The role of general practice in postgraduate basic training

Abstract

Background: In recent years, there has been growing interest in the role of primary care in postgraduate training. Relatively little has been published about benefits of early and sustained postgraduate basic training in general practice, especially for doctors with other ambitions than family medicine.

Aim: To explore young Danish doctors’ views on basic medical training including views on the participation of general practice.

Methods: We conducted a cross-sectional survey of all Danish doctors, who took part in the postgraduate basic training programmes in 2009. The survey consisted of rating scale and qualitative questions. We used a phenomenological approach.

Results: Almost all of the young Danish doctors responding felt that training in general practice is a necessary part of a postgraduate basic training programme. Early training in primary care not only gives doctors a broad understanding of the health care system but also strengthens the ability to collaborate with general practitioners upon entering another specialty. It also develops important medical and communicative competences. The training in general practice is considered beneficial for the development of professional identity. The educational environment in general practice is rated highly.

Conclusion: The inclusion of family medicine in postgraduate basic training should be considered for all doctors.

Background

Transition from medical school to clinical work is not uncomplicated and it can be harsh for young doctors (Prince et al. 2004). Students trained to pass exams suddenly find that they have to solve clinical problems laden with ambiguity, uncertainty and personal responsibility. Danish doctors do not feel that they are fully educationally prepared when they finish medical school (Petersson et al. 2006). To address this problem, the majority of countries have programmes to introduce newly educated doctors to clinical practice. However, the set-up and length of these programmes vary considerably.

Table

Practice points

General practice plays an important role in postgraduate basic training and delivers good learning frames. Doctors aiming at a hospital career learn relevant medical competences in general practice, difficult to obtain in hospital settings. Mandatory postgraduate basic training in general practice for all doctors strengthens collaboration in health care and the inter-colleague understanding.

From 1991 to 2008, the Danish postgraduate basic training programme consisted of 18 months of mandatory training, including 6 months of mandatory training in general practice. However, in August 2008, the programme has been reduced to 12 months training and the number of doctors receiving a rotation including general practice has been reduced to 80%.

In recent years, there has been growing interest in the role of primary care in postgraduate basic training for all specialties (Swanwick & Firth-Cozens 2005). Relatively little has been published about the documented benefits of postgraduate basic training in general practice, especially for doctors with other ambitions than family medicine (Swanwick & Firth-Cozens 2005).

Researchers evaluating the Danish training have demonstrated its benefit, with this primary care. The general practitioner (GP) training provides the trainees with relevant competences difficult to acquire in hospital settings (Knudsen & Lorentzen 1992; Noergaard et al. 1996).

They are allowed to work independently, seeing a growing variety of patients, which results in significant educational benefit (Noergaard et al. 1996). They learn to master common diseases and clinical problems solved in general practice. The doctors learn about illnesses and medical conditions over a period of time and across several medical disciplines, such as palliative care (Knudsen & Lorentzen 1992). The doctors are trained in a patient-centred approach and they learn the value of continuity in patient progress through the health system. They recognize the importance of compliance and patient empowerment. They learn to deal with healthy but health-concerned citizens (Maagaard & Kjaer 2005).

In the future, one in five doctors in Denmark will not be exposed to general practice before entering specialist training programmes. The purpose of this study was to gauge the attitudes of doctors in training regarding early training in general practice regarding its overall benefit.

Methods

This study is a national cross-sectional survey of attitudes and practices of all doctors completing either the 18-month training period (18mT) or the 12-month training period (12mT) in 2009. The 1034 doctors were identified from the official database. A total of 798 doctors were enrolled in the 18-month training and 236 doctors were enrolled in the 12-month programme. We performed this study in 2009 in Denmark.

We developed a questionnaire to collect quantitative and qualitative data on young doctors’ experiences and attitudes towards postgraduate basic training.

The quantitative questions were taken from the Postgraduate Hospital Educational Environment Measure (PHEEM) questionnaire, which has been validated in Danish and measures the learning environment (Aspegren et al. 2007). These questions were rated using a 5-point Likert scale. The survey included a qualitative questionnaire intended to reveal the doctors’ attitudes towards an ongoing change in the postgraduate basic training. The questionnaire addressing the 18mT doctors asked which of the three elements in the 18-month programme; internal medicine, surgery or general practice, could be eliminated. This question was excluded from the questionnaire addressing the 12mT doctors since they have only been trained in two types of wards/general practice. The complete questionnaire can be found in the Appendix.

The questionnaire was re-validated by external assessment. We performed a small pilot test in order to explore the level of comprehension of the questions. The applicability of the questions for general practice had been tested earlier (Kjaer 2008).

We e-mailed the questionnaire to all participants close to the completion of their postgraduate basic training. A reminder e-mail was sent after 3 weeks.

The internal construct reliability of the questionnaires was assessed with the Cronbach's alpha analysis, (Bland & Altman 1997). Differences between responses to general practice, as compared individually with medical and surgical ward responses, were assessed statistically by using non-paired t-tests.

The three researchers divided the responses to the qualitative questions into ‘meaning-carrying units’ by a phenomenological method (Giorgi 1985). The three researchers have different professional backgrounds and results were only included in case for agreement among all researchers in the interpretation of data. The process allowed researcher triangulation (Holstein 1996).

We combined qualitative and quantitative data in the survey in order to apply method triangulation (Holstein 1996). The results were furthermore put into perspective with our findings in the literature.

Generalizability was expected if the qualitative and the quantitative data supported each other and they were in concordance with findings in the literature.

In order to make a comprehensive presentation of results, the data were condensed into themes. During the analysis, six themes emerged.

In this article, we focus on the quantitative data from the 18mT doctors, who had been trained in all three types of learning environments. However, both groups were included in the qualitative data because we also wanted to explore the general views of the 12mT doctors, who were not trained in general practice.

Results

We received responses from 680 of the 1034 trainees (66%). However, some may not have received the mail due to invalid e-mail addresses, spam filters, etc. Based on the earlier experience with e-mail lists of this population, we estimate the true response rate is well above 66%. Gender and geographic distribution of the responders and non-responders were the same. The response rates from the two training programmes were also similar.

Quantitative data

Almost all 18mT doctors felt that training in general practice is a necessary part of a postgraduate basic training programme, with only 6% of respondents selecting general practice in answer to the question, ‘Which of the three clinical elements can best be left out if we have to leave one out?’ (Table 1)

Table 1.  Question to 18mT doctors: Which of the three clinical elements can best be left out if we have to leave one out?

Internal medicine	0%
Surgery	18%
General practice	6%
All three elements are of equal importance	76%

The educational environment in general practice is rated highly (Figure 1). In all questions, general practice is rated higher than the hospital wards (p < 0.005 comparing general practice with medicine and surgery).

Figure 1. The education environment in surgery, internal medicine and general practice. Answers from the 18mT doctors. (a) I had an informative induction programme. (b) My clinical teachers provide me with good feedback on my strengths and weaknesses. (c) I felt part of a team working here. (d) Senior staff utilized learning opportunities effectively. Y-scale: The answers were reported on a 5-step scale (strongly disagree, disagree, neither nor, agree, strongly agree) and rated 0–4. Ratings above a score of 2.0 were more positive than negative. Ratings above 3 were very positive. *The rating of general practice are significant different from medicine and surgery p < 0.005.

Internal consistency among the responses is 0.88, which is acceptable (Bland & Altman 1997).

Qualitative data

Content analysis revealed six themes discussed by the respondents. These themes and examples of responses are outlined below. There was a remarkable unanimity between the responders from the 12-month and 18-month programmes (Box 1).

Box 1. Qualitative themes

Collaboration and understanding

Identity and respect

Basic medical competence

Continuity in patient care

The role in choosing medical career

Negatives

Collaboration and understanding

It was stated by the young doctors that a period in general practice was necessary to understand the conditions and challenges of primary care. They stated that senior hospital consultants who had been trained in general practice in their basic training had a better understanding of – and collaboration with the primary sector. It was regarded as a prerequisite for a fruitful collaboration. It was especially beneficial for doctors aiming for a hospital career. It was important for them to understand the conditions and options on the other side of the fence.

I think it is a problem if you don’t learn about the workflow in General Practice, I myself gained a deep respect for the work done in primary care. (18mT)

It was obvious that the senior doctors who had been trained in general practice had a better understanding of the possibilities out there and much more respect for GPs (12mT)

Identity and respect

The period in general practice assisted young doctors in creating their professional identity. It also enhanced their respect for doctors working in general practice.

General practice made me more complete as a doctor. It is a pity that not everyone is allowed a period in general practice. General practice makes different demands on your communicative and medical-pedagogic skills. (18mT)

Medical competence

The doctors learned to treat the common diseases and clinical problems often solved in general practice but relevant for all doctors. They were trained in ‘horizontal expertise’, which they considered important to take back to the hospital sector in order to go on to a higher specialization. They learned important lessons in communication and a patient-centred approach.

… in all hospital departments you will have to use knowledge of diseases and problems, you dealt with (and learned) in general practice. (18mT)

Continuity in patient care across departments

The doctors felt they had obtained skills in the continuity of patient care. They expected better use of resources in referrals between hospital specialists due to the training they had received in general practice because referral of common minor problems could be avoided.

For each of the themes, it was stated that a period in general practice was as beneficial for doctors aiming at a hospital career.

The role in the choice of medical career

Responses indicated that training in general practice helped in choosing a career not only in primary care, it also provided insight into other specialties such as gynaecology and neurology, due to the variety of patients seen.

The GP training help me in choosing my future speciality, the broad panorama of patients seen in general practice opened my eyes for several interesting specialities such gynaecology and neurology (18mT)

Negatives

There were also negative comments. A few responders thought that general practice was only interesting for those who wanted to become a GP. Others considered that the period in general practice could be shorter or even left out, and a few regarded the training in hospital departments as much more important.

Discussion

The aim of this study was to identify junior doctors’ feelings towards the role of general practice in basic postgraduate training. The data show that the doctors trained in general practice feel they had experienced important learning.

When the 18mT doctors, who had three 6-month positions were asked to choose between the three elements, 94% regarded general practice as an important and necessary part of postgraduate basic training. The qualitative data explain why.

They had experienced that the training provided them with important insight. They felt they were given a broader understanding of the health system and had reinforced their ability to collaborate. They had learned important medical and communicative competences. The training developed respect between hospital specialists and GPs and the doctors assumed it was beneficial for continuity in patient care. These data are in accordance with earlier findings (Noergaard et al. 1996; Maagaard & Kjaer 2005; Swanwick & Firth-Cozens 2005).

The training in general practice is also reported as beneficial for the development of professional identity and as helpful in the process of choosing a future career. It is supported by other findings (Cantor et al. 1993).

Six percent of responders considered general practice training less important than the hospital training. It is a remarkably small percentage, since only about 25% of the responders intend to become a GP. The negative statements reported should be seen in this light.

In the 18mT doctors’ comparison of positions, general practice did well and was given the best ratings. This indicates that for them, the general practice period provided a good educational environment. It is remarkable that several of the responders who did not expect to specialize in family medicine stated that the training in general practice was particularly important as they aim towards a hospital career.

We asked the entire population of junior doctors in Denmark, and the response rate was well above 66%. However, the positive evaluations of the learning environment (Figure 1) could have influenced the responders’ attitudes making them more positive towards the benefits of training in general practice. The training in general practice is the last placement in the postgraduate basic training, and therefore best remembered. This could also have biased the response.

Furthermore, young doctors found early postgraduate basic training in hospital made them feel insecure and they lost confidence (Kjaer & Tulinius 2003). In general practice, they felt more secure due to the close contact with their senior colleagues (Kjaer & Tulinius 2003). These issues may also bias their evaluation in a positive direction.

All the data are from young doctors who had just finished their postgraduate basic training. We have no data from senior doctors. This is a weakness in this study since it is not possible to broaden the perspective with statements from doctors with more senior experience.

We did not ask the doctors explicitly what they had learned in general practice. Specific questions could have provided a more comprehensive description of the competences learned. We analysed the spontaneous statements by reflecting on the advantages and disadvantages of the educational restructuring. We expect therefore that the statements refer to competences the junior doctors find important.

It is possible that the positive attitude towards training in general practice could be due to aspects of professional development and young doctors’ need of professional confidence, which is provided in general practice training. The first clinical training after medical school brings a clash between cognitive and constructivists thinking (Kjaer & Tulinius 2003). Newly graduated doctors have the highest all-round fingertip knowledge, but if this is not applied to solving clinical tasks, it will diminish (Kjaer 2003). Doctors are presented with a growing variety of patients and problem types on the medical ward and in general practice. Having experienced this variety of patient contacts, the doctor uses a greater proportion of newly gained all-round theoretical knowledge.

In a hospital setting, the patients have more severe and complicated diseases, but the patients are selected and there are relevant guidelines and instructions to hand, together with easy access to laboratory and X-ray facilities.

In general practice, however, it is impossible to have guidelines for all causes of patient contacts and the presentation of problems can be ambiguous and unclear (Kjaer & Tulinius 2003). These conditions highlight the importance of clinical history-taking and the ability to reflect (Swanwick & Firth-Cozens 2005). If combined with easy access to GPs who facilitate reflective discussions, the young doctors can experience an increase in their medical competences (Schön 1983; Schmidt & Rikers 2007). Therefore, they may evaluate GP training more positive. It could be interesting to re-examine the attitudes of the young doctors later in their specialist training to see if they maintain their positive view of training in general practice.

In order to explore in detail the potential professional benefits of training in general practice, more research is needed.

Conclusion

The postgraduate basic training in Denmark has been reconstructed. In the future, 80% of rotations will include general practice.

In our study, 94% of the Danish doctors questioned found that training in general practice is a necessary part of a postgraduate basic training programme. The training gives doctors a broad understanding of the health care system and strengthens the ability to collaborate. It develops important medical and communicative competences. The training also develops respect between hospital specialists and GPs. The training in general practice is considered beneficial for the development of professional identity and is helpful in the process of choosing a future career. The educational environment in general practice is rated highly. The inclusion of family medicine in postgraduate basic training should be considered for all doctors. Studies to explore and map the medical competences learned in general practices are, therefore, needed.

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

Appendix

The questionnaire: (in English translation)

Please answer the following questions for each of you training positions (on a 5-point Likert scale)

1. The training in this post makes me feel ready for continued specialisation

2. I have enough clinical learning opportunities to obtain my learning objectives

3. I had an informative induction programme

4. I felt part of a team working here

5. Senior staff utilized learning opportunities effectively

6. There is a no-blame culture in this post

7. I feel part of a team working here

8. Senior staff utilizes learning opportunities effectively

9. My clinical teachers provide me with good feedback on my strengths and weaknesses

10. This hospital ward/general practice has a proper physical learning environment such as suitable examination rooms, access to relevant literature/IT facilities and proper accommodation for junior doctors, when on call

11. I have suitable access to careers advice

12. How sure are you, in your future chose of specializing? (on a 0–100 visual scale)

13. Please answer the following question in free text:

The basic training programme is reconstructed. It changes from three six months positions to a new programme with two six months positions and a stronger focus on supervision and learning objectives. New types of clinical departments are enrolled.

Which advantages and disadvantages do you see in this shift towards shorter but more focused basic training?

(Max 200 words)

• (n) Which of the three clinical elements can best be left out if we have to leave one out?

(For the 18mT doctors only)

1. Internal medicine

2. Surgery

3. General practice

4. All three elements are of equal importance