LIC in the time of COVID: experiences of LIC tutors during the COVID-19 pandemic in Scotland

ABSTRACT

In March 2020, due to the escalating global coronavirus (COVID-19) pandemic, clinical placements for most medical students in the UK were suspended. A phased resumption of clinical placements started at the beginning of academic year 2020/2021. For the Scottish Graduate Entry Medicine programme (ScotGEM), 2020/21 was the first year that Dundee School of Medicine’s comprehensive LIC was extended to all 54 students in the penultimate year of the ScotGEM programme. This cross-sectional qualitative study explored aspects of tutors’ experiences of supporting LIC students in their practices. Thematic analysis of the data identified significant themes relating to the effects of the coronavirus pandemic on the organisation of the LIC placements and the experiences of the tutors, and the ways in which they adapted placements to the rapidly changing clinical and social landscapes. The changes necessitated by the pandemic posed significant challenges for practice-based tutors in ensuring that students had valuable educational experiences despite the constraints of social distancing requirements and the reduction in face-to-face consultations. However, tutors also identified several positive aspects of the changes which will be of interest to those involved in the organisation and delivery of both LIC and shorter General Practice based clinical attachments. Positive relationships between LIC students and practices enhanced the success of LIC placements. We will discuss how lessons learned from the experience of tutors in the pandemic could be used in the longer term to enrich the LIC experience and General Practice placements more generally.

KEYWORDS:

• Longitudinal integrated clerkship
• COVID-19
• general practice
• tutors

Introduction

In March 2020 the world was becoming increasingly concerned about the rapidly escalating COVID-19 pandemic [1] and in the UK the National Health Service was preparing for an exponential rise in cases which it was feared could lead to significant pressures on the health service [2]. In mid-March, the Medical Schools Council released guidance to medical schools advising the prioritisation of final year qualifying exams [3] and Scottish universities moved to online learning [4]. The University of Dundee School of Medicine suspended most clinical placements for medical students including students undertaking the Longitudinal Integrated Clerkship (LIC). Following the introduction of the nationwide lockdown on 23^rd March [5], cases of COVID-19 and hospitalisations across the UK increased rapidly before beginning to fall in May 2020, with infection rates in Scotland being at very low levels by July 2020 [6]. Against this backdrop, medical schools had to make decisions about students returning to clinical placements, balancing the risks of infection for students, patients and clinical teams, with the need for students to receive adequate clinical experience to allow the next cohort of doctors to graduate [7].

For the Scottish Graduate Entry Medicine programme (ScotGEM) [8], 2020/21 was the first academic year that Dundee’s comprehensive LIC [9] was extended to all 54 students in the penultimate year of the programme. In previous years, the LIC was an option for 4^th year students in the Dundee MBChB programme [10]. LICs are an increasingly popular model of clinical medical education which have continuity as their central principle [11]. The defining features of LICs as set out by the Consortium of Longitudinal Integrated Clerkships (CLIC) are that students: (1) participate in the comprehensive care of patients over time, (2) participate in continuing learning relationships with these patients’ clinicians, and (3) meet the majority of the year’s core clinical competencies, across multiple disciplines simultaneously, through these experiences [12]. Previous research has identified positive outcomes from LICs for learners, patients, educators and communities [10,13,14].

The COVID-19 pandemic caused considerable disruption to medical services in the UK both in primary and secondary care, with a huge reduction in face-to-face consultations and a move to telephone and video consultations. Restrictions in secondary care limited patient visiting and the ability of others to accompany patients to appointments. In addition, nationwide or regional restrictions on social contacts, travel, education and access to leisure activities and services meant that LIC students and their tutors encountered a variety of challenges. In this paper we will report on how tutors and practices adapted to the challenges and constraints of the pandemic to ensure that students had educationally valuable experiences. We discuss the role that continuity as a central principle of LICs [11,15] played in enabling students to meet educational outcomes. Finally, we discuss how some of the changes brought about by the pandemic had unexpected positive effects on the educational experience by allowing more flexibility for supervising tutors and consider how these findings could influence the planning of LIC placements in the future.

Methods

The study design is a cross-sectional qualitative study. The study set out to explore GP tutors’ experiences of tutoring a LIC student and effects on their clinical practice. Data collection took place during the summer of 2021 and, although the study did not initially intend to examine the effects of COVID, it became apparent during the inductive thematic analysis that this was a major theme. This paper reports on the findings from a subset of the data that relates to the impacts of COVID on the LIC placements.

All GP tutors hosting LIC students were invited to participate by email (n = 65, as some practices had more than one named tutor). Eight participants were recruited. Participants were first asked to return a form containing some basic demographic information including age, gender, type of GP post, time as LIC tutor and extent of other teaching experience. They were then given the options of completing a written reflection on their LIC experience, participating in an interview, or both. All participants received a participant information sheet and consent forms were completed either with the returned written reflection or at the time of the interview.

Of the participants recruited, two were male and six female, age range 40–63 years. Three of the participants had hosted LIC students in their practice in the past as well as having experience of tutoring students on shorter placements. The other five had not tutored LIC students before. Of the five who were new to tutoring LIC students, all had experience of teaching medical students on traditional block rotation placements. The types of practices the tutors worked in ranged from remote and rural (two) to small towns (five) and inner city (one), representing the range of practice types represented in the LIC as a whole. One participant completed a written reflection only, five completed both a written reflection and interview and two participated in an interview only. In the collection of both written and interview data, participants were asked to reflect on how tutoring a LIC student influenced their approach to consultations, the organisation of their working week and their relationships within the practice. Interviews were carried out via Microsoft Teams by one of the authors (ZMcE) who is a practising GP and member of the GP Undergraduate Education Team at the University of Dundee and, although not directly involved in the organisation of the LIC, was known to some of the participants. Interviews were recorded then transcribed by GH and the transcripts checked against the recordings by ZMcE.

An inductive thematic analysis [16] of the written data and interview transcripts was carried out by all three authors independently then discussed to reach agreement of the main themes. At this stage it became clear that a major theme related to the effects of COVID on the LIC placement and so the relevant data were extracted from the interviews using NVivo software. This was then used to code the data using codes developed through discussion between all three authors. The analysis of this subset of the data are the focus of this paper.

Results

Analysis of the data relating to the effects of the COVID-19 pandemic on the LIC placement led to the development of the following three subthemes: Challenges in adapting the LIC placement to ensure a valuable educational experience for the student, the unexpected benefits of the changes necessitated by COVID restrictions and the importance of relationships in the LIC.

Challenges in adapting the LIC placement to ensure a valuable educational experience for the student

Participants described anxieties about how to offer a valuable educational experience for students. For some, this was their first experience of the LIC, and this combined with the changes necessitated by COVID meant that they faced a double challenge and felt very responsible for the student’s educational experience. Participant 4 commented that the student would be in the practice for ‘a quarter of his education’ and described ‘thinking how we are going to try and make this year really good’.

At the start of the placements, induction was often constrained due to COVID, with the need to maintain social distancing and minimise mixing between teams leading to less multidisciplinary team involvement:

‘we would usually send students out with all the different allied professionals, … we couldn’t put students into these teams due to COVID’ (Participant 8)

and in some cases, clinical colleagues expressed concern about social distancing which led to the student spending most of their time with one or two tutors:

‘my colleagues became quite anxious about being in the room with the student, and the student being backwards and forwards to their room’ (Participant 7)

The increase in remote consulting led to concerns that limited exposure to face-to-face consultations would limit the educational value of the placements. This concern was shared by students who tutors described as being keen to have as much face-to-face contact as possible. Teams maximised patient contact for students by using telephone triage to book consultations with the student for those patients who required a face-to-face consultation:

‘We have involved our student in phone triage and also looked to manage flexibly the student across different surgeries seeking out face to face appointments as much as possible to increase clinical exposure’ (Participant 1)

Some students participated in telephone triage, either listening in as their tutor consulted via speakerphone or an additional headset, or leading the telephone consultation with their tutor also participating in the call. Students more commonly used telephone consultations to follow up patients they had seen face-to-face in the practice.

Another challenge identified was the lack of exposure to minor illness for students due to this being dealt with entirely over the phone during the triage sessions; Participant 6 commented that ‘the whole of minor illness basically was filtered out’. Conversely, those patients the students did see face-to-face tended to be complex presentations of multimorbidity or major pathology that could have significant emotional impact on the students:

‘we had a number of very late cancer presentations last summer which was just awful, and, well, our ScotGEM students, … each of them had a patient that they dealt with in that category which was difficult’ (Participant 6)

Participants commented that students struggled to gain experience in secondary care, particularly at the start of their placements, as a result of COVID:

‘I know in the original plan they would follow them into the hospital … and of course that hasn’t happened because of COVID’ (Participant 2)

However, in some rural areas, students were able to arrange to spend time in community hospitals more local to their practices, and as restrictions lifted, they were able to arrange more secondary care experience towards the end of their LIC year. Students were able to follow up patients they had seen in the practice, ensuring opportunities to experience continuity of care:

‘where there was regular follow-up to be had that we would then identify … that the patient was happy to see the student, … inevitably the response from patients has been positive. So that’s something that you just cannot provide in a 5 week block’ (Participant 6)

Tutors also commented on the changes to their own consultations brought about by remote consulting or initial telephone consultation with a face to face follow up: ‘you’ve got … half the history already because you tend to see the people you’ve already spoken to’ (Participant 8). They were conscious of how they modelled consultations for the student because of the pressures they were under:

‘You know, I can hear myself sometimes on the phone … if things are very busy … being quite directive, and I think oh this isn’t ideal’ (Participant 4)

Unexpected benefits of the changes necessitated by COVID restrictions

As well as the significant challenges, participants reported that the changes in their practice necessitated by COVID brought unexpected benefits. The move to predominantly telephone consultations resulted in increased flexibility for supervising students, allowing tutors to book patients in around teaching and supervision more easily:

‘I’ve got the luxury of just not booking anybody in for a face-to-face consultation when I’m supervising both students’ (Participant 6)

Telephone consultations were seen as easier to fit around supervision:

‘I don’t have any patients booked to see me, but I help out with the triage pool so I can dip in and out of that’ (Participant 4)

Participant 6 commented that the move to mainly telephone consultations reduced concerns over keeping patients waiting for supervising tutors as ‘you weren’t pressured by so many people piling up in the waiting room’.

Some participants highlighted the move to phone consultations due to COVID as being beneficial for student education, both due to the ability to select patients for the student to see:

‘it was fairly selective in what they were seeing, we could choose different topics for each week … so COVID has brought in so many advantages’ (Participant 8)

and because it was felt that telephone consulting was an important skill for students to learn:

‘we do significantly more virtual, mainly telephone, consultations, but this has provided good learning opportunities for the students’ (Participant 1)

Advantages for patients were also identified; telephone triage prior to consultations meant patients could be informed about the involvement of students in consultations immediately in advance of the appointment: ‘that’s the upside of COVID, … we’ve explained to them that they’ll see the student’ (Participant 4) and due to the spacing out of appointments, patients were less likely to experience delays waiting for student or tutor if they were running late.

Participants noted the benefits of the pandemic to furthering their own education due to greater ease of access as more things were moved online:

‘tutorials that used to be, you know you’d have to go into the postgraduate centre, whereas now it’s an online on Teams so I can sit and do that for an hour at night’ (Participant 7)

Importance of relationships

Relationships within the clinical team, between student and tutor, and with patients, were vital to the effective running of the LIC during the pandemic. Although students lacked some opportunities to develop relationships with Allied Health Professionals and other clinicians due to concerns about COVID, most tutors reported that students ‘welcomed being part of the team’ (Participant 8). A number of participants identified that being part of the practice social network was important for students given the potential social isolation brought about by COVID restrictions. Often the practice was an important focus of students’ social interactions during their placement, with strong relationships developed:

‘[students] were shocked as to the attachment they got to staff and patients … because COVID was fairly isolating for a lot of people, and I know a couple of the students have certainly felt that’ (Participant 8)

Participants described making efforts to integrate students despite the restrictions:

‘we emphasise the need that people do go for coffee, we’re very fortunate that we’ve got a big enough coffee room to get 8 or 9 people in a socially distanced way. … that’s invaluable to have those informal networking discussions’ (Participant 6)

For practice teams too, the presence of a new team member during the pandemic was a positive, with students contributing both practical support:

‘he did volunteer for the vaccination clinics and that he did all the IT stuff for us … he just mucked in and helped, so he’s a really good team player’ (Participant 5)

and boosting morale ‘in recent times which were pretty miserable actually, [LIC student was] quite a nice breath of fresh air’ (Participant 8). Conversely, in the one case where the tutor felt the LIC year had been less successful than in previous years, it was felt that lack of integration of the student into the team was a contributing factor to this: ‘I began to realise as well that he didn’t really feel a part of the team’ (Participant 3). Some participants noted that the whole of the primary care team was under stress and pondered how this may have affected the students:

‘there’s been huge stresses and strains in the last year within the practice, … he’s maybe a bit more in tune with what’s going on because he’s there a bit more?’ (Participant 3).

Patients also benefitted from having LIC students in practice teams. Tutors mentioned patients with mental health problems who derived support from their relationships with students, noting that this was particularly important to these patients during the pandemic.

‘he was really good with some of the young men who had mental health problems, and of course we’ve seen a lot of that through COVID’ (Participant 5)

Finally, for new tutors particularly, the inability to meet with their peers face to face for development sessions was felt keenly. Although online events and local tutor private social media groups were set up to facilitate contact, the lack of in person contact was regretted:

‘it would have been so nice for the Highland tutors to meet up and just actually have … informal conversations … I do think you really gain from just meeting people and talking’ (Participant 4)

Discussion

Tutors and practices demonstrated flexibility and ingenuity in their responses to the challenges of the pandemic. The guiding principles of LIC, namely continuity of relationships with patients and supervisors, meaningful involvement in patient care and the meeting of the majority of the year’s core clinical competencies across multiple disciplines simultaneously were all possible even under the constraints of COVID restrictions. In fact, it could be argued that there were more opportunities for students to become embedded firmly within the practice’s Community of Practice [17]. Practices were an important source of social interaction during the pandemic for team members, and opportunities for legitimate peripheral participation [18] were increased as the range of skills required of practice teams in meeting the challenges of the pandemic expanded to include activities in which students could more easily participate. Students performed important roles in practices that contributed to meeting the challenges of the pandemic such as helping practices solve technological problems, volunteering for vaccination clinics, providing support to patients with mental health problems and terminal illness, and boosting morale within teams. Continuity of relationships with practice staff, clinicians and patients meant that students could incrementally take on more responsibility, for example with telephone consulting and following up patients, enabling them to meet their educational needs. The length of the placement meant that it spanned a period of varying COVID restrictions, allowing students access to secondary care at some point during their attachment. The placement length also allowed more opportunities for students to follow up patients within the practice.

This research suggests some important considerations for the organisation of future LIC placements and placements in General Practice more broadly, particularly if increased remote consulting remains the norm. Time management is a frequently reported challenge for GPs who teach medical students [19,20], and the ability for tutors to remove waiting room pressures and increase flexibility by scheduling only telephone consultations when supervising medical students might help to ease workload pressures. The ability to filter patients for students to see also offers the possibility to increase curriculum coverage if multiple consulters book into student appointment slots, and if they have an awareness of conditions or problems that students have identified as learning needs. However, the danger with seeing largely filtered cases means that students may miss out on the key step of assessing for themselves whether a patient’s presentation is serious. This could inhibit their development of clinical reasoning skills, given that active participation in the problem-solving process is known to be important in the development of these skills [21]. Consideration also needs to be given to the importance of assessing minor illness in enabling students to build their own bank of illness scripts, another vital step in developing their clinical reasoning skills [22]. Developing skills in both telephone consulting and triage seem likely to be important competencies for the doctors of the future [23], and guidance for tutors and students regarding how to manage this within placements would be of benefit, given the need for students to carry out full assessments of both minor illness and more serious conditions to develop skills in clinical reasoning.

Finally, further research to explore the experiences of students, practice staff, Allied Health Professionals and patients of the LIC during the coronavirus pandemic would be helpful to understand their perspectives on the success or otherwise of the LIC under these circumstances.

Strengths and weaknesses

The main strength of this research is the richness of the data gathered. The fact that the effect of the coronavirus pandemic on the LIC was not the intended focus of the research meant that participants’ contributions on the topic were not prompted. This may have led to wider discussion of the topic. Conversely, the fact that COVID was not the main focus of the interviews could mean that some areas were not explored fully. The relatively small number of participants is another potential weakness though the number of participants represents 12% of tutors. The low response rate is likely to be a result of the pressures facing General Practice during the LIC pandemic and raises the possibility that tutors with more negative experiences did not participate.

Conclusions

LIC placements based in General Practice provide valuable educational experiences for students and benefit tutors, practices and patients even when operating under significant social distancing restrictions. Students were able to form strong working relationships with tutors and practice staff during the pandemic, gaining social benefits from these interactions themselves as well as contributing to social cohesion, practice response to pandemic and team morale. Despite challenges in accessing secondary care, students were exposed to a wide range of clinical cases. The increased use of triage allowed tutors to choose patients for students to consult with to ensure wide curriculum coverage and the length of their placements allowed LIC students graded exposure to remote consulting skills. The length of the attachment and the continuity of relationships with clinical teams and patients were important factors in the success of these placements.

Building in flexibility for supervising tutors, targeted filtering of patients for students to meet unfulfilled educational needs, and graded exposure to telephone consulting are adaptations to placements prompted by the pandemic that could be usefully incorporated into both LIC and shorter attachments in General Practice to enhance the experience for both students and tutors.

Ethical approval

Ethical approval was granted by the University of Dundee School of Medicine and Life Sciences Research Ethics Committee (SMED REC reference 21/28).

Disclosure statement

The Authors report no conflicts of interest.

Additional information

Funding

This work was supported by a University of Dundee School of Medicine Education Vacation Scholarship awarded to GH in 2021.