Teaching Practice Organization in the vocational training of GPs in the Netherlands

1. Teaching Practice Organizationin the vocational training of GPs in the Netherlands April 2014 Fred Dijkers, MD, PhD general practitioner Afdeling Public health en Eerstelijnsgeneeskunde

2. Leiden University Medical Center LUMC Afdeling Public health en Eerstelijnsgeneeskunde

3. Place of the Dutch GP in the healthcare system Dutch GPs are gatekeepers in the Dutch healthcare system. Every Dutchman is inscribed with his or her GP. A fullltime GP has about 2200 patients inscribed. Dutch GPs mostly work together in a practice. Some are also owner of the practice, others work as employee (of an organization or of another GP). Dutch GPs offer a 24/7 service for their patients (during out-of-office hours concentrated in special centres). Afdeling Public health en Eerstelijnsgeneeskunde

4. The healthcare system is not a stable system these days. Care given by the general practice is cheaper than care given in the hospitals. If the quality of the care is equal, then there will be a shift form hospital-care to GP-care. There are more fields in the health care system where comparible shifts can be made. Think of the domains public health, mental health and work-related healthcare. Often this means in GP-practice more (and a new type of) personnel and a greater building. Choices must be made. Afdeling Public health en Eerstelijnsgeneeskunde

5. Practice organization is essential for GPs Known elements of practice organization are: • Practice building • Registration system • Diagnostic equipment • Equipment for treatment • Personnel / staff Afdeling Public health en Eerstelijnsgeneeskunde

6. Practice organization is essential for GPs But practiceorganization is more, e.g. • Cooperation withother care professionals • Patient information • Programs forpatientsafety • Infection prevention • Quality management • Change management , time management • Negotiations • Finances Afdeling Public health en Eerstelijnsgeneeskunde

7. Practice organization has two levels? Thinking of the different aspect of practice organization the field seems to have two levels: • 1. Aspects, relevant for all GPs • 2. Aspects, relevant for practice owners Afdeling Public health en Eerstelijnsgeneeskunde

8. Vocational training of GPs In the Netherlands the vocational training of GPs takes about three years. The trainees have some special stages (emergency care, work in a nursing home), but work most of the time in two different GP practices under supervision of an experienced GP. During their training they come to one of the eight university institutes one day a week for education. Afdeling Public health en Eerstelijnsgeneeskunde

9. Vocational training of GPs On that day the trainees get education and they have discussions in groups of 12 together with two group companions, a GP (mostly not a practice owner) and a psychologist. Practice organization is a part of the education, but the knowledge is not given separately. That would have resulted in an overflow of the teaching program. So practice organization is mostly given, embedded in other subjects. Afdeling Public health en Eerstelijnsgeneeskunde

10. Is this way of teaching succesfull? • No !! During the process: • The groupcompanionshardlyexplainaspects of practiceorganzation in the programms. • They have no experience in this field andit is nottheircore business. Afdeling Public health en Eerstelijnsgeneeskunde

11. Is this way of teaching succesfull? • No !! During the process: • The trainees learntheoretically relevant (new) aspectsof practiceorganization, but theyoften do notrecognizethem in the training practice. So these aspects are forgotteneasily. Afdeling Public health en Eerstelijnsgeneeskunde

12. Is this way of teaching succesfull? • No !! After the process: • New trainedGPs say theyhaven´t had enoughpracticeorganization in theirvocational training. Afdeling Public health en Eerstelijnsgeneeskunde

13. Is this way of teaching succesfull? • No !! After the process: • New trainedGPs say theyhaven´t had enoughpracticeorganization in theirvocational training. • We do notknowwhetherthis is a true or a false statement: most new GPsfunctiongood. But obviouslythey are uncertainaboutthis subject. Afdeling Public health en Eerstelijnsgeneeskunde

14. Change ! Afdeling Public health en Eerstelijnsgeneeskunde

15. Considerations (1) • The GP, working as group companion, is mostly not a practice owner, so he or she misses experience in some fields of practice organization. • Some investigations have been done to measure the interest of trainees in practice organization. This interest is concentrated in the last 6 monthes of their vocational training (and in the two years after settlement). Afdeling Public health en Eerstelijnsgeneeskunde

16. Considerations (2) • The students that want to become a medical doctor are mainly interested in curing patients. If their interest would have been ´management´ then they probably had chosen another study. • Learning of management is easier from projects than just from theory. Afdeling Public health en Eerstelijnsgeneeskunde

17. Considerations (3) • The university institutes are not very interested in practice organization. They love publications. • In the Netherlands a lot of work is done to make general practice an evidence based profession with a lot of international publications. Practice organization is often experience based and strongly related to the healthcare system in a country. That makes it less suitable for international publications. Afdeling Public health en Eerstelijnsgeneeskunde

18. A new start • For the teaching of practice organization in the vocational training of GPs we choose four spearheads: • 1. All trainees do a project in the training practice • 2. Extra attentention to those trainees who are interested • 3. Help training practices optimizing their organization • 4. Teach the group companions in the institute Afdeling Public health en Eerstelijnsgeneeskunde

19. 1. A project in the training practice • All trainees start a project about infection prevention in their first training practice. In the second one they do a small project around quality improvement. • These projects are not easy and they are often not finished in time. But they give insight in this kind of work. The accompaniment in the institute is not optimal yet. Afdeling Public health en Eerstelijnsgeneeskunde

20. 2. Extra attentention for interested trainees • Interested trainees can make a differentiation in their vocational training. They can choose for extra lessons in practice organization during 6 days in the last year of their training. This is organized in Leiden also for three other university institutes. • This differentiation is very popular under trainees. It is a great succes. Afdeling Public health en Eerstelijnsgeneeskunde

21. 3. Improvement of the organization in training practices • The teaching of practice organzation is focussed on the settled GP in the training practice. The training practice is the shop floor for the new GPs. She or he works most of the time in that practice. We offer the settled GP in the training practice a problem-oriented way of learning. In this way the trainee can perceive the new developments in practice organization and can become familiair with them. • This programm was also a great succes.But it is not obligatory for all training practices yet. Afdeling Public health en Eerstelijnsgeneeskunde

22. 4. Teaching and instruction in the institute • The teaching of practice organization is not only focussed on trainees and on training practices, but also on the group companions in the institute. • This is the most difficult job. Because we have to convince the group companions that this knowledge is usefull and necessary. It takes a lot of energy. Afdeling Public health en Eerstelijnsgeneeskunde

23. Instruments • To reach our goals two instruments has been made beside the known teaching programms: • 1. A book • 2. A course to get new teachers Afdeling Public health en Eerstelijnsgeneeskunde

24. Text-book The knowledge of practice organzation, relevant for GPs is written down in an book, written by >40 authors. It contains the most relevant elements of practice organization for GPs and is made in cooperation with the NHG (the scientific organisation of Dutch GPs). The text-book is available in printed form and as e-book. The e-book has deeplinks in the text to internet sites. It also offers several multiple choice questions per chapter and the correct answers (as a test for the right understanding). Afdeling Public health en Eerstelijnsgeneeskunde

25. Text-book practice organization in general practice Afdeling Public health en Eerstelijnsgeneeskunde

26. Teachers • In order to get enough teachers for all the education programms a new course has been started some years ago in Leiden. It is a postacademic course in Practice Organization for settled GPs. This course takes about one day a week during two years. Today we have some 45 graduates. Afdeling Public health en Eerstelijnsgeneeskunde

27. Conclusion • If you want to teach practice organization in the vocational training of GPs then you can not just give theory (lessons and workshops). Probably this combination is a good idea: • Give all trainees projects in this field and offer extra education to the trainees who are interested. • Offer problem-oriented education to settled GPs. • Offer education about practice organization to the group companions in the institute. Afdeling Public health en Eerstelijnsgeneeskunde

28. Does it work? We willsee. Afdeling Public health en Eerstelijnsgeneeskunde

29. The end ? • Do you have questions? • Thanksforyour attention. Afdeling Public health en Eerstelijnsgeneeskunde