Richard Knox

A BEME systematic review of UK undergraduate medical education in the general practice setting: BEME Guide No. 32

Abstract Background: General practice is increasingly used as a learning environment in undergraduate medical education in the UK. Aim: The aim of this project was to identify, summarise and synthesise research about undergraduate medical education in general practice in the UK. Methods: We systematically identified studies of undergraduate medical education within a general practice setting in the UK from 1990 onwards. All papers were summarised in a descriptive report and categorised into two in-depth syntheses: a quantitative and a qualitative in-depth review. Results: 169 papers were identified, representing research from 26 UK medical schools. The in-depth review of quantitative papers (n = 7) showed that medical students learned clinical skills as well or better in general practice settings. Students receive more teaching, and clerk and examine more patients in the general practice setting than in hospital. Patient satisfaction and enablement are similar whether a student is present or not in a consultation, however, patients experience lower relational empathy. Two main thematic groups emerged from the qualitative in-depth review (n = 10): the interpersonal interactions within the teaching consultation and the socio-cultural spaces of learning which shape these interactions. The GP has a role as a broker of the interactions between patients and students. General practice is a socio-cultural and developmental learning space for students, who need to negotiate the competing cultures between hospital and general practice. Lastly, patients are transient members of the learning community, and their role requires careful facilitation. Conclusions: General practice is as good, if not better, than hospital delivery of teaching of clinical skills. Our meta-ethnography has produced rich understandings of the complex relationships shaping possibilities for student and patient active participation in learning.

Undertaking effective medication reviews

In the General Medical Council-funded PRACtICe study around half the prescribing and monitoring errors identified involved repeat prescriptions. This suggests a need to improve the effectiveness of medication reviews in order to ensure that any errors are detected and corrected. In this article we focus on identifying the elements of an effective medication review; providing examples of medication reviews, and identifying and tackling adherence issues. The article gives the reader opportunities to reflect upon different scenarios, and there are also suggestions for additional continuing professional development activities.

Piloting the use of an interprofessional stroke care learning package created by and for students.

Stroke is a major cause of death in the UK; although stroke mortality rates have fallen by approximately a third since 1970, the prevalence of stroke in England is increasing (Scarborough et al., 2009). To maintain low mortality, an effective stroke service is needed. A key component of efficient stroke care is communication between members of the interprofessional team (Strasser et al., 2005). Improvement in the interprofessional teamwork and communication has been shown to reduce institutionalisation and mortality associated with stroke (Langhorne & Duncan, 2001). Vital for this effective communication is the need for understanding the roles and responsibilities of each member of the team. For this to occur, interprofessional education (IPE) has a clear role. ‘Interprofessional education occurs when two or more professions learn with, from and about each other to improve collaboration and the quality of care’ (CAIPE, 2002). This article outlines the piloting of a learning package and its evaluation. The pilot was delivered by four second year medical students to two groups of six second year health and social care students to improve interprofessional understanding and education. The authors, who were second year medical students, developed the learning package with the aim of approaching IPE from a student’s perspective of the best learning method.

Research into practice: safe prescribing

Over the past 10 years our team has been involved in a wide range of studies of prescribing in general practice, but one we feel that has really made a difference is the PRACtICe study, which was funded by the General Medical Council.1,2 In this study we took a sample of 15 general practices across England and did a retrospective review of the clinical records of a random sample of over 1700 patients, and over 6000 prescription items. Using a definition of error that focused on clinically important problems,1 we found that one in 20 (5%) prescription items was associated with one or more prescribing or monitoring errors, and that one in 550 prescription items contained what we regarded as a severe error1 (with seriously inadequate monitoring of patients taking warfarin the biggest culprit). We found that per prescription item, errors were more common in children and older people, and that nearly half of patients receiving >10 items over the course of a year were the recipients of an error. The commonest types of error related to incomplete information on the prescription, dose-strength errors, and timing-frequency errors. Using interviews, root cause analyses and focus groups, we explored the underlying causes of the errors and, not surprisingly, found them to be multifactorial.2 Of the various underlying causes, we felt that several were amenable to intervention, including improving safety systems in general practices; making best use of our electronic prescribing systems, including computerised clinical decision support; improving prescribing and monitoring at the interface between primary and secondary care, and better training for GPs in therapeutics and safe prescribing (accepting that most GPs already have good therapeutic knowledge and are highly committed to patient safety). We made a number of recommendations from our research and have taken …

Facilitating a Small Group Teaching Session

The small group is one of the more common settings in which you may find yourself teaching. It can take many forms from the breakout group on a vocational training scheme day, to an undergraduate ethics discussion, or a newly diagnosed patient information event. The skill of facilitation has many transferable attributes, including those associated with chairing a meeting. A greater understanding of the role of the facilitator can also help you get the most out of education events that you attend as a user. This article aims to equip you with seven carefully considered tools to enhance your facilitation skills and also discusses ways in which you can actually demonstrate those abilities.

Providing the right dose instructions

The General Medical Council -funded PRACtICe study investigated the prevalence and causes of prescribing errors in general practices. The results showed that around one in three of the prescribing errors detected were associated with incomplete information on the prescription whilst around one in 10 involved giving a medicine at the wrong time. In this article we focus on achieving clear and unambiguous dosing instructions including how clinical computer systems can help to alleviate the problem. We also look at the cautionary and advisory labels added during the dispensing process. The article gives the reader opportunities to reflect upon different scenarios, and there are also suggestions for additional continuing professional development activities.

Providing the right medication monitoring

In order for medication to be prescribed effectively and safely, many medications require monitoring. Medication monitoring may involve blood tests but can also include other monitoring such as blood pressure, weight or electrocardiograms. Monitoring can be required before initiating medication, soon after starting, or regularly over the course of treatment. Ensuring that this monitoring has been undertaken is an important part of medication review involving repeat prescribing. The General Medical Council-funded PRACtICe study looked at prescribing and monitoring errors in primary care. Out of the 302 errors identified, 55 (18%) were monitoring errors. Of those drugs that required blood test monitoring, 7% of prescriptions contained a monitoring error. This article gives the reader opportunities to reflect upon different scenarios that involve medication that requires monitoring decisions and how monitoring could be managed in primary care. There are also suggestions for additional continuing professional development activities.

Selecting the right dose

Around one in six of the prescribing errors detected in the General Medical Council-funded PRACtICe study involved either the wrong dose or the wrong strength of medication. Around one in 10 of the prescribing errors involved giving a medicine at the wrong time. In this article we focus on the factors that need to be taken into consideration when selecting the right dose for an individual patient. We also highlight the importance of selecting the right timing for particular medicines. The article gives the reader opportunities to reflect upon different scenarios, and there are also suggestions for additional continuing professional development activities.

Avoiding hazardous prescribing

Around one in 13 of the prescribing errors detected in the General Medical Council-funded PRACtICe study involved either contraindications or hazardous drug-drug combinations In this article we focus on these issues and also cover the problem of selecting the wrong drug, or drug strength, from computer-based drop-down menus. The article gives the reader opportunities to reflect upon different scenarios involving hazardous prescribing, and there are also suggestions for additional continuing professional development activities.

Selecting the right drug

Around 1 in 10 of the prescribing errors detected in the General Medical Council-funded PRACtICe study involved incorrect drug selection or unnecessary prescriptions. In this article we focus on the principles involved in selecting the right drug for individual patients. We also highlight the usefulness of prescribing formularies and explain when it is appropriate to prescribe generically and when it is necessary to prescribe by brand. The article gives the reader opportunities to reflect upon different scenarios involving prescribing decisions, and there are also suggestions for additional continuing professional development activities.