Joint undergraduate and postgraduate teaching in general practice: a case study of the continuum of medical education in practice

Background: Despite a large body of literature on teaching in general practice, the majority of this focuses on a single learner level. The Australian literature frequently refers to the concept of Vertical Integration (Dick et al., 2007), while UK policy refers to “a continuum approach”, yet no formal definition of the latter exists. Purpose: This is an exploratory study of the reality of the continuum of medical education as it occurs in the context of general practice (family medicine) in the West of Scotland. Through a better understanding of the reality, this study aimed to contextualise the rhetoric through the following research questions: 1. How does Activity Theory enable us to understand the activity of teaching in GP practices with multilevel learners? 2. What are the tensions experienced by GPs in multilevel learner practices in relation to their teaching? 3. How have these tensions shaped the activity of teaching in multilevel learner GP practices? 4. How does Activity Theory enable understanding of continuum of medical education in GP practices with multilevel learners? Methodology A collective case study approach was used to address the research questions and this comprised of two phases: an online questionnaire of 180 GP teachers (response rate 60%) and 17 semi-structured interviews. A combination of Activity Systems Analysis (ASA) and Thematic Analysis was used for interview analysis. Results: Five themes were identified in the interviews: 1. General practice in 2017 – The current context of workload pressures and recruitment problems in general practice impacted teaching at every level of the continuum of medical education. Recruitment to general practice was shown to be a bidirectional continuum problem. 2. External relationships - Working with at least two external organisations presented challenges for GPs. Different expectations, processes and communication channels all added to the complexity and volume of work for GP teachers in multilevel learner practices. 3. The joint teaching practice – Common facilitating factors for teaching across the continuum were a practice teaching culture and good organisation of teaching. The impact on GPs and their practices of the tension between teaching and service delivery was described and strategies to minimise this identified. 4. GP as a Teacher – The teaching, organisational and assessment tools which support teaching delivery in multilevel learner practices were highlighted. The motivators for teaching across the continuum were identified while the stress of multilevel teaching was demonstrated. 5. Near peer teaching (NPT) - In contrast to some areas, NPT in the practices in this study was relatively underdeveloped. The uncertainty related to this is described and the local and external barriers to further development of NPT presented. Discussion The use of a sociocultural approach to study the continuum of medical education enabled the importance of the current context of general practice to be appreciated and facilitated identification of key teaching-related tensions and the learning possible from these. Through the use of ASA, this study conceptualised the current GP recruitment crisis as a bidirectional challenge spanning across the continuum of medical education. Identifying relevant tensions within the systems (e.g. the expanding practice team as both a teaching opportunity and a threat) enables innovative practice and learning to be identified. While a structural continuum existed, the practices in this study did not fit with the Australian definition of Vertical Integration. This study suggested that this lack of a continuum approach originates in the separate organisational structures for postgraduate and undergraduate education. For meaningful widespread adoption of a continuum approach, these organisational tensions would need to be addressed. Conclusions: This study demonstrated a gap between the rhetoric of “a continuum approach” and the reality of “a continuum”, provided evidence why that might be and presents suggestions as to how that might start to be addressed more widely

Girls in scrubs:An ethnographic exploration of the clinical learning environment

BACKGROUND: Gender bias is an enduring issue in the medical profession despite women being more represented within medical schools and the health care workforce in numerous countries across the world. There have been frequent calls for further exploration of gender-based discriminations within medical education, owing to its lasting impact on student's professional development and career trajectories. This paper presents an ethnographic exploration of the experiences of female medical students and doctors in the clinical learning environment (CLE), aiming to disrupt the cycle of gender inequity in the clinical workplace.METHODS: Our research field involved two teaching wards in a Scottish urban hospital, where 120 h of non-participant observations were conducted over 10 months. Combining purposive and convenience sampling, we conducted 36 individual interviews with key informants, which included medical students, foundation doctors, postgraduate trainees, consultant supervisors, and other health care professionals such as nurses and pharmacists. Data was thematically analysed using Bourdieu's theory of social power reproduction. The research team brought diverse professional backgrounds and perspectives to the exploration of data on gendered encounters.RESULTS: Combining the observational and interview data, five themes were generated, which suggested gender-related differentials in social and cultural capital that the participants acquired in the CLE. Experiences of discriminatory behaviour and stereotypical thought processes impacted the female students' engagement and drive towards learning, implying an adverse influence on habitus. In contrast, the valuable influence of gendered role-models in building confidence and self-efficacy signified a positive transformation of habitus. The research participants displayed considerable internalisation of the gendered processes in the CLE that appeared to be linked to the transient nature of clinical placements.CONCLUSIONS: This research reveals that despite constituting the majority demographic of medical school, female students struggle to gain social and cultural capital. Gendered hierarchies that structure clinical workplaces disadvantage female students and doctors, and the differential experiences transform their habitus. Based on our theoretically informed investigation, we advocate for role-models given their positive impact on students' and doctors' habitus. Additionally, medical educators may consider extended clinical placements that provide opportunities for female students and early-career doctors to secure social and cultural capital through integrating better in health care teams and building meaningful interprofessional relationships.</p

Girls in scrubs:An ethnographic exploration of the clinical learning environment

BACKGROUND: Gender bias is an enduring issue in the medical profession despite women being more represented within medical schools and the health care workforce in numerous countries across the world. There have been frequent calls for further exploration of gender-based discriminations within medical education, owing to its lasting impact on student's professional development and career trajectories. This paper presents an ethnographic exploration of the experiences of female medical students and doctors in the clinical learning environment (CLE), aiming to disrupt the cycle of gender inequity in the clinical workplace.METHODS: Our research field involved two teaching wards in a Scottish urban hospital, where 120 h of non-participant observations were conducted over 10 months. Combining purposive and convenience sampling, we conducted 36 individual interviews with key informants, which included medical students, foundation doctors, postgraduate trainees, consultant supervisors, and other health care professionals such as nurses and pharmacists. Data was thematically analysed using Bourdieu's theory of social power reproduction. The research team brought diverse professional backgrounds and perspectives to the exploration of data on gendered encounters.RESULTS: Combining the observational and interview data, five themes were generated, which suggested gender-related differentials in social and cultural capital that the participants acquired in the CLE. Experiences of discriminatory behaviour and stereotypical thought processes impacted the female students' engagement and drive towards learning, implying an adverse influence on habitus. In contrast, the valuable influence of gendered role-models in building confidence and self-efficacy signified a positive transformation of habitus. The research participants displayed considerable internalisation of the gendered processes in the CLE that appeared to be linked to the transient nature of clinical placements.CONCLUSIONS: This research reveals that despite constituting the majority demographic of medical school, female students struggle to gain social and cultural capital. Gendered hierarchies that structure clinical workplaces disadvantage female students and doctors, and the differential experiences transform their habitus. Based on our theoretically informed investigation, we advocate for role-models given their positive impact on students' and doctors' habitus. Additionally, medical educators may consider extended clinical placements that provide opportunities for female students and early-career doctors to secure social and cultural capital through integrating better in health care teams and building meaningful interprofessional relationships.</p

Developing a career as a GP educationalist: contemporary challenges and workforce solutions

GP educationalists are crucial in training the future medical workforce and in developing and advancing the field of primary care medical education, yet opportunities in the UK are patchy and varied. In this article, a group of GP educationalists summarise the challenges facing the sustainability of this particular group of clinical academics and outline opportunities available at each career stage, from medical students through to senior GP educationalists. Recommendations to support the growth of this workforce include the development of a nationally recognised framework for GP educationalist careers, collaboration with professional and educational bodies and taking steps to level out opportunities in order to reduce existing inequity

Reflections on the integration of virtual GP tutorials to the medical undergraduate curriculum at Glasgow

Virtual tutorials were introduced into the Year 3 medical undergraduate curriculum at Glasgow in 2020/21. This model of teaching proved highly successful from tutor and student perspective. A hybrid teaching model, comprising virtual tutorial teaching alongside placement time will be implemented this year. Virtual (videoed) GP patient cases are selected for tutorials each week, linked to other curriculum content in Year 3. Pedagogically, this aligns pathological and clinical learning for our students and enables some consistency of taught GP content. Concomitant clinical placement time complements this learning with actual patient cases. Communication and consultation techniques considered in the virtual tutorials with facilitated tutor discussion are practised on GP placement days, encapsulating the essence of experiential learning. Challenging or unusual patient cases can be selected for teaching from the virtual case repertoire. This provides uniform exposure to clinically important aspects of general practice, and simultaneously enables an increased diversity of patient cases for our students. Logistical advantages of virtual tutorial delivery include its appeal to a different demographic of GP tutor, enabling us to diversify and expand our teaching team. Remote tutorial delivery offers a futureproof adjunct to the traditional practice-based GP teaching models

Knowing me, Knowing you: Evaluation of the impact of trainer involvement at an enhanced induction programme for International Medical Graduates (IMGs)

Addressing differential attainment between International Medical Graduates (IMGs) and their peers who hold UK Primary Medical Qualifications remains one of the most significant challenges facing postgraduate General Practice (GP) training. Enhanced Induction programme, such as the Scottish Trainee Enhanced Programme (STEP), is one tool designed to try and facilitate transition into training and reduce this inequity. The STEP course is attended by both the trainee and their educational supervisor, and aims to lay the foundations of a successful and supportive supervisory relationship. Previous work has evaluated this programme from the perspective of the trainee. Through the use semi-structured interviews, we evaluated the impact and the benefits of the programme from the perspective of the educational supervisors, building on the literature on interventions to support inequity in medical education

Foundation Year 2 doctors’ reasons for leaving UK medicine : an in-depth analysis of decision-making using semistructured interviews

This work was funded by a Scottish Medical Education Research Consortium grant.Objectives:  To explore the reasons that doctors choose to leave UK medicine after their foundation year two posts. Setting : All four regions of Scotland. Participants:  Foundation year two doctors (F2s) working throughout Scotland who were considering leaving UK medicine after foundation training were recruited on a volunteer basis. Maximum variation between participants was sought. Primary and secondary outcome measures:  Semistructured interviews were coded using template analysis. Six perspectives, described by Feldman and Ng, were used as the initial coding template. The codes were then configured to form a framework that explores the interplay of factors influencing Foundation Year 2 (F2) doctors’ decisions to leave UK medicine. Results:  Seventeen participants were interviewed. Six perspectives were explored. Structural influences (countrywide and worldwide issues) included visas, economic and political considerations, structure of healthcare systems and availability of junior doctor jobs worldwide. Organisational influences (the National Health Service (NHS) and other healthcare providers) included staffing and compensation policies, the working environment and the learning environment. Occupational influences (specific to being a junior doctor) comprised the junior doctor contract, role and workload, pursuit of career interests and the structure of training. Work group influences (relationships with colleagues) included support at work, task interdependence and use of locums. Personal life influences consisted of work-life balance, and support in resolving work-life conflict. The underlying theme of ‘taking a break’ recurred through multiple narratives. Conclusions:  F2s give reasons similar to those given by any professional considering a change in their job. However, working within the NHS as an F2 doctor brought specific challenges, such as a need to make a choice of specialty within the F2 year, exposure to workplace bullying and difficulties in raising concerns. Despite these challenges, most F2s did not view their decision to leave as a permanent job change, but as a temporary break from their current working lives.Publisher PDFPeer reviewe

Cultural diversity and inclusion in UK medical schools

Background: Racially minoritised groups across the globe continue to experience differential outcomes in both health and education. Medical schools can play an instrumental role in addressing both these disparities, by creating inclusive student communities and ensuring that tomorrow's doctors can care for our increasingly diverse populations. Objectives: This collaborative, qualitative study led by three United Kingdom (UK) institutions aimed to explore the perspectives of Heads of Primary Care Teaching (HOTs) on cultural diversity and inclusion across UK medical schools. Methods: In December 2020, five focus groups were conducted remotely with 23 HOTs, or a nominated deputy. We explored participants' opinions regarding opportunities and barriers to cultural diversity and inclusion in medical education, ways to overcome these challenges and shared examples of best practice. Data were transcribed verbatim and thematically analysed by three researchers. Results: Investigators identified six themes from the data: lack of faculty diversity, tokenistic faculty training, institutional mindset, diversifying the formal and hidden curricula, intersectionality and student voice. Conclusion: Medical schools worldwide face similar challenges, uncertainties and opportunities when integrating diversity and inclusion throughout the learning environment. Although the importance of the topic is increasingly acknowledged, current efforts are viewed as being passive and tokenistic, hindered by challenges at multiple levels. Partnership with students and collaboration within and between institutions nationally and internationally will enable us to move forwards with both local and global positive, sustainable change

Foundation Year 2 doctors' reasons for leaving UK medicine:an in-depth analysis of decision-making using semistructured interviews

Objectives To explore the reasons that doctors choose to leave UK medicine after their foundation year two posts. Setting All four regions of Scotland. Participants Foundation year two doctors (F2s) working throughout Scotland who were considering leaving UK medicine after foundation training were recruited on a volunteer basis. Maximum variation between participants was sought. Primary and secondary outcome measures Semistructured interviews were coded using template analysis. Six perspectives, described by Feldman and Ng, were used as the initial coding template. The codes were then configured to form a framework that explores the interplay of factors influencing Foundation Year 2 (F2) doctors' decisions to leave UK medicine. Results Seventeen participants were interviewed. Six perspectives were explored. Structural influences (countrywide and worldwide issues) included visas, economic and political considerations, structure of healthcare systems and availability of junior doctor jobs worldwide. Organisational influences (the National Health Service (NHS) and other healthcare providers) included staffing and compensation policies, the working environment and the learning environment. Occupational influences (specific to being a junior doctor) comprised the junior doctor contract, role and workload, pursuit of career interests and the structure of training. Work group influences (relationships with colleagues) included support at work, task interdependence and use of locums. Personal life influences consisted of work-life balance, and support in resolving work-life conflict. The underlying theme of € taking a break' recurred through multiple narratives. Conclusions F2s give reasons similar to those given by any professional considering a change in their job. However, working within the NHS as an F2 doctor brought specific challenges, such as a need to make a choice of specialty within the F2 year, exposure to workplace bullying and difficulties in raising concerns. Despite these challenges, most F2s did not view their decision to leave as a permanent job change, but as a temporary break from their current working lives.</p

Modeling the Galaxy Distribution in Clusters using Halo Cores

The galaxy distribution in dark matter-dominated halos is expected to approximately trace the details of the underlying dark matter substructure. In this paper we introduce halo `core-tracking' as a way to efficiently follow the small-scale substructure in cosmological simulations and apply the technique to model the galaxy distribution in observed clusters. The method relies on explicitly tracking the set of particles identified as belonging to a halo's central density core, once a halo has attained a certain threshold mass. The halo cores are then followed throughout the entire evolution of the simulation. The aim of core-tracking is to simplify substructure analysis tasks by avoiding the use of subhalos and, at the same time, to more easily account for the so-called ``orphan'' galaxies, which have lost substantial dark mass due to tidal stripping. We show that simple models based on halo cores can reproduce the number and spatial distribution of galaxies found in optically-selected clusters in the Sloan Digital Sky Survey. We also discuss future applications of the core-tracking methodology in studying the galaxy-halo connection.Comment: 17 pages, 20 figures, 1 Appendix; version accepted by OJ