Why do students choose to do an extended GP placement?

ABSTRACT

The drivers for medical students’ decision making when considering which Student Selected Component (SSC) to undertake is poorly understood. Furthermore, it is unclear why students undertake a specific SSC allowing them to have an extended placement in GP in their final year. It is known that high quality GP placements encourage students to subsequently choose GP as their career, therefore if the decision-making process of students in this area can be better understood, then this may help inform medical school actions to encourage a greater uptake of these extended placements.

Semi-structured interviews were conducted with final year medical students at a Scottish University. Students were selected to provide a mixture of those who had and had not chosen to undertake the extended placement. The data was transcribed and analysed using thematic analysis to generate themes which represented the data.

This showed that career intention was a major factor driving SSC choice. Additionally, students sought peer feedback and tended to avoid specific SSCs if they felt a lack of internal motivation. Considering the choice for the extended placement, students tended, again, to choose based on career intentions, and they also based their decision on previous experiences of GP.

Career intention and prior experience are key factors in student choice of SSC and whether to undertake an extended GP. In order to address the national shortage of GPs medical schools need to consider how they might influence these drivers.

KEYWORDS:

• Medical education
• general practice
• extended placement
• student selected components
• medical curriculum

Introduction

In the UK there has been a requirement that medical students be given the option to choose areas they are interested in studying within the undergraduate curriculum since 1993 [1]. Often, students elect to study a particular area via a Student Selected Component (SSC) which offers the opportunity to study a subject area in more depth than within the core curriculum. As SSCs run alongside the core curriculum, time must be balanced between these two demands [2].

This policy of SSCs has been implemented differently by UK medical schools, resulting in quite diverse practice [3]. At the University of Dundee (UofD) students undertake at least one SSC in most years of the course. Little research has been carried out around the factors which influence medical student choice regarding SSCs. Given that all students undertake SSCs during their studies, what motivates them to choose one particular SSC over another is poorly understood. If the factors which motivated students to choose one particular SSC over another were known, then it might be possible to ensure that SSCs are designed in such a way as to encourage student engagement.

Presently, there is a national shortage of graduates choosing General Practice (GP) as a career leading to a national shortage of GPs in the UK [4]. This, combined with several other factors, has brought about a crisis in the GP workforce [5]. It has been shown that medical student experience whilst at medical school has a significant impact upon their perception of General Practice as a career, with various factors such as the hidden curriculum and the influence of other medical students leading students to view GP in a negative light [6]. It is also known that undergraduate exposure to good quality teaching in a general practice context (typically on a GP placement) increases the likelihood of that student choosing GP as a career [7]. The Scottish Government has therefore commissioned all five Scottish medical schools to increase teaching in general practice [8]. This is partly due to the issues outlined above, and also the evidence which suggests that good quality teaching in general practice is considered to contribute to preparedness of students for clinical practice and is also valued highly by students [9,10].

In the final year of the undergraduate medical course at UofD, students have the option to undertake an extended GP placement whereby a 4-week SSC placement is combined with the standard 4-week GP placement to allow an 8-week continuous placement in one practice. In keeping with the lack of knowledge as to why undergraduates may choose any SSC, it is not known what factors influence students’ choice to undertake this SSC in general practice. If this was understood better, it may be possible to encourage more students to undertake such an SSC.

Methods

All final year students who were undertaking a GP placement in the cohorts running from August until December 2019 were contacted via email and invited to attend a semi-structured, audio recorded, interview conducted either in their GP placement practice or in the medical school. This represented 55 students undertaking 4-week blocks and 10 students undertaking the extended blocks. The interviews explored the student’s thoughts around their choice of placement, their experience whilst on placement and asked them to compare this with their expectations of the placement. These interviews were transcribed and the data analysed using a Thematic Analysis approach [11].

Student participation was voluntary and no incentives were offered. Written consent was obtained and data was stored in keeping with local GDPR policies. Ethical approval was granted from the University of Dundee prior to the recruitment of any students to this study.

Results

Six students responded to the recruitment emails (3 male, 3 female) and were recruited to the study. Of these, two had undertaken a shorter 4-week placement, and four had undertaken the extended 8-week placement. All were interviewed individually between December 2019 and February 2020.

Career intentions drive choice

Career intentions were a significant motivator for SSC choice and were cited by all students as a reason for choosing a particular SSC.

If I want to do neuro I have to do everything neuro-related that there’s an option for … so every option I did from then up until this SSC [student 2]

I’m considering general practice as a career, so I think also just getting more experience to see if I would like it or not, just for a bit longer. [student 3]

I did the 8 week placement cause I was sort of deciding whether or not to be a GP and I wanted to get a longer placement with it to sort of get into the swing of it cause I find that often the 4 week placements … you get used to it and then you move on. [student 6]

Students 2 and 3 have clear career intentions and are choosing their SSCs accordingly, and student 6, whilst less certain, still uses their SSC choice to ‘Test the water’ of a potential future career.

Furthermore, students who don’t have particular career intentions still consider this in their decision making regarding SSCs.

I don’t really know what I want to do. So, it was more a case of, like, asking people in the year above what the SSCs that were on the list were like and then deciding from there kind-of what ones I wanted to do … But … the more proactive student, or somebody who has a very particular interest, then they’ll probably have a more useful SSC experience because they’ll have gone out of their way to find the right supervisor and get the right experience for what they want. [student 1]

Here we see how the lack of career intention still guides their SSC choice as they consciously employ a different decision-making strategy, peer feedback. In keeping with data from other students, peer feedback is also a significant influencer of student SSC choice but students appear to only resort to this when they lack a personal career intention.

The learning experience

As well as peer feedback, students will consider the SSC structure as well as its content.

I really wanted to spend longer in one place because in 4th year there was a lot of short blocks, some of them 1 week, max 4 weeks, so I always felt that by the end of the block I was only just getting to know how it worked and how the team worked and who everyone was and what I was meant to be doing and things [student 3]

Here we see the student clearly valuing the positive aspects which come from undertaking an extended placement that they feel are missing from shorter placements. They describe the challenges of settling into a team and establishing their own identity and purpose and only managing this shortly before having to leave the short placement again. Feeling part of the team is valued by the student as they describe the lack of this to the detriment of the placement.

However, the extended nature of the placement seemed daunting to some students.

… if I had gotten there and actually not really enjoyed it, or not felt as welcome as I did, then 8 weeks is a really long time to have committed to that. Whereas, like, any 4 week placement, even if it’s awful, you know you’re gonna get to the end of it. [student 1]

Here we see apprehension that if the student feels unwelcome or doesn’t enjoy the placement, they feel it would be very difficult to complete the extended placement. Whereas, for shorter placements, the student expects to derive a sense of resilience from the fact that the end comes much more quickly and therefore can participate in a shorter placement, even if it is challenging for them. This student undertook a shorter placement; therefore, these concerns are important to consider as it is likely that they are a driver against students choosing to undertake extended placements.

Prior experience

Previous positive experience in a GP placement was a motivator for choosing an extended placement.

I really enjoyed my GP placement last year and it was a 4 week one, so I was keen to do a bit longer … I was always really keen on paediatrics, but my GP placement in fourth year kind of swayed me a bit towards GP [student 3]

Here we see the impact of a well-perceived previous GP placement on the student’s choice of undertaking an extended GP placement. The student discusses a previous inclination towards paediatrics which has been altered by a positive GP placement.

Discussion

This study suggests that medical students choose their SSCs primarily based upon career intentions and peer feedback, but also the learning experience anticipated depending on length of placement, and this sits comfortably with what is already known in the literature [11,12]. Given it is known that extended periods of time on a high quality GP placement may influence career intentions [7], schools should consider actively promoting extended opportunities in GP. Furthermore, even if extended GP placements are made compulsory, then similar effects on career intentions are still seen.[13] Therefore, medical schools should consider requiring students to complete an extended amount of time in GP in their senior years.

Students value feeling part of a team on clinical placement and indeed consider this to be of high educational value [14]. Extended GP placements provide the stability of location and team environment and much could be made to promote this to medical students, specifically acknowledging that not all students undertaking an extended GP placement will wish to become GPs but can still benefit from the positive aspects of the extended placement such as the clinical decision-making skills of a GP attachment which are readily transferrable to other areas of medicine. It is known that a supportive, stable team environment helps to promote medical student resilience [15] and therefore should improve student learning and wellbeing and this could be promoted to students in the knowledge that the skills acquired are not limited in utility to a career in GP.

It is already known that positive experience in a GP placement means that medical students are more likely to choose GP training in due course [7]. In this study, we see this phenomenon playing out in the undergraduate environment where a positive experience in one GP placement means a student is more likely to choose an extended GP placement. Consideration should be given to early years exposure to the clinical GP environment to encourage greater uptake of additional primary care placement opportunities in later years of the course. It is also evident in this study, and in the literature, that peer feedback is a factor in SSC choice [12] therefore medical schools should consider use of student ambassadors to further promote the choice of extended GP SSCs in the more junior years within the school.

The main negative driver identified was that of apprehension about the duration of an extended placement if the student found the placement unenjoyable. This is unlikely to only relate to extended GP placements as evidence shows that uncertainty is a significant contributing factor to emotionally challenging situations for medical students. However, the same research showed that the impact of this may be mitigated by having a defined position in a healthcare team [16]. Therefore, practices should be encouraged to ensure that medical students on placement do have a clear role within the team contributing to patient healthcare, and this should be made clear to students in any promotional material about the extended placements.

Conclusion

When developing GP SSCs, medical schools should ensure that the positive benefits for students are articulated for students who may or may not plan to pursue GP as a career. Medical schools should consider making available positive feedback for extended GP placements to students when they are making their SSC choice as well as promoting SSCs using positive peer feedback, including the potential of using student ambassadors. Finally, GP placements should be provided to earlier years students in order to promote later year extended GP placements and ultimately influencing career intentions after graduation.

Ethical statement

Ethical approval obtained School of Medicine Research Ethics Committee ref SMED REC 19/101.

Acknowledgments

Thanks are provided to the participants who contributed their time.

Disclosure statement

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

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.