An extra year of GP training – what difference does it make?

1. An extra year of GP training – what difference does it make? Eamonn O’Shea Western Training Programme in General Practice Eamonn O'Shea, Western Training Programme in General Practice

2. “To be trained is to arrive – to be educated is to continue to travel” Calman, 1994 Eamonn O'Shea, Western Training Programme in General Practice

3. Background • Vocational training has been shown to be effective • Recent suggestions that traditional 3 year model is too short to produce independent, capable family doctors • Reports of extended programmes show • Increased enthusiasm for GP • Increased confidence in GPR clinical judgement • Makes GPR feel more prepared for independent practice Eamonn O'Shea, Western Training Programme in General Practice

4. Background – the Western GPTP • Embarked on 4th year of training in April 2006 • PLP in third year • Registrars allocated to a different practice • 1 day release per week • 25 % of this spent in group peer learning • Remaining time for private study, research, hospital speciality attachments, pursuit of further educational qualifications • Practice management project/audit Eamonn O'Shea, Western Training Programme in General Practice

5. Aims To compare and contrast the expectations and experiences of 3 distinct groups: • GPs who completed the traditional 3 yr training programme and were interviewed after 1 year of independent practice • GP registrars who were the first entrants into the new extended year of training • GP trainers who were the first trainers involved in the extended year of training Eamonn O'Shea, Western Training Programme in General Practice

6. Methods • Systematic, non-probabilistic sampling • Focus groups • Transcript analysis using an adapted version of grounded theory analysis (Charmaz, 1973)  • Emergent themes Eamonn O'Shea, Western Training Programme in General Practice

7. Eamonn O'Shea, Western Training Programme in General Practice

8. Results - Themes • Support & Protection • Need for standardisation • Preparation for the real world • A new training relationship • Individualised learning Eamonn O'Shea, Western Training Programme in General Practice

9. Support & Protection • 4th year GPR • Valued support received while on TP • Valued protected time • 3 year graduates • Missed regular contact with peers/PD • Those in sessional work had v little support • Those in assistantships were more reluctant to ask questions of a senior partner • ? False sense of security created on TP Eamonn O'Shea, Western Training Programme in General Practice

10. Support & Protection • “There was no one to discuss a case with” FGP1 • “You are afraid to ask stupid questions” MGP1 • “When you are a GP trainee no question is too stupid” MGP2 Reflection on findings Eamonn O'Shea, Western Training Programme in General Practice

11. Need for standardisation • GPR/Graduates • Standardisation of training practices • Difference in expectations of GPR within practices • Need for protected time • Standardisation of financial aspects • Trainers • Ideal practice or “Marks & Spencers” general practice Eamonn O'Shea, Western Training Programme in General Practice

12. Need for standardisation • “You feel then gosh if you had even a small question that you wanted to ask but because of the time constraints then or that you know that you’re already running late and you’ve already got another 2 hours of that, that you avoid going out to ask a question because you know you’re just going to be delaying yourself by another 10 or 15 minutes, I don’t think that’s any good” FR5 • There’s huge discrepancies between practices” FR4 • “I think if you are in a practice where the assistant can keep the money from on call work and you have your membership, I think it is ridiculous to be left in working all weekend and hand over like every penny of it………even if there was some recognition of the fact that you were there on a Saturday or a Sunday” FR4 Eamonn O'Shea, Western Training Programme in General Practice

13. Need for standardisation? • “I don’t think that standardising practices would be such a great idea I think it’s a great idea to see different practices, I wouldn’t mind doing that myself to see what other people do” T2 • “I think maybe once we have a contract, maybe our teaching time and our tutorial time would be fairly standard. I think in terms of the design of a practice and how its run you know we are all different practitioners running different practices and I certainly have over 30 years developed my practice the way I like to do it. And I feel if the trainee likes it that’s great if they don’t like it well you know, I think you have to take into account the trainees ability, their speed of consultation and that should happen at the beginning. But I don’t think we should become the Marks and Spencers of General Practice.” T5 Eamonn O'Shea, Western Training Programme in General Practice

14. Preparation for the real world • 3rd year group – underprepared for IP but concerned that extension delayed becoming independent • 4th year group felt more prepared • Experience of 2 practices • Self directed learning • Different nature of day release • Trainers- mixed views • More mature registrar – more interested in practice management • ? Still unrealistic protected time for learning Eamonn O'Shea, Western Training Programme in General Practice

15. Preparation for the real world • “It was a huge leap – you are suddenly cut off completely” FGP1 • “Well I suppose the contrast of the seeing different ways of how things are managed and how the different principals deal with things. Its more exposure to it, more experience ; you pick up good points and bad points from each one of the trainers. “ FR2 • “Are we giving them the impression with all sorts of protected time to do further courses that this is the reality in general practice with busy careers, family etc?” T2 Eamonn O'Shea, Western Training Programme in General Practice

16. Increased confidence • “For me it was definitely a time that I built up my confidence more than anything else, I am now way more confident than I was and whether that’s a culmination of just time but I think some of that was getting the extra teaching, that bit of protection, a bit of everything, I think the culmination for me is definitely more confidence.” FR4 • “I would say a safer kind of confidence in the sense that the 3rd year I always felt if you had 3rd year trainees who were supremely confident and had no right to be so and you had also trainees who felt themselves very inadequate and lacked real confidence and there was no problem with them. I think the 4th years have a better idea of where they are at and what they can do. I think they are probably, their confidence more fits where they are at.” T5 Eamonn O'Shea, Western Training Programme in General Practice

17. A new training relationship • Trainers • More mature outlook • More mature interaction • A greater challenge as registrars have prior training • 4th Year Registrars • Tutorials less structured • Less focus on exams/assessment • Generally training received very worthwhile Eamonn O'Shea, Western Training Programme in General Practice

18. A new training relationship • “It is not really teaching anymore it is an exchange of ideas” T4 • “It’s nice to have somebody who’s mature and enthusiastic. My trainee certainly matured during that year and I encouraged him to adopt ownership of patients of responsibility and decision making and I felt I learnt from him” T8 • “I think definitely trying to think how I am going to fill up all these tutorials. Because I feel you know the thunder is being stolen a bit by the 3rd year trainers. And you are trying to figure out, having said that I thought there was more motivation to learn about the nuts and bolts of a practice, you know.” T4 • “Yeah I think the trainers found it a bit strange, they didn’t know what they were meant to be talking to us about in tutorials MR2 Eamonn O'Shea, Western Training Programme in General Practice

19. Tension between trainers and registrars •  “Sometimes I think they take us a bit for granted” FR1 • “Because it strikes me in talking to the group of trainees that you know their expectations are very high but they do not realise that we are doing this virtually free-gratis. And that their demands of the practice you know what they expect from us in return for what we are getting, you know, they are poles apart. “ T6 Eamonn O'Shea, Western Training Programme in General Practice

20. Customised learning • 4th Year Registrars • Valued protected time • Valued the programme being centred on their needs • Trainers • Felt the continuity of care was disrupted • Felt this could create unrealistic expectations of learning opportunities in general practice Eamonn O'Shea, Western Training Programme in General Practice

21. Customised learning • “Its good that we have choice, to decide what to do ourselves for the fourth year; that was definitely a positive thing about it.” FR4 • “I think it’s funny in hindsight, when we started off I don’t think I was entirely happy about it and now I have to say I think it was a fantastic opportunity. I really, really enjoyed it and it definitely gives you, it kind of focuses you a bit more, makes you concentrate on doing other stuff that you mightn’t have been necessarily able to do or that you mightn’t be inclined to do if you were under pressure going out on your own and looking for a job.” FR2  Eamonn O'Shea, Western Training Programme in General Practice

22. Customised learning • “Unfortunately, the emphasis seems to be on more exams and courses rather than “face to face with patients building up flying hours” T1 • “It is everything but general practice” T7 • “There was a feeling that we talked about that general practice is going to get eaten into, that’s exactly what has happened, they have contributed less time to general practice than we thought they should have.” T3 Eamonn O'Shea, Western Training Programme in General Practice

23. A Gender Difference? • “You know I mean I had somebody tell me that because I was just married that I was a time bomb and nobody would employ me now. You know they shouldn’t be allowed to get away with that in this day and age do you know what I mean.” FGP2 • “Then I really found as a woman it was discrimination against women, women were offered the sessional stuff” FGP1 Eamonn O'Shea, Western Training Programme in General Practice

24. Gender difference? • “I have yet to meet a trainee who has any ambition other than to be a sessional doctor.” T1 • “All female are they?” T8 • “Yeah, yeah, and that is it, we can’t teach them to be sessional doctors“ T1 • “Now going back on the point, I’ve had 2 female doctors who really wanted to go into general practice, one did actually, she was very focused. I never got the feeling she was going to be a sessional doctor. We had another girl who was focused on getting a partnership, knew what she wanted to do, so I don’t think its fair to generalise but I would, you know, that’s my personal experience, the last 2 or 3 female GP trainees have been very focused and wanted general practice as a career, a full time career.” T3 Eamonn O'Shea, Western Training Programme in General Practice

25. Discussion – Key findings • Registrars felt better prepared for the “real world of independent practice • ^ confidence • Experience of working in different practices • ^ knowledge of practice management • Career guidance received during extended year • A new training relationship is emerging: mentor > trainer Eamonn O'Shea, Western Training Programme in General Practice

26. Discussion – Key findings • Customised design of year provides an easier transition to independent practice but trainers concerned that it may create unrealistic expectations • Dissonance between trainers and registrars • Customised learning • Standardisation • Outlook • Expectations Eamonn O'Shea, Western Training Programme in General Practice

27. Discussion - Limitations • Small number of groups and participants • Limited to our geographical area • Limitations of focus group approach • Personal bias Eamonn O'Shea, Western Training Programme in General Practice

28. Future Research • Follow up of fourth year group to see if their apparent confidence was sustained • Joint focus groups between trainers and registrars to allow for exchange of views and development of their relationship • Inclusion of other stakeholders in the research: programme directors, patients, other GPs and ancillary staff in training practices. Eamonn O'Shea, Western Training Programme in General Practice

29. Acknowledgements • Focus group participants • Dr Gennie McGuire and colleagues • Ms Pauline Clerkin • Prof Andrew Murphy • Dr Anne McFarlane • Dr Liam Glynn • Dr Peter Cantillon Eamonn O'Shea, Western Training Programme in General Practice