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A Mixed Bagfinalshownotes
1. A mixed bag: students’ experiences of general practice placements in the first 2 years of their medical training Dr Rachel Lindley & Dr Sarah Smithson Manchester Medical School University of Manchester
to put our work in context :- At Manchester Medical School the initial clinical exposure that the students have is called Early Experience which is during the first 2 years. The focus is on meeting patients and staff in healthcare environments. Emphasis on communication skills training in small group workshops then practice with SP, then going out on these visits and talking to patients to learn about the patients perspective. As we were one of the last Medical schools to introduce some form of early experience, its only been introduced since 2004, so 5 years. The students go to different sites each visit, which includes = GP practices and both teaching hospitals and District general hospitals to see spectrum environments I was really focussing on what they thought of the community parts of these visits.
This work has arisen from information I gathered in a workshop at the very start of the 3 rd year, which was trying to help students get the most out of their future community placements. I asked the students to note the ‘good’ and ‘not so good’ parts of their community visits on separate post it notes, then put them under the headings on the flipchart. As a group we then discussed the topics they covered. Once the workshop was over, all the comments were collated and each post it notes comments were analysed using the constant comparative method, where Sarah and I refined the themes which emerged. In terms of anonymity - Although during the workshop the tutor may have seen who wrote which comment, to be honest, there were so many, you could hardly remember who had put up what once they were up.
133 students did the workshops, but I was dependent on other tutors bringing the work back to me, and in the end, I got 66% of the students comments back. The main difficulty was that the workshops were in a number of different sites across Manchester and over different dates. Although it was only 66% I do think it was a representative sample as the students were randomly allocated to the groups and ALL the data from those groups was collected.
Predictably , the 3 main themes to emerge were issues around The GP, the Practice and the Patients. I’ll go into more detail about the ‘good’ and ‘not so good ‘ aspects of each of these in turn, with a few of our thoughts at the end. So first the ‘ good’ aspects under the theme of the GP....
communication skills and clinical abilities and lovely things like what seems like a hint at the ‘wonder’ of the GP coming up with a DDx in the middle of working.
highlighted the ‘active’ involvement of the student in the visit , by doing things and being helped to understand what was happening
They also valued the positive role modelling they saw. Now onto what they felt were the ‘not so good parts’....
So again there were issues around poor communication skills, at odds with what they’ve already been taught about by this stage
As a teacher – issues of GPs motivation / skills and professionalism
So they are also seeing what they view as negative role models
So what messages came out of this... Their ability to make very strong judgements about the GP after at most a day in their company was a surprise. How the strong negative judgements, so early in their career , may affects them later on isn’t clear? WHO helps them understand what is happening in these environments - possibly it is falling to peers – and the question is how well are they able to help other students understand the wider issues arising from these clinical experiences. We can discuss these and other issues coming from this at the end. So moving onto the good elements of the practice...
The staff category held some useful clues about how much they valued relationships with the practice team.
And another surprise was how well they remembered about food and drinks issues, with simple appreciation of a nice cup of tea. Even for 1 day visit its an important aspect of feeling welcome somewhere.
The practicalities of running a General practice was also something they enjoyed about their visit.
As was appreciating the differences to their hospital learning environments .
They didn’t like feeling left alone and abandoned somewhere strange – fair enough
Travel is always a source of complaints, so this wasn’t a suprise.
Nor was them not likeing feeling like a spare part.
So a summary of some of the key features for us we around just how important it is for them to feel welcome, expected and part of the practice team. The practices preparedness for the students is really key here. Also we felt that there was a feature about it in terms of the students feeling like they couldn’t control any of these factors if they went wrong – so ‘being stuck’..
Issues around the patients were very much about the wide variety of cases they saw in both the surgery as well as ..
On home visits – seeing patients in their own environments.
And starting to appreciate other peoples lives for whom they’ve possibly had very little contact.
This moves us onto one of the most interesting areas for me which are the not so good features around patient issues... They included the students not liking seeing who they termed work skivers / druggies . Its interesting to see those negative statements used about patients they barely know
They were also didn’t like some aspects of how patients behaved . The first comment was said to a female student in a consultation room, when the GP had left the room to go and get something. She’d not discussed it with anyone else to that point.
A number of them didn’t like what they viewed as ‘minor’ illness. Are patients already boring in the few years of training?
As is often the case, all this information provokes more questions than it answers. How they view patients – Rather than seeing the health needs of the people – poss the most needy of input , they are saying these are things that they don’t like = is this prior to them coming to medical school or since ? Is it the patient they don’t like or the difficult topics that arise – difficult consultations / the role of the doctor / how to handle difficult personal feelings that come from difficult consultations etc What is the role of the tutor here = are Tutors being explicit about own feelings and how they manage these or is all this hidden to the students. ((( don’t say here but rememberAlso our themes - ( this may well be a feature of the pair of us both being GPs as much as any themes emerging- it would eb interesting to ask people from different backgrounds, or even better, some students to analyse their own themes. ))))
Profound Impact these visits have , as relatively short contact time– significant aspects both good and not so good. They’ve also had at between 4- 23 months since the experiences, so its surprising how much they recall. In the session that I ran – they were honest and open as part of a teaching session, and the philosophy of the session in that this information was being used to help move them forward. Had we got different information to if we’d asked them to complete an evaluation form ?? They can recognise aspects of a what they see as a good teacher / practice but they are also forming a judgement about good patient and not so good patient. We don’t know whether this has come from the student, or more worryingly , the Doctor that they’ve been placed with. If it is from the doctor, who is functioning as a potential role model, then it is an example of what Dewey termed ‘ miseducation’ in that the students are learning things that you really don’t want them to. And when they talk about not so good issues, it is also about core aspects of community health care such as ‘ minor illness’. We might not be surprised by them seeing lots of what is seen as boring / minor illness, as they are just dropped in for a few hours, and miss the benefits such as Longitudinal / continuitiy of care / seeing what the team does and how it all fits in together, but the important feature is whether this negative attitude is being formed at a very early stage and is then even harder to alter. – particularly if they weren’t having the opportunity to explore these experiences more objectively. We were concerned as well as to how many of these negative value statements about patients are challenged with the students, if at all, if ever in an environment where you could explore where your opinions have come from and how they may affect your functioning as a doctor. They have given us their ideas of good and not so good aspects and how may this relate to the GMC guidance ‘duties of a doctor’. .
And finally Should this shape how the community aspects of EE are delivered? Well , some of this was already known about, but not from students at such an early stage, so there are already some new changes....by 2 new developments being rolled out this academic year across all the bases. We need to continue looking to provide quality placements for all the early experience students , to help maintain all the positive learning experiences we have heard that the students are having
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