Sophie Park

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.

Working with words:Exploring textual analysis in medical education research

Medical Education 2012: 46: 372–380

Caring for quality of care: symbolic violence and the bureaucracies of audit.

BackgroundThis article considers the moral notion of care in the context of Quality of Care discourses. Whilst care has clear normative implications for the delivery of health care it is less clear how Quality of Care, something that is centrally involved in the governance of UK health care, relates to practice.DiscussionThis paper presents a social and ethical analysis of Quality of Care in the light of the moral notion of care and Bourdieu’s conception of symbolic violence. We argue that Quality of Care bureaucracies show significant potential for symbolic violence or the domination of practice and health care professionals. This generates problematic, and unintended, consequences that can displace the goals of practice.SummaryQuality of Care bureaucracies may have unintended consequences for the practice of health care. Consistent with feminist conceptions of care, Quality of Care ‘audits’ should be reconfigured so as to offer a more nuanced and responsive form of evaluation.

Confronting the quality paradox: towards new characterisations of 'quality' in contemporary healthcare.

This editorial introduces the special Biomed Central cross-journal collection The Many Meanings of ‘Quality’ in Healthcare: Interdisciplinary Perspectives, setting out the context for the development of the collection, and presenting brief summaries of all the included papers in three broad themes 1) the practices of assuring quality in healthcare 2) giving ‘space to the story’ 3) addressing moral complexity in the clinic, the classroom and the academy. The editorial concludes with reflections on some of the key messages that emerge from the papers which are relevant to policymakers and practitioners who seek to improve the quality of healthcare.

Reconsidering ‘ethics’ and ‘quality’ in healthcare research: the case for an iterative ethical paradigm

BackgroundUK-based research conducted within a healthcare setting generally requires approval from the National Research Ethics Service. Research ethics committees are required to assess a vast range of proposals, differing in both their topic and methodology. We argue the methodological benchmarks with which research ethics committees are generally familiar and which form the basis of assessments of quality do not fit with the aims and objectives of many forms of qualitative inquiry and their more iterative goals of describing social processes/mechanisms and making visible the complexities of social practices. We review current debates in the literature related to ethical review and social research, and illustrate the importance of re-visiting the notion of ethics in healthcare research.DiscussionWe present an analysis of two contrasting paradigms of ethics. We argue that the first of these is characteristic of the ways that NHS ethics boards currently tend to operate, and the second is an alternative paradigm, that we have labelled the ‘iterative’ paradigm, which draws explicitly on methodological issues in qualitative research to produce an alternative vision of ethics. We suggest that there is an urgent need to re-think the ways that ethical issues are conceptualised in NHS ethical procedures. In particular, we argue that embedded in the current paradigm is a restricted notion of ‘quality’, which frames how ethics are developed and worked through. Specific, pre-defined outcome measures are generally seen as the traditional marker of quality, which means that research questions that focus on processes rather than on ‘outcomes’ may be regarded as problematic. We show that the alternative ‘iterative’ paradigm offers a useful starting point for moving beyond these limited views.SummaryWe conclude that a ‘one size fits all’ standardisation of ethical procedures and approach to ethical review acts against the production of knowledge about healthcare and dramatically restricts what can be known about the social practices and conditions of healthcare. Our central argument is that assessment of ethical implications is important, but that the current paradigm does not facilitate an adequate understanding of the very issues it aims to invigilate.

The missing self: competence, the person and Foucault

Any conversation about the use of meta-analytic techniques in judging sufficiency should also consider the challenges of interpreting cumulative findings from quasi-experimental education studies. A non-randomised study may suffer from serious confounding, such as selection bias, which accounts for the findings more convincingly than the nominal intervention. Moreover, a study that starts out randomised may become confounded by participant attrition. Given the difficulties inherent in conducting medical education research, a narrative review should probably always accompany a meta-analysis, and should play an important role in the drawing of conclusions from the results.

Educational Research in Primary Care: addressing the challenges through creation of a Special Interest Group and a Doctoral Student Network.

Two new groups within the Society of Academic Primary Care (SAPC) seek to respond to the challenges of providing high-quality collaborative research in primary care education. Here, we introduce the Special Interest Group in Educational Research (SIGER) along with the new Doctoral Student Network and consider their contribution to promoting the SAPC goal of research and teaching excellence within primary care in the United Kingdom.

‘Divided we fail’: understanding inter-relations and the role of the generalist

The Harveian Oration, an annual event at the Royal College of Physicians (RCP), was established by William Harvey in 1656. In October 2011, Iona Heath, President of the Royal College of General Practitioners, was invited to speak — the second GP ever to do so in over 350 years. We reflect here upon some of the important issues discussed within this oration, but also urge the reader to seek out and enjoy the original and inspiring text. At its centre is her invitation to expand our repertoire of care and kindness towards patients. Harvey determined the oration should be delivered on the Feast Day of St Luke’s (patron saint of the physician). Iona pays tribute to the relevance of St Luke’s gospel as a source of miracles and parables concerning healing, kindness, and concern for the poor: an approach this piece itself replicates. In her Oration ‘ Divided we fail ’ Iona draws upon experience, literature, and research, including her 35 years of clinical practice.1 She uses a multifaceted lens to examine the professional work of doctors through a series of dyads. These include the central dyad of medical practice: doctor–patient; the key dyad of the NHS: generalist–specialist; and the Cartesian split of mind–body. These dyads also extend within her text to illness–disease; subject–object; life–death; technis–praxis; and collaboration–competition. Why dyads? Viewing the world as ‘divided’ facilitates our understanding of relationships. This may invoke ideas of synergy, balance or harmony between component parts: ‘But let there be spaces in your togetherness, And let the winds of the heavens dance between you. … And stand together yet not too near together: For the pillars of the temple stand apart, And the oak tree and the cypress grow not in each other’s shadow.’ Kahil Gibran On Marriage (1923). However, Iona also uses …

Evidence synthesis software

It can be challenging to decide which evidence synthesis software to choose when doing a systematic review. This article discusses some of the important questions to consider in relation to the chosen method and synthesis approach. Software can support researchers in a range of ways. Here, a range of review conditions and software solutions. For example, facilitating contemporaneous collaboration across time and geographical space; in-built bias assessment tools; and line-by-line coding for qualitative textual analysis. EPPI-Reviewer is a review software for research synthesis managed by the EPPI-centre, UCL Institute of Education. EPPI-Reviewer has text mining automation technologies. Version 5 supports data sharing and re-use across the systematic review community. Open source software will soon be released. EPPI-Centre will continue to offer the software as a cloud-based service. The software is offered via a subscription with a one-month (extendible) trial available and volume discounts for ‘site licences’. It is free to use for Cochrane and Campbell reviews. The next EPPI-Reviewer version is being built in collaboration with National Institute for Health and Care Excellence using ‘surveillance’ of newly published research to support ‘living’ iterative reviews. This is achieved using a combination of machine learning and traditional information retrieval technologies to identify the type of research each new publication describes and determine its relevance for a particular review, domain or guideline. While the amount of available knowledge and research is constantly increasing, the ways in which software can support the focus and relevance of data identification are also developing fast. Software advances are maximising the opportunities for the production of relevant and timely reviews.

Exploring provision of Innovative Community Education Placements (ICEPs) for junior doctors in training: a qualitative study

Objective Medical education in community settings is an essential ingredient of doctors’ training and a key factor in recruiting general practitioners (GP). Health Education Englands report ‘Broadening the Foundation’ recommends foundation doctors complete 4-month community placements. While Foundation GP schemes exist; other community settings, are not yet used for postgraduate training. The objective of this study was to explore how community-based training of junior doctors might be expanded into possible ‘innovative community education placements’ (ICEPs), examining opportunities and barriers to these developments. Design A qualitative study where semistructured interviews were undertaken and themes were generated deductively from the research questions, and iteratively from transcripts. Setting UK community healthcare. Participants Stakeholders from UK Community healthcare providers and undergraduate GP and community educators. Results Nine participants were interviewed; those experienced in delivering community-based undergraduate education, and others working in community settings that had not previously trained doctors. Themes identified were practicalities such as ‘finance and governance’, ‘communication and interaction’, ‘delivery of training’ and ‘perceptions of community’. ICEPs were willing to train Foundation doctors. However, concerns were raised that large numbers and inadequate resources could undermine the quality of educational opportunities, and even cause reputational damage. Organisation was seen as a challenge, which might be best met by placing some responsibility with trainees to manage their placements. ICEP providers agreed that defined service contribution by trainees was required to make placements sustainable, and enhance learning. ICEPs stated the need for positive articulation of the learning value of placements to learners and stakeholders. Conclusions This study highlighted the opportunities for foundation doctors to gain specialist and generalist knowledge in ICEPs from diverse clinical teams and patients. We recommend in conclusion ways of dealing with some of the perceived barriers to training.