Moving the clinical GP placement online in a pandemic: lessons learned

Context

The GP attachment in year 4 of the Edinburgh Medical School MBChB programme is an established and much-valued part of the curriculum, at that time, involving students going out to GP practices for 4 weeks. During the initial stages of the Covid-19 pandemic, that course, like many others, had to be moved swiftly to the online environment. There were 60-year 4 students on GP placement who were divided into 4 online groups of 15 students. Each group had a near peer student – a year 6 student – assigned and the GP tutors’ role was to develop the material and oversee the afternoon’s teaching. These four groups existed for the duration of the course. In the morning students were given material to read/watch/interact with. In the afternoon, there was an interactive online tutorial on a common clinical topic seen in general practice, often with a case-based discussion focus, frequently with role-play. The students had 10 tutorials over 4 weeks with largely the same tutor.

Project aim

Anecdotally the sessions appeared to run well, but we felt it was important, as it was clear that some of the format would have to remain for later in 2020 and perhaps into 2021, that we should evaluate this course properly. The aim was therefore to gain insights into the experience of moving a clinical course online rapidly and to evaluate the course to learn what developments would be required for future course planning.

Description

Semi‐structured interviews with staff and students involved in the course were conducted (13 interviews in total – 7 4^th year students, 4 near peer tutors (6^th year students) and 2 GP tutors). Interview transcripts were de‐identified and manually coded using an inductive method. Thematic analysis was conducted.

Outcomes

Five main themes were identified: acceptability; learning community; lack of apprenticeship; limited authenticity and importance of visual cues/engagement. Perceptions within the three different interviewee groups overlapped significantly and so have been discussed together, although they were coded separately.

Acceptability

The teaching the students experienced was considered acceptable, with many saying it was as good as it could be and there was little room for improvement, considering the constraints and speed with which it was put together.

Learning community

There was some suggestion that students and tutors alike took time to establish their confidence and sense of comfort when engaging in the online environment, but that continuity and near peer teaching helped the community develop.

Lack of apprenticeship

All participants were aware that the missing elements were observational learning, apprenticeship and role modelling. This seemed to be a separate point from one of simply being able to practice skills but captured the subtle learning you might pick up on a placement.

Limited authenticity

Despite having role-plays of clinical scenarios and trying to base their learning as clinically as possible, all participants felt students missed learning in a true clinical environment, with authentic patient encounters.

Importance of visual cues/ engagement

The final theme brought up the use of mics/video cameras in providing a sense of engagement and conversely the issues that arose when students in particular did not use their cameras. This was possibly something felt more palpably by the tutors but also picked up on by students.

Table of relevant quotes

Acceptability	‘Done as well as I would have expected it to go. I think it was well done under the circumstances’. S7	‘In the circumstances I really don’t think that the programme could have been done much better.’ S5	‘.filled the gap quite reasonably’. GP1
Learning Community	‘for our group at the beginning at least sort of people were more likely to type in the first one or two days and then eventually people felt more comfortable in using their microphones and speaking’ S6	‘ … had that sort of nice group feeling and you did get to know sort of (tutor name) and how it was going to operate. I think the more the more chopping and changing, the more awkward it probably would have been’. S5	‘ … a group or with time you feel a bit more comfortable offering their own ideas and you look more comfortable like no silly questions sort of thing and yeah I think people maybe just do feel a bit more supported amongst a group … ’. T1
Lack of Apprenticeship	‘And just seeing how things work in a hospital or a GP practise, cause you do subliminally pick up a lot from that’. T1	‘It’s just the kind of stuff you learn, just the kind of stuff you pick up automatically, if you’re just sitting in with a GP for and then trying out yourself.’ S1	‘But I think seeing somebody do it, especially if they do it well gives you a sort of template to emulate’. S6
Limited Authenticity	‘I don’t think it it could ever replace being on a GP placement and seeing patients in real life. And actually you know taking histories, practising your skills and things like that.’ S5	‘um I don’t think it was in any way a substitute for a clinical placement in General Practice. I think there were a number of the softer type of issues that we just didn’t, the students just didn’t get any sort of appreciation that – I think it was very clinically … I think it was actually probably too clinically focused in some ways’ GP2	‘It was quite hard to do that with this. I could have no idea whether or not I’d want to go into general practise from this because I feel like you didn’t get to really like see what it is like’. S2
Importance of visual cues/ engagement	“it feels more personable when you can see the person talking at the other end. S5	‘I found having seen someone’s face makes it 10 times easier to talk to them, makes them a lot friendlier than just hearing this unknown faceless voice off the screen’ T2	‘I think not being able to see … the students mostly having their cameras switched off is problematic. I think it is better if you could actually see their faces … it’s hard sometimes hard to know who is engaging how many, what portion are engaging.’ GP2

S = student T = student tutor GP = GP tutor.

Conclusions

This study shows that both staff and students can adapt well to forced change and that these changes were generally accepted and viewed well. The interviewees could clearly articulate positives such as good knowledge acquisition and dedicated teaching time but were aware of missing out on patient encounters, aspects of role modelling and learning points picked up ‘by osmosis’ and through an ‘authentic’ placement. The study also highlighted the importance of using cameras for perceiving engagement. Looking forward, it was clear that students needed to regain some authentic clinical exposure and this is what they have now – a hybrid of online knowledge and some softer skill development, around video observation of consultations, with real clinical placements. We need to consider how to retain some of the more successful online aspects, such as using very close peers and having group continuity. As the year has progressed, the issue of a lack of video use, highlighted in this research/evaluation, has continued to be very relevant and is potentially an area for further research. As with the changes we have witnessed during the pandemic clinically and as one of my interviewees said, using Yeats as inspiration, ‘it’s part of how change happens anyway sometimes. Something changes then everything then changes utterly’. Now as students return to the clinical environment, but one which has changed a lot, we need to work out how we can make this changed environment still appealing to them and continue to think innovatively about how we do this.

Disclosure statement

No potential conflict of interest was reported by the author(s).