognized that different skills were needed when running a session for a group of trainers.

‘presenting to a big meeting is a very different style to doing a tutorial and maybe the two aren’t linked.’

‘I think a lot of it comes down to identifying the need of the group, setting aims and objectives and then deciding whether you have the resources to meet those aims and objectives. It may be that you don’t.’

There was also recognition of the lack of financial support for the time it takes to prepare a session for a group of trainers.

‘when you haven’t got any protected time to prepare it … it becomes a real burden, so I think that influences peoples enthusiasm to volunteer as well, as more and more and more trainers become younger, part time with other responsibilities its just not like being when you are free.’

Confidence was an issue for trainers with regard to taking on facilitation of educational CPD sessions for the group.

‘we are all expecting it to be valuable and there is a high expectation that what you go to has got to be good and therefore you are scared to put your head above the parapet.’

9. Quality

The word “quality” was rarely used in the focus groups, but this code represents issues which were discussed a lot. It had four main properties:

• Quality of teaching delivered by trainers.

• Quality of GPRs (in terms of academic and clinical standards).

• Quality of Educational CPD (including trainers’ courses and university courses in medical education).

• Quality and value of the trainer as an individual.

It was possible to identify links with other codes here—particularly between individual quality, professional teaching status, and the dynamic tension between “higher level” adult learning and “basic” teaching.

‘The value to the NHS of us providing a well-trained new GP is enormous but the money (that) comes towards us for making the effort is very small.’

‘We are probably all bouncing off the walls a little bit in terms of not being highly supported, not being highly valued and questioned.’

‘I don’t think it's to do with money I think it's to do with seeing the value of some people’

10. Communication

Trainers did not feel confident about their value in the eyes of the Deanery, and saw their relationship with the Deanery in this light. Their lack of perceived value was particularly linked to the quality of communication that occurred between trainers and the Deanery.

‘The thing I sense lacking is the sense of value and respecting what is going on. You sometimes get the impression they are so determined to balance the budget or make sure they keep the political masters off their back that actually all the value and respect of everything else that is not costed is gone.’

‘I think communication is an issue because they don’t value you and don’t seem to worry about communication they are just saying this is what we are going to do.’

‘I don’t think the Deanery has ever asked my opinion about anything.’

‘I would like to know what the values are behind the decisions.’

‘I am not sure I would know resources of the Deanery … the communication channels aren’t there.’

‘The Deanery seems a little bit remote’

Trainers expressed the feeling that the Deanery was very separate to them, and significantly, did not share the same set of values as them. This came up in discussions about the funding for venues for educational events for GP trainers, amongst other issues.

‘the fact that they don’t understand that bothers me and when you hear them saying why can’t you have it in an afternoon at the post graduate centre, you think perhaps they are missing the point somewhere.’

‘you feel very far away from them’

‘There is actual anger … we were actually being told to do something about appraisal by February … really angry with the Deanery, that's not a relationship. It's just getting nebulous the Deanery.’

There was disappointment that the Deanery did not feel like an educational organization.

‘the Deanery doesn’t feel educational, it feels administrative and that it's doing the government's work. There is a huge agenda which must come down from on high but they are not an educational resource and they should be really.’

Trainers were looking for more positive action to aid communication—and this could sometimes be quite simple, such as a more specific trainer's area on the Deanery website.

‘I know I keep banging on about the website but it is terrible and what they really need is a trainer's page. Log on, click trainer and within that you should have information on resources that are available to you, current good ideas, chat room whatever, but just something for us.’

‘they could facilitate a newsletter that told us of where courses were and that sort of thing.’

‘it could just be communicating to all trainers regularly about their strategic view of things which we don’t get’

‘I feel rather cut off from the Deanery, in fact they have probably forgotten me, they have forgotten I exist actually, it certainly feels like that sometimes. You log onto the website and there is this kind of big impersonal website that it's impossible to navigate around and that's about it, it's the only contact I have with the Deanery now.’

Applying the activity theory framework

Activity Theory is used as an heuristic device for exploring a system of activity. The model derives originally from the work of Vygotsky on cultural-historical psychology in the 1920s and 1930s (Vygotsky et al. 1978; Bleakley 2006) and was further developed by others (Bleakley 2006, Daniels 2004, Engeström 1987, Leont'ev 1978). It is an attempt to understand learning and development as a dynamic interaction between individuals and the cultural, social, and historical setting in which they operate. It is a challenge to the purely cognitive models which dominate contemporary thinking about adult learning.

In Activity Theory the focus of analysis is a shared activity, and Engeström (1987) proposed a graphic model to demonstrate the interacting forces (Figure 1). It is usual to begin with some identifiable outcomes, verify that the activity in question may contribute “objects” to that outcome, and thereafter consider in turn all the other components of the model. The object produced by an activity may not be a simple physical product, and could be a collectively shared problem that a team addresses during their unfolding activity. Division of labour is both horizontal and vertical, and includes the negotiation of responsibilities, tasks and power relations. Rules may be explicit or tacit. The themes identified from the coding process are presented using the headings in Engeström's graphic model (Figure 2).

1. Outcomes

The outcome of interest to the activity of GP training is the fully trained GP who emerges at the end of the process into independent practice.

1. Object

The object is the GPR undergoing training. It may at first seem odd to describe adult learners as “objects”—but this term has a more complex meaning in Activity Theory. Bakhurst (1995) described an object as “an embodiment of meaning, placed and sustained by ‘aimed-orientated’ human activity.” In this sense, it is reasonable to see the GPR in a practice as the focus of collectively shared activity.

1. Subject

The subject in Activity Theory is the individual (or group) whose actions are the focus of analysis, in this case, the GP Trainer.

1. Mediating artefacts (tools)

In this system, there were two levels of mediating artefacts. The first of these was the teaching methods GP trainers used in their educational work. The second was the process of Educational CPD: the activities undertaken by GP trainers to develop themselves as educators.

1. Rules

External rules impact on the system of GP training: some apply to the GPR (summative assessments, requirements for certification). Some apply to the trainer's practice (accreditation criteria set by the Deanery, employment regulations for GPRs). Others apply specifically to the trainer (accreditation of trainers by the Deanery). Although in the West Midlands Deanery at the time of this study there was no requirement for trainers to undertake a Certificate in Medical Education, trainers expressed a lot of concerns about this becoming a rule.

1. Community

This element of the Activity Theory framework matched exactly a code used in the analysis of the data.

1. Division of Labour

As well as the GP Trainer, other partners in the practice and other team members all frequently took an active part in the training of a GPR. In addition, the GPRs spent time on half-day release, and other trainers from neighbouring practices provided some teaching if GPRs took part in “practice swaps”. The Deanery organized regional educational events for GPRs too. These other resources for learning are valued by trainers, but were not discussed in detail.

Figure 1. Engeström's activity system.

Figure 2. Engeström's activity system applied to GP training.

Another very important aspect to division of labour is the recognition that GP trainers have other roles: particularly clinical and managerial, but also in their personal and family lives.

Discussion

Doctors teach because of the intrinsic satisfaction of being involved in education, the enjoyment of having knowledge and skill about teaching, the sense of belonging to a group of teachers, and the feeling of a sense of responsibility to teach medicine (Starr et al. 2003). GP trainers are also motivated by their own experiences as learners and GP training is seen as having a high status within the profession (Spencer-Jones 1997).

This study has shown that trainers felt that their teaching role enriched their clinical role, and that the whole practice usually benefited from the presence of a GPR. This begins to place the motivation to teach in its socio-cultural setting. Additionally, GP trainers were motivated to develop themselves as teachers much more by having high-quality GPRs than by registrars who enter the practice with a poor level of clinical performance. GP trainers were most challenged to improve their own teaching skills and knowledge (particularly in what they referred to as Adult Learning) by having a high-performing learner. In Activity Theory terms this is an example of the “object” (the GPR) influencing the development of the “subject” (the GP trainer).

Previous studies (Bland & Simpson 1997; Langlois & Thach 2003; Cole et al. 2004) have clearly identified how a sense of belonging to a group is important to doctors who teach in primary care. The present study has shown that the GP trainer community also acts as a resource for professional development. Membership of the community provides motivation for GP trainers to develop themselves.

GP trainers felt that their efforts to develop themselves as teachers led to increased approval, respect and praise from their partners. With the perspective offered by Activity Theory, the attitude of the trainer's GP partners can be seen as a pivotal force affecting GP trainer development.

Trainers were very sensitive to the effect that their absence from the practice had on their partners. This is compounded by a culture which gives clinical work a much higher value than any other activity in the practice. GP trainers also have a great loyalty to their patients and were conscious of lost appointments when they took protected time for educational CPD.

A conflict was perceived by trainers with regard to finding time to develop their training role, whilst finding sufficient time to support their other clinical and non-clinical CPD. The training role was seen as a peripheral (“tag-on”) activity, and so worthy of less time for CPD than their “core” work.

Because trainers have no day-to-day opportunity to share their teaching with other trainers they find benchmarking their performance as teachers very difficult. The close relationship established with a GPR was also seen as an obstacle to receiving honest objective feedback on the effectiveness of their teaching. Trainers, particularly those new to the role, felt they would benefit from more active guidance in their development, from a mentor or coach. In these respects, there is perhaps an insufficient discourse between trainers and their peers, and with their learners.

In general, trainers perceived the Deanery as a managerial entity rather than an educational organization. Trainers looked to the Deanery for leadership and direction, and expressed disappointment that this was not more regularly in evidence. Bland and Simpson (1997) emphasized that without clear leadership from the organization, it is difficult for individual faculty members to be self-directed in their development as teachers. Ullian et al. (2001) identified the importance of individualized two-way communication between preceptors and their course directors. In terms of Activity Theory, what was being described was dissatisfaction with the type of discourse trainers had with the Deanery and this was seen as a further obstacle to their development as teachers.

One of the purposes of this research has been to document the attitudes of GP trainers themselves with regard to the professionalization of their role (Rashid & Siriwardena 2005). In contrast with the ambitious tone of much that is written about professionalization, GP trainers themselves often used more reticent language, describing the role as a “tag-on” and “a hobby” compared with the “real work” of seeing patients. The informality of the apprenticeship model appealed to GP trainers, and the increasingly formalized environment of GP training and registrar assessment was not welcomed. Largely, GP trainers were not wishing to be “professionalized”. In Activity Theory terms, the discourse between GP trainers and the rules which govern their teaching was seen as having a negative influence on their development as teachers.

However, trainers saw a potential benefit in terms of the recognition a university teaching qualification could bring them within their own practices and in the wider “educational marketplace”.

Conclusions

GP Trainer Educational CPD can be understood in terms of the discourses occurring between trainers and their environment—in relation to their partnership, the GPR, the community of trainers in the locality, the Deanery, their patients, and historically, between trainers and their own experiences of being taught. A more complete picture emerges in this way compared to the one obtained from a view of GP Trainers as a group disconnected from their interacting environment. Steinert's et al. (2006) call for a better understanding of medical teachers can be partly answered by using the filter of Activity Theory when examining GP trainers’ attitudes to their own development as teachers.

Some suggestions for further action may be drawn from this study:

• Trainers are keen to develop, and look to the Deanery for direction, support and resources in doing this.

• The local trainers’ group (and their workshop meetings) is a key resource, and any intervention to support trainers should build on this potential. Trainers need to be helped to develop their confidence in facilitating learning in groups, and this is an area in which Deaneries could invest. Trainers in the first few years of training particularly need support from outside their practice to develop as teachers, and this could be formalized and funded.

• Trainers will always look for proportionality in their CPD—and whilst the training role occupies a small part of the working week, and is poorly remunerated, they will not wish to spend excessive time on Educational CPD. If undertaking a Certificate in Medical Education were to be made mandatory, some trainers in the West Midlands may consider ceasing training.

• At the time of this study, trainers in the West Midlands felt distanced from, and undervalued by the Deanery. They looked for a more usable website, with more “trainer-specific” content, and would appreciate a more active dialogue with the organization. They would like to see the Deanery behaving as an educational organization, not just an administrative one.

• Trainers (and their practices) need more support when they have a challenging GPR. As well as the immediate burden of managing the situation, Deaneries should note that trainers may also become de-motivated, and be less likely to want to address their own development as teachers after this kind of experience.

• Adult learning models are not seen as helpful by trainers when dealing with poorly performing GPRs. Further exploration is needed to identify more suitable models, although the work by Grow (1991) may be a good starting point.

• Using Activity Theory as a model for understanding the dynamic nature of professional development of GP trainers offers richer insights than the more conventional individually-situated models of learning.

Declaration of interest: The authors report no conflicts of interest the authors alone are responsible for content and writing of the article

Additional information

Notes on contributors

Mark Waters

Dr MARK WATERS has been a GP Trainer for 14 years. His main research interest is in continuing professional development for medical educators.

David Wall

Professor DAVID WALL is deputy regional postgraduate Dean and Professor of medical education. His main interests in medical education are in faculty development, curriculum studies, doctors and dentists in difficulty and research training in medical education.