Samantha Scallan

GP workload: time for a rethink of the generalist model of care to promote retention

Much has been written in recent months about the ‘crisis’ in general practice; a crisis that has been linked to difficulties in recruiting to and retaining the workforce, changing working patterns, increasing care demands, and bureaucracy in the system of care. The debate has rippled through the press,1,2 been the subject of discussion at conferences and in the pages of journals,3 as well as prompting a number of reviews.4–6 While rarely out of the headlines or journals, it would seem that there is more ‘heat than light’ in identifying a way forward. This lack of clarity prompted us to seek the experiences of GPs and their views of working in general practice today, and to ask them to look ahead to the future. This article is based on an analysis of data gathered in Wessex by a survey of GPs ( n = 1445) and interview of a purposive ‘key informant’ sample of seven,7 reflecting different ages, career stages, and role types. The latter were recruited by invitation through local GP and practice networks, and those participating consented to undertake semi-structured telephone interviews. Both datasets were thematically analysed, and a fuller description of this work can be found elsewhere.8 A recent article in BJGP by Abbt and Alderson3 argues ‘It’s not workload’ , however the views expressed by our informants would challenge this. They described today’s general practice working environment as being very different to that of some 20 or 30 years ago. The lack of a well-defined career structure, alongside other influences, was seen as being a significant factor in GPs no longer seeking to be partners, especially those in the early stages of a career. This seems to have arisen as a result of the extended responsibilities that come …

Clinicians with dyslexia: a systematic review of effects and strategies

For educators, an awareness of the impact of dyslexia on learners in the clinical workplace is vital: first, to be able to identify whether dyslexia may underlie certain traits and behaviours; and second, to be able to provide appropriate advice and support when dyslexia is identified. We reviewed the primary research evidence concerning the effects of dyslexia on clinicians (in or after training) in the workplace, and adaptive strategies (‘workarounds’) that are presently in use.

Medical appraisal and revalidation: can it improve patient care?

Revalidation for all doctors in England, following the process defined in the Medical Appraisal Guide,1 finally started in December 2012 after ten years’ experience of developmental appraisal in the NHS. There has been significant debate about preserving the formative nature of the appraisal conversation in the context of the recent need for the appraiser to make explicit some of their professional judgements within the appraisal meeting.2 These include judgements which evaluate the portfolio of supporting information and whether it shows that the doctor is ‘on track’ to revalidate; deciding whether there are any emerging patient safety issues or performance concerns; and assessing whether the doctor has engaged appropriately in the appraisal process in reviewing his or her full scope of work.3 Appraisers need to gain ‘a rounded impression’4 of the doctor being appraised in order to agree a personal development plan (PDP) and to judge progress towards revalidation. As Wakeling and Cameron5 recognise, the appraiser and his or her skills ‘will become even more pivotal in “enhanced” appraisal’, or what is now referred to as ‘medical appraisal for revalidation’. Up to now the issues surrounding medical appraisal for revalidation have largely been considered from the perspective of the doctor being appraised, engagement in the process and the evidence presented, with little account being taken of the role of the appraiser, who now has to manage both formative and summative aspects.5 Lyons6 has argued that, in spite of concerns such as those found by Wakeling and Cameron,5 appraisers have not experienced role conflict to the extent predicted by the debates, though there is a lack of research into how appraisers balance these opposing demands. Thus, it may be argued, the spotlight is moving from engagement to practice, illuminating the knowledge and skills required by appraisers to manage the different elements of medical appraisal for revalidation. This next chapter is set within a broader agenda of the quality assurance of appraisal services. Ultimately, under the umbrella of revalidation, practice across health sectors needs to be bench-marked by those delivering it. This is to ensure that all doctors revalidate to the same standards, as it is acknowledged that currently appraisal systems are variable.7 This shifting agenda is already evident and strands of work are emerging which describe the development of advanced appraiser skills;8–12 make explicit the knowledge and skills required for the role13,14 and formally recognise them.15 Other work facilitates bench-marking through the development of quality assurance tools;16–18 and demonstrate cross-sector working, for instance in training appraisers.19 In the light of this shift in focus towards practice and process, we argue that there needs to be a similar shift in research and development activity concerning appraisal. Up to now research concerning the benefits of appraisal is sparse and generally based upon self-reported perceptions of change by doctors being appraised.20 One of the key aims of appraisal for revalidation is the promotion of quality improvements in patient care through the professional development of doctors.1 Although the benefits of appraisal for doctors are recognised, demonstrating that it drives improvements in patient care is difficult. Hitherto the focus of research has been on the individual doctor, with change being defined in the context of the individual’s practice. There is a pressing need to look at the outcomes of appraisal not only from the individual’s perspective, but also in terms of the wider context of a practice, locality and the healthcare system: ‘[W]e owe it to patients and all other stakeholders to demonstrate that a process that impinges on time devoted

The benefits of appraisal: a critical (re)view of the literature

Abstract It has been acknowledged that little is known about the impact of general practice (GP) appraisal on clinical and professional practice, as may be demonstrated by identifiable or ‘hard’ outcomes, and further, that the way in which appraisal informs professional development is unclear. In spite of this acknowledgement and the existence of a substantial number of studies about GP appraisal, to date an overview of the field of enquiry which maps what is known, has been lacking. In this leading article we present the first extensive thematic narrative synthesis of the literature on appraisal. In it we highlight the issues and tensions around research into appraisal, based on what we found (or didn’t find) in our review. Key conclusions concern the focus of existing research – which has tended to report the perceptions of change from individual appraisees, rather than specific examples of change captured from other sources and perspectives – and the scope of research – which has been limited to certain data collection methods. Based upon our review, we draw out implications for research and researchers in the future.

Procedures and processes of accreditation for GP trainers: similarities and differences

A survey of all UK deaneries was carried out to identify the processes and procedures associated with the approval of GP clinical and educational supervisors and to document the current similarities and difference between deaneries. The results of the survey were placed in the context of recent literature. Results showed notable variation in some areas as well as relatively recent developments becoming established practice, such as the requirement for a certificate of medical education. Overall, results indicate a time of transition and the potential for practice to be aligned across deaneries and local education and training boards (LETBs).

High fidelity trainee simulation to improve trainer performance

Background:  Using trained actors to simulate trainee doctors in difficulty is a cost‐effective communication skills teaching tool that can be enhanced by techniques that are familiar to hi‐fidelity electronic simulation. Simulation has two broad strands: the first exchanges the patient for an actor in the clinical encounter, and the second introduces some form of technology to the encounter. The strand concerning actors is well developed, and generally focuses on ‘the consultation’. Where simulation draws on technology, the spectrum is broad: it may be relatively low‐tech, for example computer‐based scenarios to test prescribing, through to more high‐tech approaches to learning practical skills using sophisticated manikins that replicate patient signs and symptoms. Over the years simulation has radically changed medical training, and is set to continue to do so in the future.

The application process for general practitioner trainers in United Kingdom deaneries: similarities and differences.

A survey was undertaken of the application and reapplication forms used by all the UK deaneries for general practice (GP) specialty training. The aim of the survey was to identify similarities and differences between deaneries in terms of the content and nature of the information requested, and the relationship of that information to the Postgraduate Medical Education and Training Boards (PMETB) Quality Assurance Framework (QAF). The details requested on the application forms were compared to the guidance set out in Generic Standards for Training, in order to see if they reflected the areas and standards required by the PMETB for the quality assurance of medical education and training. Although many similar areas of information were requested in the application process, great variation was found across some items which were not attributable to regional or contextual differences. The survey also found that the majority of domains of Generic Standards for Training are not well covered in the paper application process. Although deaneries may view their application processes for trainer approval as robust, this paper makes a number of recommendations and argues for the development of a standardised form for the appointment of general practice specialty training (GPST) trainers across the UK, based upon the PMETB QAF.

A comparison of the learning experiences of full-time (FT) trainees and less than full-time (LTFT) trainees in general practice.

The paper describes a small-scale enquiry amongst GP specialty trainees that aimed to identify the educational experiences and perceptions of trainees training less than full-time (LTFT). The study found several significant challenges facing these trainees, as well as positive aspects of training LTFT. The work has led to the development of a peer-mentoring scheme in Dorset and monthly meetings of an LTFT group to improve support for these trainees.

Doctors with dyslexia: strategies and support.

Looking beyond dyslexia as an individual doctors issue requires adjusting a working environment to better serve the needs of doctors with dyslexia. With an increasing number of doctors disclosing dyslexia at medical school, how can educators best provide this support? Our research looks at the impact of dyslexia on clinical practice and the coping strategies used by doctors to minimise the effect.

How can educators support general practice (GP) trainees to develop resilience to prevent burnout

Abstract Context: Burnout impacts adversely on professional and personal life, and holds implications for patient care. Current research on burnout mainly focuses on established general practitioners but it is unclear how early the signs of burnout really start. This work seeks to identify whether specific GP trainee groups are particularly at risk of burnout and the aspects of training they find stressful. Methods: A longitudinal cohort study, collecting qualitative and quantitative data through a single mode of data collection (questionnaire) took place with trainees from all GP training years (ST1–3), across a vocational training scheme (n = 48). Data gathered included the Oldenburg Burnout Inventory (OLBI). Results: Higher than anticipated levels of burnout were displayed by all trainees. A sub-group self reporting higher levels of burnout comprised all-female, UK-trained-at-undergraduate GP trainees, with a partner but no children. Top reported stressors included knowledge/uncertainty, workload/time pressures and ePortfolio. Less than 50% of trainees perceived their burnout levels to be as high as their OLBI showing potential lack of insight. Conclusions: This research demonstrates that high levels of burnout are experienced in GP trainees as early as the first year of training. Early identification of burnout amongst trainees is essential by GP educators to help protect the future GP workforce.