Management of common mental health in primary care

Mental health is recognised as a global burden of disease and amongst the leading contributors to disability, with common mental health affecting one in six adults. The impact of these conditions on individuals and the economy are significant. Primary care is the first point of contact and general practitioners, as public health gatekeepers are of key importance in the recognition and management of these. It is suggested that general practitioners find consultations challenging, though it is not clear what these difficulties are. The aim of this thesis was to investigate what, if any, problems general practitioners experience with regards to the common mental health consultation. A scoping study and survey provided information on general practitioners’understanding of common mental health and its management. Another survey investigated the perceptions, beliefs and understanding of the general public in relation to common mental health and its management. A theory of planned behaviour study looked at factors that influenced general practitioners’ prescribing and referral behaviours. And finally, a triangulation study examined the findings from the programme of research with other key professionals who are also part of the pathway of care - primary care counsellors and clinical psychologists. Results of this thesis suggest that general practitioners do experience difficulties with the management of common mental health. Challenges were shown to be associated with the general practitioner’s role as the patient’s advocate, lack of knowledge and education, confidence, personal experience, patient expectation and management systems. Results also showed General practitioners’ and lay persons’ understanding of common mental health in everyday practice was different to that in public policy. General practitioner treatment management was shown to be in conflict with clinical guidelines. Furthermore, prescribing and referral behaviours were shown to be influenced by their attitude, significant others and whether they possessed adequate skills or knowledge

How to use coping strategies and become more resilient

It is well recognised that the transition period from medical student to qualified doctor is a particularly demanding time. However, the life course of a doctor presents its own challenges of equal or greater significance and the job of a doctor is becoming increasingly difficult (Figley, Huggard and Rees 2013). Evidence for this relates to organisational, system, societal and clinical factors. Specifically: pressure of patient through-put; patient expectations; lack of organisational and social support; increasing isolation - no time to develop teams and communities of practice; and increasingly complex cases and patient co-morbidities. As doctors progress in their career they become increasingly responsible for the coordination of care in response to traumatic events and patient outcomes, while also managing outside pressures. Such factors can lead to an increase in errors (Jackson and Moreton 2013). Errors may be linked to patient diagnosis and treatment, performance of skills and errors in equipment use. Furthermore, the incidence of errors increases along with the amount of sick leave, with the performance of a growing number of doctors attracting scrutiny from the General Medical Council (GMC 2014). The topic of stress management and resilience has therefore attracted a great deal of attention. This ‘How to’ is a guide to strategies that can be used to relieve immediate physiological stress responses and when practised assist in the development of your resilience

A mixed-methods evaluation of the Educational Supervision Agreement for Wales

Objectives In a bid to promote high-quality postgraduate education and training and support the General Medical Council’s (GMC) implementation plan for trainer recognition, the Wales Deanery developed the Educational Supervision Agreement (EdSA). This is a three-way agreement between Educational Supervisors, Local Education Providers and the Wales Deanery which clarifies roles, responsibilities and expectations for all. This paper reports on the formative evaluation of the EdSA after 1 year. Design Evaluation of pan-Wales EdSA roll-out (2013–2015) employed a mixed-methods approach: questionnaires (n=191), interviews (n=11) with educational supervisors and discussion with key stakeholders (GMC, All-Wales Trainer Recognition Group, Clinical Directors). Numerical data were analysed in SPSS V.20; open comments underwent thematic content analysis. Participants The study involved Educational Supervisors working in different specialties across Wales, UK. Results At the point of data collection, survey respondents represented 14% of signed agreements. Respondents believed the Agreement professionalises the Educational Supervisor role (85%, n=159 agreed), increases the accountability of Educational Supervisors (87%; n=160) and health boards (72%, n=131), provides leverage to negotiate supporting professional activities’ (SPA) time (76%, n=142) and continuing professional development (CPD) activities (71%, n=131). Factor analysis identified three principal factors: professionalisation of the educational supervisor role, supporting practice through training and feedback and implementation of the Agreement. Conclusions Our evidence suggests that respondents believed the Agreement would professionalise and support their Educational Supervisor role. Respondents showed enthusiasm for the Agreement and its role in maintaining high standards of training

Can a mobile app improve the quality of patient care provided by trainee doctors? Analysis of trainees case reports

OBJECTIVES: To explore how a medical textbook app (‘iDoc’) supports newly qualified doctors in providing high-quality patient care. DESIGN: The iDoc project, funded by the Wales Deanery, provides new doctors with an app which gives access to key medical textbooks. Participants’ submitted case reports describing self-reported accounts of specific instances of app use. The size of the data set enabled analysis of a subsample of ‘complex’ case reports. Of the 568 case reports submitted by Foundation Year 1s (F1s)/Year 2s (F2s), 142 (25%) detailed instances of diagnostic decision-making and were identified as ‘complex’. We analysed these data against the Quality Improvement (QI) Framework using thematic content analysis. SETTING: Clinical settings across Wales, UK. PARTICIPANTS: Newly qualified doctors (2012–2014; n=114), F1 and F2. INTERVENTIONS: The iDoc app, powered by Dr Companion software, provided newly qualified doctors in Wales with a selection of key medical textbooks via individuals’ personal smartphone. RESULTS: Doctors’ use of the iDoc app supported 5 of the 6 QI elements: efficiency, timeliness, effectiveness, safety and patient-centredness. None of the case reports were coded to the equity element. Efficiency was the element which attracted the highest number of case report references. We propose that the QI Framework should be expanding to include ‘learning’ as a 7th element. CONCLUSIONS: Access to key medical textbooks via an app provides trusted and valuable support to newly qualified doctors during a period of transition. On the basis of these doctors’ self-reported accounts, our evidence indicates that the use of the app enhances efficiency, effectiveness and timeliness of patient-care in addition consolidating a safe, patient-centred approach. We propose that there is scope to extend the QI Framework by incorporating ‘learning’ as a 7th element in recognition of the relationship between providing high-quality care through educational engagement

Technology in postgraduate medical education: a dynamic influence on learning?

The influence of technology in medical workplace learning is explored by focusing on three uses: m-learning (notably apps), simulation and social media. Smartphones with point-of-care tools (such as textbooks, drug guides and medical calculators) can support workplace learning and doctors’ decision-making. Simulations can help develop technical skills and team interactions, and ‘in situ’ simulations improve the match between the virtual and the real. Social media (wikis, blogs, networking, YouTube) heralds a more participatory and collaborative approach to knowledge development. These uses of technology are related to Kolb's learning cycle and Eraut's intentions of informal learning. Contentions and controversies with these technologies exist. There is a problem with the terminology commonly adopted to describe the use of technology to enhance learning. Using learning technology in the workplace changes the interaction with others and raises issues of professionalism and etiquette. Lack of regulation makes assessment of app quality a challenge. Distraction and dependency are charges levelled at smartphone use in the workplace and these need further research. Unless addressed, these and other challenges will impede the benefits that technology may bring to postgraduate medical education

'Black sheep in the herd'? The role, status and identity of generalist doctors in secondary care

Changing patient demographics raise important challenges for healthcare providers around the world. Medical generalists can help to bridge gaps in existing healthcare provision. Various approaches to medical generalism can be identified, for example hospitalists in the US and the restructuring of care away from medical disciplines in the Netherlands, which have different implications for training and service provision. Drawing on international debates around the definition and role of generalism, this paper explores one manifestation of generalism in the UK in order to understand how abstract ideas work in practice and some of the benefits and challenges. Broad-based training (BBT) is a two-year postgraduate training programme for doctors recently piloted in England. The programme provided 6-month placements in four specialties (General Practice, Core Medicine, Psychiatry and Paediatrics) and aimed to develop broad-based practitioners adept at managing complex and specialty integration. Our longitudinal, mixed-methods evaluation of the programme demonstrates that although trainees value becoming more holistic in their medical practice, they also raise concerns about being perceived differently by co-workers, and report feeling isolated. Using identity theory to explore the interplay between generalism and existing boundaries of professionalism in healthcare provision, we argue that professional identity, based on disciplinary structure and maintained by boundary work, troubles identity formation for generalist trainees who transcend normative disciplinary boundaries. We conclude that it is important to address these challenges if generalism in secondary care settings is to realise its potential contribution to meeting increasing health service demands

‘It's surprising how differently they treat you’: a qualitative analysis of trainee reflections on a new programme for generalist doctors

Objectives An increase in patients with long-term conditions and complex care needs presents new challenges to healthcare providers around the developed world. In response, more broad-based training programmes have developed to better prepare trainees for the changing landscape of healthcare delivery. This paper focuses on qualitative elements of a longitudinal, mixed-methods evaluation of the postgraduate, post-Foundation Broad-Based Training (BBT) programme in England. It aims to provide a qualitative analysis of trainees' evaluations of whether the programme meets its intentions to develop practitioners adept at managing complex cases, patient focused care, specialty integration and conviction in career choice. We also identify unintended consequences. Setting 9 focus groups of BBT trainees were held over a 12-month period. Discussions were audio-recorded and subjected to directed content analysis. Data were collected from trainees across all 7 participating regions: East Midlands; West Midlands; Severn; Northern; North Western; Yorkshire and Humber; Kent, Surry and Sussex. Participants Focus group participants (61 in total) from the first and second cohorts of BBT. Results Evidence from trainees indicated that the programme was meeting its aims: trainees valued the extra time to decide on their onward career specialty, having a wider experience and developing a more integrated perspective. They thought of themselves as different and perceived that others they worked alongside also saw them as different. Being different meant benefitting from novel training experiences and opportunities for self-development. However, unintended consequences were feelings of isolation, and uncertainty about professional identity. Conclusions By spanning boundaries between specialties, trainee generalists have the potential to improve experiences and outcomes for patients with complex health needs. However, the sense of isolation will inhibit this potential. We employ the concept of ‘belongingness’ to identify challenges related to the implementation of generalist training programmes within existing structures of healthcare provision

'I felt forced to find an alternative': a qualitative analysis of women medical educators' narratives of career transitions

Objectives While institutional and systemic attempts to increase women’s participation in medical education have enabled increasing numbers to enter the field and achieve more senior positions, little is known about lived experiences of female clinical educators. Women clinicians are more likely to change careers and work less than full time. This study focuses on women medical educators’ narratives of career change, with the aim of exploring the interplay between factors affecting career decision-making, career trajectory and professional development.  Methods We employed narrative enquiry approaches to two data sources (55 written accounts of turning points; 9 semistructured interviews reflecting on periods of career transition). Through analysing themes within each dataset before comparing and contrasting datasets simultaneously, we identified three areas of inconsistency and tension. Results Participants reported feeling both drawn and pushed into medical education. Some respondents reported that they were compelled by circumstances to enter medical education. Participants’ narratives were ambiguous regarding personal and professional identities. Additionally, participants asserted their position as autonomous agents while acknowledging their powerlessness when encountering organisational, social and cultural expectations limiting the ability to make independent choices. Even where primary decisions to pursue medical education were positive and motivated by interest, subsequent disappointments and challenges led some participants to doubt their choices. Conclusions Career advancement in medical education may involve women taking significant personal or career sacrifices, partly due to the continued existence of a medical culture allowing men to dominate senior ranks. Women medical educators achieving satisfying senior roles in the field may harbour lingering regret and resentment at the personal and career costs