David Snadden

Portfolio learning in general practice vocational training – does it work?

Reflective learning has been widely addressed as an important learning mechanism in the educational literature. The creation of portfolios has been seen as a mechanism to promote this, though there has been little exploration of the place of a portfolio in general practice training. This study examined the introduction of a model of a portfolio learning strategy into one training region. The model had been developed by previous pilot work. The study explored the model in terms of its usefulness in general practice training and its relationship to reflective learning. An educational facilitator was used to support this introduction.

Changing to generic formulary: how one fundholding practice reduced prescribing costs

Abstract Objectives: To observe one general practices attempt to reduce prescribing costs on becoming third wave fundholders through the introduction of a generic formulary applied to all new and repeat prescribing. To assess the impact on patients and prescribing patterns. Design: An observational study using interviews with patients and practitioners; questionnaires for patients and prescribing data. Setting: One urban general practice with five partners in Scotland. It became fundholding in April 1993. Subjects: 71 searches of the register of repeat prescriptions identified 1274 potential changes in drugs. Questionnaires were sent to a stratified random sample of 280 patients four months after the changes were made; 33 interviews were conducted with 17 patients selected by local pharmacists to represent a wide range of opinion. Main outcome measures: Changes in prescribing and response and satisfaction of patients. Results: Of intended changes, 129 (70%) were in place after four months. Thirty three (20%) of the 167 patients who returned questionnaires were “very unhappy,” though interviews suggested that this was primarily with the communication they received rather than the change itself. Generic prescribing rose from one in three (37%) to over a half (58%). The volume of treatment dispensed (as treatment days) fell by 67674 (10.7%), and the average cost per days treatment fell by 3.1p from 32.3p per day in 1992 (9.4%), producing a total absolute saving of 24% (pounds sterling137712) over the first year. Conclusion: This practice has achieved a large reduction in prescribing costs rapidly. These were tolerated by patients, none of whom is thought to have left the practice for this reason. Great care must be taken to inform patients appropriately. Key messages Key messages Financial incentives are increasingly being used to encourage cheaper prescribing It seems that patients will accept large scale changes, at least within the context of fundholding The introduction of such changes should be carefully planned, particularly the way in which patients are informed There is a need for more research into the balance between prescribing expenditure and the provision of other services

Portfolio-based learning and general practice vocational training

This action research project developed a portfolio‐based learning system, based around a ‘log diary’, with the trainers and general practitioner registrars of one training region in the UK. For those that found benefit from the system, the diary became an important way of holding all the events of a training year together; a way of looking back, in order to view the progress made, and looking forward, to view potential learning needs. Such portfolios were not found to be effective formal assessment mechanisms because the threat of assessment influenced the type of material collected. The enthusiasm of trainers was crucial in encouraging use of the model. The action research process was fundamental in stimulating exploration of ideas on reflective learning. There remains some resistance to the idea of reflective writing, and in this context, portfolios may be one educational tool for use by some, but which may not be universally applicable. Their development and implementation requires considerable local support through facilitation.

Free choice and career choice: clerkship electives in medical education

Introduction  Medical education experiences, particularly in clinical years, are reported determinants of career choice. Less is known about features of clinical education experiences including length, discipline, setting and choice, which may serve as landmarks in career choice decisions. This studys purpose was to explore the benefits of a free choice clerkship elective, and more specifically, its role in clarifying career choice.

The experience of asthma

A group of seven asthmatics were identified from family practice, following administration of a questionnaire, as expressing feelings of stigma or pessimism concerning their condition. They were interviewed in depth, using interpretive research methods, concerning their experience of asthma. Interpretive research uses qualitative methods to explore the emotions, feelings and meaning of the event of interest. All the interviews were transcribed verbatim by the principal researcher and analyzed by the technique of immersion and crystallization. The picture of asthma that emerged for the participants in this study gave rise to the concept of a dynamic model to illustrate their asthma experience. The model showed asthma as a continuum from diagnosis to final acceptance. The transition phase included a need to integrate knowledge, experience and self-awareness before progressing to acceptance and control. A mentoring relationship greatly facilitated resolution of the transition phase. Progress along the continuum was accompanied by diminishing fear. Another important theme to emerge was the fact that tiredness and physical limitations were common feelings, irrespective of the severity of the asthma in medical terms. The implications of this research for health workers is that they have much to contribute in assisting asthmatics to gain control over their condition, particularly in respect to understanding what knowledge concerning their condition is relevant to asthmatics and in understanding the potential benefit to asthmatics of a mentoring relationship.

Rapid prescribing change, how do patients respond?

The cost of prescribed medication is an increasing burden on health care systems. British general practitioners have been encouraged to reduce their prescribing costs through financial incentives within the fundholding scheme. This study reports on one general practice which reduced prescribing expenditure as part of the move to fundholding. Interviews performed with practice staff and patients were analysed and combined with prescribing statistics and questionnaire data to give a picture of the balance between the experience of patients and practitioners. Fifty-three interviews with 17 patients revealed that most were willing to try cheaper treatments and that dissatisfaction was primarily with the communication they received rather than the change itself. Each patient had to decide how to respond to the change in their medication. The decision-making process and the main factors involved are described and discussed. The experience of having long-standing treatment changed can have an impact on the doctor-patient relationship. This was not found to be a large problem and, it is suggested, can be guarded against. Large-scale economies in prescribing are feasible for some practices, and patients will tolerate such changes if attention is paid to sensitive communication.

Developing a medical school: Expansion of medical student capacity in new locations: AMEE Guide No. 55

Background: A concern about an impending shortage of physicians and a worry about the continued maldistribution of physicians to medically underserved areas have encouraged the expansion of medical school training places in many countries, either by the creation of new medical schools or by the creation of regional campuses. Aims: In this Guide, the authors, who have helped create new regional campuses and medical schools in Australia, Canada, UK, USA, and Thailand share their experiences, triumphs, and tribulations, both from the views of the regional campus and from the views of the main Medical School campus. While this Guide is written from the perspective of building new regional campuses of existing medical schools, many of the lessons are applicable to new medical schools in any country of the world. Many countries in all regions of the world are facing rapid expansion of medical training facilities and we hope this Guide provides ideas to all who are contemplating or engaged in expanding medical school training places, no matter where they are. Description: This Guide comprises four sections: planning; getting going; pitfalls to avoid; and maturing and sustaining beyond the first years. While the context of expanding medical schools may vary in terms of infrastructure, resources, and access to technology, many themes, such as developing local support, recruiting local and academic faculty, building relationships, and managing change and conflict in rapidly changing environments are universal themes facing every medical academic development no matter where it is geographically situated. Further information: The full AMEE Guide, printed separately, in addition contains case examples from the authors’ experiences of successes and challenges they have faced.

General practice and medical education: What do medical students value?

An external evaluation [1] of the fourth-year medical student attachment in general practice at the University of Dundee was conducted to determine the strengths and weaknesses of the teaching programmed. Written evaluations of the attachment were obtained from 75 medical students. In addition, interviews were conducted with students and their tutors and a focus group was arranged at the conclusion of the attachment. The overall evaluation by the students was positive. Students liked the opportunity for the hands-on practice of medicine and the collegial reception from their tutors. Major criticisms related to the lack of adequate opportunities for some students to see patients on their own and to learn practical procedures. Many students would like to have a longer attachment. Problem areas which may provide valuable learning experiences, such as dealing with ‘difficult patients’ need to be addressed in advance and during the attachment. Other health professionals need to be adequately prepared for, and ...

Evaluating distributed medical education : what are the community's expectations?

Objectives  This study aimed to explore community members’ perceptions of present and future impacts of the implementation of an undergraduate medical education programme in an underserved community.

Clinical education: context is everything

There are times I wish I was a cartoonist and this is among them. How else can we easily portray the mad dash of medicine into the subspecialty stratosphere? This trend leaves behind too few to sort out the messy collision between the human experience of illness and the complexity of modern medical care that occurs where we mostly live – in the community. The debates I see in medical schools, at the operational level, are often not about what sort of doctors our societies will need in the next decade or so and how we will achieve them. Rather, the focus is on the problem of having insufficient curriculum time to represent the fullness of an emerging subspecialty and how and where to fit it into the existing curriculum. On top of this, generalism as an endpoint is often demeaned. The result is a situation in which we do not have enough doctors with the right skills in the right places, accompanied by an alarming lack of interest amongst students in following generalist careers. Something somewhere has to give. The needs of populations are changing: complex comprehensive care is needed more and more; multiple chronic conditions dominate, and rural areas, in particular, are increasingly underserved by doctors. We need doctors in rural and underserved areas. We also need generalists, not just family doctors, but general internists, paediatricans and surgeons too. We just don’t seem to be able, or perhaps willing, to train generalists anymore, at least not in the numbers we need. These pressures have led to a number of developments which include increasing the intake of students into medicine, the creation of rural schools or campuses and reforms of postgraduate specialty training. Reacting to need often happens in advance of any research results to guide that reaction, but there are a number of educational initiatives that have been established long enough to begin to produce useful research. This issue of the journal contains two reports that focus on learning environments. The first, from Australia, examines the experiences of students learning core clinical medicine in an integrated, community-based, rural environment and compares these experiences to those of their peers, who are following traditional discipline rotations in a tertiary care centre.